Globally, the population of adults aged 65 years and over has been projected to rise from 10% in 2022 to 16% in 2050 (United Nations, 2022). Predictions for the Republic of Ireland establish that by 2041 this cohort will have almost doubled, with a threefold increase in those aged 80 years and over (Health Service Executive, 2023).
The World Health Organization's (WHO) Global Network (GN) connects communities worldwide with the purpose of promoting healthy ageing (WHO, 2018) and Ireland is one of the member countries (WHO, 2020). Age Friendly Ireland (AFI), which is affiliated with the GN, is the national body responsible for the programme (AFI, 2014).
As the majority of older people wish to age in their homes, a priority for governments is to work towards enhancing the person-environment fit. The age-friendly approach maximises the physical and socio-economic environments by making responses that address the wider determinants (The King's Fund, 2018), promoting inclusion and quality of life (AFI, 2019).
Within the continuum of choices between independent living and residential care, day care (DC) is seen as part of an essential population-based strategy to support the person-environment fit (WHO, 2017). The GN's portrayal of DC is mirrored in descriptions used by others (Government of Ireland, 1968; Donnelly et al, 2016; Lunt et al, 2018; Pierse et al, 2020; Orellana et al, 2020). Orellana et al (2020) have provided a comprehensive definition for DCs, describing it as:
‘…community building-based services that provide care and/or health-related services and/or activities specifically for older people who are disabled and/or in need’.
In the Republic of Ireland, the Health Service Executive in nine geographic areas known as Community Healthcare Organisations provide primary care services to the population. In each of the nine areas, community nurses in the Public Health Nursing service have responsibilities which include: caring for older people, profiling local populations, and contributing to age-friendly strategies (Nursing and Midwifery Board of Ireland, 2015; 2023). Alongside this, the delivery of home care, known as Home Support Services which are funded through the Health Service Executive's Social Care Division, have moved primarily to commercial agencies funded by public bodies (Mercille and O'Neill, 2020). In the study area, which is one of the nine community healthcare organisations (McDonald et al, 2019), the projected 2022 population aged 65 years and over was 653 392, and 10 202 of this cohort were aged 85 years and over.
The Health Service Executive's Older Persons' Care service includes Home Support Services (personal care and home help), meals on wheels, DC, residential services, long stay and respite. The costs for both directly supplied and funded Health Service Executive DC services constitute a significant part of the funding expenditure for older persons (Department of Public Expenditure and Reform, 2018) and include groups with a social focus, to those providing care services, or those targeted at specific conditions such as Alzheimer's disease (www.hse.ie).
Variation in DC services has been highlighted, and waiting times have been reported to range from 5 months to a year (Donnelly et al, 2016). That all older persons' home care services are in fact population-based, integrated and age-friendly is widely advocated (Mazars, 2016; Health Information and Quality Authority, 2017; Health Service Executive, 2018; Department of Health, 2021).
Despite the lack of research into DC services, their typology, effectiveness and sustainability (Lunt et al, 2021), there is evidence that day centre communities do achieve their goal of supporting ageing in place while making unique contributions to attenders' lives (Donnelly et al, 2016; The Institute of Public Health in Ireland, 2018; Orellana et al, 2020).
Ecosystems compr ising actors, organisations, environments and interconnections between them, are defined as complex systems (Sixsmith et al, 2023). Age-friendly ecosystems are a relatively new and evolving concept, the success of which requires the active participation of a diverse group of older people in shaping their communities (Sixsmith et al, 2023). The new Health Service Executive structure of Community Healthcare Networks—building blocks of the community healthcare organisations comprising populations of 50 000 persons—could be considered as discrete ecosystems. This research highlights DC facilities as one element of a complex ecosystem and explores the experiences of older people attending DC in one discrete locality. The contribution that ensues from sustained attendance at DC services and the opportunity to participate in shaping future services is also explored with older people.
