r1 Arch. Copy 1 World Health Organization -~ Regional Office for Europe I! Copenhagen EURO Reports and Studies 79 Medicosocial work and nursing: the changing needs Report on two WHO meetings World Health Organization a Regional Office for Europe ~ ~ Copenhagen ~ ~ EURO Reports and Studies 79 Medicosocial work and nursing: the changing needs Report on two WHO meetings Cologne 16-19 November 1981 Helsinki 1--4 September 1981 ICP/S PM 031 ICP/ SPM 032 ISBN 92 890 1245 5 © World Health Organization 1983 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Conven- tion. For rights of reproduction or translation , in part or in rota. of publications issued by the WHO Regional Office for Europe application should be made to the Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen 0, Denmark. The Regional Office welcomes such applications. 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PRINTED IN DENMARK ISSN 0250-8710 CONTENTS Page Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii PART I: CONFERENCE ON NURSING AND MEDICOSOCIAL WORK IN THE CARE OF THE ELDERLY Introduction The present situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Haza rd con trol and health promotion 2 Early detection and treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Rehabi litation and continuing care 8 Some problems and constraints and suggestions for dealing with them . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Assessing needs accurately . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 2 Some problems in the clinical and medicosocial fields . . . . . . . . . . . . . . . . . . I 5 Some other problems and constraints 20 Some new practices and schemes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 New approaches to care and nurse-training programmes in Czechos lovakia . . . 2 I Home care in Denmark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 The contribution of volunteer groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Day hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Development of services specializing in ps yc hiatry of o ld age 25 Future planning 28 Some demographic trends and facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Some priorities for the future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 iii Education of workers in both disciplines in health care of the elderly ................................. 31 The complementary roles of nursing and medicosocial work . . . . . . . . . . . . . 31 Education for professional workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Suggestions for curriculum development . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Education of auxiliaries Education of volunteers 34 35 Education of other members of the public . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Education for teamwork and work with the community 36 Services research 37 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Developing nursing and medicosocial services for the elderly 39 Developing nursing and medicosocial manpower for the health care of the elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Development of research and st udies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 International liaison 43 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Annex 1. Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Annex 2. List of participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 PART 2: WORKING GROUP ON MEDICOSOCIAL SERVICES IN HOSPITALS Introducti on 53 General discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Welfare and social services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Social goal of health for all by the year 2000 . . . . . . . . . . . . . . . . . . . . . . . . 55 Medicosocial services in the European Region . . . . . . . . . . . . . . . . . . . 55 iv Organization of medicosocial services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Dependency groups and their needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Lifestyles in the community Medicosocial services in hospitals 60 60 Communication: methods and means . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Educational needs of medicosocial workers . . . . . . . . . . . . . . . . . . . . . 64 Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Curriculum conten t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 lntercou ntry coopera tion 65 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 National leve l . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Internati onal level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 WHO level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Annex I. List of participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 V FOREWORD This publication is the result of two activities carried out by the WHO Regional Office for Europe as part of its medium-term programme in nursing/midwifery covering the period 1976-1983. The first part of this book consists of the report on the Conference on Nursing and Medicosocial Work in the Care of the Elderly, which was held in Cologne in 1981 in conjunction with the Working Group on Prevention of Disability in the Elderly, some recom- mendations of which relate to nursing and medicosocial work. The second part presents the discussions and conclusions of the Working Group on Medicosocial Work in Hospitals, which met in Helsinki in 1981. Both reports are based on an analysis of the present situation of medico- social and nursing services, as well as on an identification of the changing needs of the elderly population, the individual with social problems, and the "dependency groups''. The conclusions and recommendations have been developed in the light of the European regional strategy for attaining health for all and relate to (a) the development of appropriate and efficient medicosocial and nursing services, (b) the creation and development of educational problems for the professionals of these two disciplines, and (c) the necessity and importance of intensifying collaboration and coordination through intra- and inter- professional teamwork and the need for further research and studies. It is expected that this publication will contribute to a more explicit identification and deeper understanding of the characteristics of medico- social work and its interrelationship with nursing, so that the Member States will be able to take these elements into consideration for the future develop- ment of their health manpower policies and planning. Political will, however, is required if the challenge of "adding years to life by adding health to life and life to years" is to become a reality. vii PART I CONFERENCE ON NURSING AND MEDICOSOCIAL WORK IN THE CARE OF THE ELDERLY Cologne 16-19 November 1981 INTRODUCTION A Conference on Nursing and Medicosocial Work in the Care of the Elderly was convened by the Regional Office in collaboration with the Government of the Federal Republic of Germany in Cologne from 16 to 19 November 1981. The Conference was attended by 30 participants from Member States, 16 tem- porary advisers , and representatives of 7 nongovernmental organizations. A list of participants is given as Annex 3. Members of the Working Group to Define Means of Prevention of Disability in the Elderly (J), which met during the same period, joined the participants for plenary sessions. The Conference formed part of the Regional Office medium-term pro- gramme in nursing/midwifery and its purpose was: - to review the present situation in countries of the European Region regarding nursing and medicosocial work in the health care of the elderly; - to identify common problems and constraints and explore ways of dealing with them; - to study recently introduced practices in the health care of the elderly (including those involving lay personnel); - to make proposals for improving the education of workers in both disciplines with regard to care of the elderly; - to suggest ways in which improvements can be made by nursing and medicosocial personnel in the health care they provide to elderly populations of the Region. In many countries, in order to achieve "health for all by the year 2000", reorientation of health programmes is required, with activities arranged in three main programme areas: - promotion of lifestyles conducive to health; - reduction of preventable conditions; - provision of care that is adequate, accessible and acceptable to all. Translated into a health care of the elderly programme these include : - hazard control and health promotion; - early detection and treatment to stabilize, control or repair, or to prevent an impairment from becoming a handicap ;a - rehabilitation with continuing care (between home and institute; between institutes when care in these is necessary) and including terminal care. While it would be unwise to make predictions of changes expected by the year 2000, it is apparent that self-care, self-help, family and friends, the neighbourhood, and the wider community of lay people are all critical in maintaining the wellbeing of elderly people . It was considered both necessary and wise , therefore , to discuss the contribution of nursing and medicosocial work against that background. THE PRESENT SITUATION Discussion of the current pos1t1on in the Region revealed many differences in relation to national policies, resources, systems, structures and services, as well as to educational and research programmes. It was clear that in most countries there is a growing awareness of the need to incorporate services for the health care of the elderly into the national health and social systems. From many it was reported that there is also an appreciation that not all is well with the present situation and that both medium- and long-term planning and shifting of resources are long overdue. Many interesting points were made and a number of common problems , difficulties or constraints were discussed more fully. Hazard control and health promotion Reference was made early in the Conference to the regional strategy for attaining health for all by the year 2000 .b One aim expressed therein, "to get people to take responsibility for their own health", had received a fairly a The concepts of "impairment", "disability" and "handicap" used here are those as defined in the International classification of impairments, disabilities, and handicaps, published by WHO on a trial basis in 1980. See Annex 1, p. 45 . b Document EUR/RC30/8. 2 wide consensus of agreement in Member States. Care had to be taken, how- ever, to see that it was not misinterpreted. It could be used by govern- ments to justify cutting down on health expenditure. It could also be used by traditionally-minded physicians to justify limiting their practice to prob- lems for which a clear medical solution is required. The participants emphasized three main points relating to self-care practised by elderly people . First, self-care can very easily become self- neglect. Second , many difficulties experienced by older people are the result of a combination of physical, social and psychological needs. Third, self-care implies self-knowledge : knowledge of human growth and the aging processes; knowledge of health and significant deviations from it ; and know- ledge of the availability of aids and appliances that will prevent an impair- ment from becoming a handicap. Efforts to improve the living conditions of all citizens should, of course, benefit the elderly but they should not only be beneficiaries, for while old people have rights they also have responsibilities. They can, and should whenever possible, contribute to the development and advancement of the community in which they live. Nor should the problems of older people be considered without refer- ence to the problems of other age groups within their society. Govern- ments, struggling with the problem of equitable distribution of resources , are often faced with pressures to favour one group at the expense of an- other. It is essential, however , when resources are limited, to allocate them preferentially to the most deprived people. Frequently the reverse happens : the economically and socially deprived groups - and they include the elderly poor - receive the smallest share of the health services. It has to be re - membered that the line between self-care and self-neglect is alarmingly fine and easy to cross, especially in the context of health care of elderly people. It can also be a costly one . If identified at an early stage , an impair- ment or difficulty can often be dealt with, or at least controlled. Unnoticed, or allowed to continue, costs can soar alarmingly - to the old person in terms of quality of life , and to the country in terms of resources. Surveil- lance, with sensitive awareness of the importance of every person's privacy, followed by prompt and effective intervention, can help the old person to continue self-care, confident that support is, and will be, available when needed. The support required may be of a nursing nature, such as giving advice on incontinence or dental care, supplying an aid or appliance, or providing psychological support at times of redundancy, retirement or bereavement; or it may be an intervention of a social service kind, such as giving advice on housing, financial benefits, special transport facilities, where to obtain legal advice , or where to go for intellectual stimulus. It was suggested that to help nursing and social service personnel to make 3 the right intervention at the right time, a conceptual framework that can assist in the provision of comprehensive care is one