The study area
The study area was the selected pilot site for a larger EU Horizon 2020 Research and Innovation Programme which aimed to deliver better access to services for older people. The name of this research was titled Socatel and the results of the larger programme were published by McDonald et al (2019). The specific area for the study included seven DC services supporting a population of 20 000 older people. Management of the DC services varied: three were provided directly by the Health Service Executive, four were operated by the voluntary sector funded by the Health Service Executive. A total of six DCs provided a five-day service per week, including access to transportation from home.
Methodology
Design
A descriptive qualitative study allowed for the experiences of older people to be captured using focus group methods.
Aim and objectives
The aim of this study was to explore the experiences of older people attending DC services. The objectives were:
- To understand how older people engage with DC services and the impact continuing engagement has on the quality of their lives
- To identify other factors which shape an age-friendly environment.
Ethical approval
Ethical approval for the wider co-designed study was obtained from the human research ethics committee at the participating academic institution Trinity College Dublin on November 2017 (Ref 749).
Sample and recruitment
Purposive sampling was used to recruit 104 participants into 24 homogenous groups for the study. Recruitment was undertaken by a public sector partner as part of the co-designed collaboration as they had access to a range of primary and secondary care services. Participants provided informed and written consent in advance of data collection. A total of two of the seven DC centres were selected for further analysis – one nurse-led service and one non-clinical manager-led service.
One of the DC centres accommodated a variety of groups of older people. An all-male group was in attendance on the day the focus group was scheduled, and five men participated. The second DC service provided group services and seven women participated on the day the focus group was scheduled.
Measurements
Focus group interviews lasted 60–90 minutes and were audio-recorded and transcribed. During the fieldwork, authors wrote memos and field notes reflecting on what they learnt from the conversations. A grounded theory approach was used to guide the descriptive analysis including open coding, axial coding and selective coding to guide the emergent categories (Strauss and Corbin, 1988). Grounded theory studies maintain openness to unexpected findings when enquiring into processes related to the topic under investigation.
Final categories reported experiences of older persons in relation to how they engaged with DC services, the impact that continued attendance had on their lives, and other factors which shaped the person-environment fit.
Findings
Demographics
Two focus groups (FGs) comprising 12 participants who regularly attended DC services were interviewed. Participants' ages ranged between 70–100 years. The majority lived alone and were in receipt of statutory Home Support Services (Table 1).
Table 1. Focus group composition
| Focus group (FG) | Female | Male | Total |
|---|---|---|---|
| FG1 | 0 | 5 | 5 |
| FG2 | 7 | 0 | 7 |
| Total | 7 | 5 | 12 |
Engagement with day care
Community nurses were the most frequently reported agents to signpost older people to services:
“The district nurse recommended I go here.”
(FG1)
Reasons why participants were advised to attend DC varied from loneliness due to bereavement, to supporting those with progressing disability and to encourage mobility:
“..because I lost my wife 2 years ago and I was dealing with her because she had Alzheimer's.”
(FG1)
“And I fell on the floor with my walker. So I haven't walked since. I was in the acute hospital for a week…and in the rehabilitation hospital for 6 weeks.”
(FG2)
The engagement process differed between groups, with men showing initial reluctance:
“…when I walked into the room and I saw the tables and old men drinking tea and I said let me out of here, I didn't see myself as that old you know. But I am actually.”
(FG1)
The men's group described a need for ‘easing in’, to support attendance and grateful for the initial welcome that was extended:
“You know but when you are starting it's hard.”
(FG1)
“Anyway I got used to it very quick and they are all very kind. It's about kindness.”
(FG1)
The women expressed gratitude for the opportunity:
“Well, when I came I was really at my lowest, so it was great.”
(FG2)
“…yea I couldn't see myself sitting at home on my own, no, no way.”
(FG2)
Most participants used the transport provided by the DC service and the positive comments extended to the bus drivers:
“I came by the bus……X collects us.”
(FG2)
The women described what engagement meant to them through activities such as crafts and social outings, and through intergenerational programmes:
“Yea, we do the knitting and the craft.”
(FG2)
“We did a few projects down in X, you know. With the young people you know.”
(FG2)
The men understood engagement as a sense of solidarity rather than the actual social activities:
“We all have a little in common.”
(FG1)
All participants praised the staff in relation to their person-centred approach:
“…and the staff here are so kind, you know…. and they look after everyone individually.”
(FG1)
“But if we're out sick or anything, she's the first on the phone to send us our meal.”
(FG2)
Engagement with other older people attending the service created a sense of solidarity:
“Especially when you talk…everybody has their own story, you say, well you're not the only one in the world. And they are all at different angles, a great bit of craic.”
(FG1)
“So then I began to see there was gold there you know, just this man here was wise and a gentleman. So there were rewards, and in the social context we swapped stories.”
(FG1)
Participants described the personal added benefit of being part of a group:
“So I love it, almost depend upon it. Because it's the only social thing that I do. It brightens up the week.”
(FG1)
“…it's like going to a second home…and you get to know everybody.”
(FG1)
Factors which shape the environment
The women reported awareness of local nurses, describing them as proactive and having a strong community presence:
“You kind of know the nurses, they do be in and out of here all the time, X and Y and we know them all. We know their names and all you know.”
(FG2)
“They're easy to get in touch with, you don't have to… and they are very good, like if they can do it for you, they will.”
(FG2)
The nurses were described as health promoters, showing a willingness to modify and individualise services:
“But I was glad to get out of the house and the nurse was encouraging me to try and get out even one day a week, back over here. She says you'll be mixing with your friends…she said if you want to go home after dinner, X, that's the chap that drives the bus, will bring you home.”
(FG2)
The men shared their awareness of local nurses from experiences of home visiting:
“.. a district nurse called out and probably told me about home help…that I could have home help if I needed them. And then it went on from there.”
(FG1)
“I have a nephew and niece that are very helpful. And the nurse, the district nurse. They all help me.”
(FG1)
Participants described other health and social care professionals as supportive and accessible:
“Well I have a very good doctor; I can chat with her.”
(FG2)
From participants' descriptions, the majority were in receipt of Home Support Services and appreciated the efforts of healthcare professionals in gaining access to services for them:
“When you go home, she said (hospital social worker), you won't be able to do much by yourself for a long, long time. And she fought for it and I have carers coming in the mornings. And a carer coming in the evenings.”
(FG2)
Some participants, mostly men, had difficulty with accepting formal help coming into their homes and with change:
“I find it an intrusion on my privacy…and then this stranger comes in, and maybe has strong views on something.”
(FG1)
A few managed to be independent with the assistance of family members, while others acknowledged the support of neighbours and a mix of formal and informal support:
“No, only my sons and daughters. Otherwise, they look after me so well, they do….Because I can't drive anymore.”
(FG1)
“We have good neighbours as well, you know that can do things for you”
(FG2)
“I do have the carers coming in and then my two sisters; well they ring during the weekdays…and even some of the neighbours they do knock on the door and then I'd be alright.”
(FG2)
Discussion
Irish DC services were recommended for both their preventive aspect and to avoid or delay admission to residential care and were viewed as a method to provide relief for family carers, through a range of therapies (physiotherapy, occupational therapy, chiropody) and a midday meal (Government of Ireland, 1968). Both DC centre environments demonstrate an age-friendly space for older people to congregate, promoting social connectedness and engagement with local health services in line with current recommendations (Health Information and Quality Authority, 2022). Regular attendance provided a home-from-home experience and an opportunity for assessment, case finding, early intervention and health promotion for health and social care professionals. Importantly, older people's opinions were valued, promoting their active participation in co-developing DC services within the wider ecosystem.
‘I began to see there was gold there, you know’.
Engagement and impact on day-to-day living
Community nurses from the local Public Health Nursing service were the most frequently reported health and social care professionals to initiate referrals and encourage initial engagement. Although it was opportunistic that groups were separated by gender for data collection, the data highlights multiple engagement styles that differed and were valued equally. Men described needing encouragement to engage with DCs, voicing challenges in accepting their ageing process. For all participants, engagement with services happened over time and was sustained, chiefly because of established connections with community nurses and the understanding of DC staff, which allowed participants to be ‘drawn in’.
Participants described solidarity in regularly meeting with peers in a structured and harmonious environment; it brought added benefit to their daily lives in which their human rights were upheld (Health Information and Quality Authority, 2022). The activities and social outings played a part, as did the connection with and confidence in both the DC staff and local community nurses. Equality in service provision was demonstrated by efforts to both meet individual needs and to sustain developing relationships by providing an informal outreach and in-reach service. These factors are also, no doubt, contributory aspects in the experience of person-centred care to which the concept of age-friendliness aspires (WHO, 2017; 2018).
Other factors which shaped the environment
Those in receipt of Home Support Services have higher health and social care needs and an increased likelihood to attend DC services (Walsh and Lyons, 2021). In Ireland, it has been suggested that a proposed statutory Home Support Services scheme will help to embed home care within the full range of care (Mazars, 2016). However, in this study, there was no sense that significant relationships existed with Home Support Services' healthcare workers, or that the Home Support Services were connected to the local ecosystem. Insights into the changing nature of community nurses' work with older adults and the challenge of building relationships with local Home Support Services have previously been reported (McDonald et al, 2021).
Public health nurses hold registers of older people in their care and undertake community profiles to predict the need for local services, including DC (Nursing and Midwifery Board of Ireland, 2023). In the absence of a national electronic health record (Government of Ireland, 2023) or a local register of the primary care population, there are limitations in linking local intelligence into Community Healthcare Networks' structures. Valuable ‘bottom up’ information and insights routinely collected by community nurses and health and social care professionals do not currently inform population-based planning. Population-based planning is one of the cornerstones of an integrated care environment (Health Service Executive, 2018). Community nurses can contribute valuable data when systems exist and thus, demonstrate their professional advocacy for older people with whom they have built trusting relationships.
These and other significant gaps in age-friendly information and communication are acknowledged by the WHO, which maintains that exposure to these shortfalls can be addressed by listening to older people in the context of focus groups such as these (WHO, 2017). Including the voice of stakeholders in public health developments remains ever more pertinent (Fouladi et al, 2023).
Limitations
The limitations of this study include the qualitative study design. The results are not generalisable, and the data emerging can be used to describe the lives of those who participated. However, this study is part of a larger European co-designed collaborative study informing the development of older person services with, for and by older people.
Conclusion
The added value that age-friendly DC facilities offer to older people is undeniable and supports the philosophy of provision of care in the right place, as demonstrated by this study. Access to local community nurses, transport, experienced DC staff and structured person-centred care, which allowed active participation and extended beyond the walls of the DC facility, all enabled the person-environment fit. Opportunities for the ever-expanding Home Support Services to be fully integrated into these established ecosystems have been missed and this impacts the quality of the age-friendly environment. Addressing this service gap at the Community Healthcare Networks' level will require team building across statutory and non-statutory agencies.
Collecting valid and reliable information about those in receipt of primary and social care services provides population-based information for service planning, maximises the opportunity for integrated age-friendly environments and enables Public Health Nursing expertise to be embedded in population-level health planning. Acknowledging the expertise of registered nurses and of older people themselves is critical to the development of DC services and age-friendly services.
Key points
- Unprecedented ageing and growth of the global population of older people is predicted
- Relationships built by community nurses with older people and knowledge of their local communities fosters community participation and promotes ageing well in place
- Day care is an essential part of a population-based strategy to support ageing well in place
- Older people benefit from and value participation in day care
- National commitment to population-based age friendly environments is required to facilitate the health and wellbeing of a growing older demographic.
CPD reflective questions
- Describe the day care facilities available in your work/study area and their source(s) of funding; what services/activities do these day care centres provide, how many days per week is the service available, and is transport available to and from the facility?
- How many older people attend these local day care services, what is the ratio of men to women, what is the average age of participants?
- In your opinion does the day care intervention bring added value to these older people's lives and are there sufficient day care services available for all eligible older people?
- Do you engage with participants and staff at day care centres and are they aware of your community nursing role and do they know how to contact you?
- How many of these participants are in receipt of other community services such as Meals on Wheels or Home Support Services?