that: - recognizes the interacting health needs of the elderly and their families at different stages, mastering the developmental tasks required at each; - assists them in self-care activities so that they can remain independent in the community; - supports their efforts to assume responsibility for their own health and welfare. The participants emphasized that psychological and social needs should be recognized as such and not treated as medical problems. The physical , social and psychological needs of elderly people are often intertwined and therefore require a multidisciplinary team approach by which physician, nurse, social worker and therapist can ensure that their combined skills and knowledge are used to help old people to remain independent, and also to assist their families to continue to give them appropriate support. A significant impact on an old person is that of multiple loss : loss of spouse, loss of role, loss of work and earned income, loss of mobility and social interaction, loss of social status and self-esteem. With advancing age, therefore , large numbers of elderly people undergo great stress, often lead- ing to emotional problems and sometimes to increased dependency. In the extreme, inability to cope with life's crises undoubtedly contributes to alco- hol and drug abuse and to the rising rates of suicide among older people. In spite of the potential benefits of early treatment in the prevention of mental illness in older people, however, they are very rarely represented pro- portionately in a country's mental health care system. This could reflect their reluctance to ask for help, or possibly a lack of knowledge of where to go for help; it could even be due to the care-givers' own lack of interest. To trace older persons who have mental health problems, or who are at risk , requires some effort , as often they are living in remote areas , sometimes even in isolation. On the other hand there is a great deal of contact between the generations, and in developed countries only a small proportion of the elderly (an average of 5-7%) are institutionalized . Should the focus, then, be on continuing and strengthening support to their families and friends? To help the elderly and their families to counteract anxiety, emotional imbalance and psychosomatic disorders, more and relevant educational pro- grammes should be made available to them. Appropriate education and train- ing should also be given to all professionals and lay volunteers who work with old people. As is well known , local programmes make it easier to define and respond to the problems of a community, but whose responsibility is it to initiate these? And who teaches the teachers? Among the disadvantages suffered by many older citizens in the majority of societies in the Region are job discrimination, reduced access to services, 4 poor food and inadequate housing. Decisions affecting these are often made without the participation of the old people themselves, policy-makers and programme planners being unwilling to listen to the aged. An obvious state- ment, but one that needs to be made , repeated and transformed into action, is that "the creation of healthy environments designed to enable aging per- sons to realize their full potential will increase the probability that they will contribute to society". This could make redundant the well-used ex- hortation to ''integrate old people into society", for they will have remained a part of society. Some participants felt that there was a tendency among research workers to concentrate exclusively on the prevention of disabilities. They suggested that the prevention of premature aging was also important and more research was required on aging as such. The effect of living conditions The last 30 years have brought an enormous rise in living standards through- out Europe, but even in the richest countries the living conditions of re- tired old people are less satisfactory than those of the working population. The rise in the standard of living of working people has been more rapid, thus increasing the gap between their living conditions and those of the old. A certain proportion of old people live in particularly poor conditions. Of course, living standards depend not only on objective values but also on regional customs. Any evaluation of living standards must therefore take into account the "model of living" typical for a given society. The higher social classes not only secure better living conditions but also create a higher model of living as one ideal point of reference. In lower social groups the model of living is lower , and so therefore are their unfulfilled needs. Improvement of one's economic position tends to-increase automatically the level of one's expressed needs. Consideration of living conditions cannot be disassociated from prob- lems of disability. The poor living conditions of some elderly people often mean increased isolation and likelihood of disability. On the other hand , an advanced physical or mental handicap may greatly limit the possibili- ties for rehousing. Prevention of disability must take into account the over- all living conditions of old people in a given society as well as individual living conditions. The most important factors influencing the living standards of old people were identified by the group as being family structure , income and housing conditions. Most people, including many old people themselves, consider that the aged are better off in their own homes whatever the disadvantages may be. Sometimes because their homes appear to be full of hazards and dangers ef- forts are made to remove them to a "safer" environment. The participants 5 felt that elderly people have the right to make their own decisions and to live at their own risk but, they emphasized, old people also have the right to expect the health and social services to assist them in their attempts to stay healthy and to maintain a degree of mobility, safety and independ- ence in their own homes. likewise, their families have the right to health and social services that support - but not supplant - their own care of an elderly relative at home. Those who work in these services have responsibilities to make such assistance available and to provide such support as required. The promotion of health and the prevention of disability are two main goals of the primary health care team, and the responsibilities of its members include teaching, counselling and signposting people to the various services provided by statutory and voluntary agencies and organizations. Medicosocial workers and nurses need to be knowledgeable not only about aging and elderly people, but also about the help and information available locally. Early detection and treatment Many intractable health problems of the elderly have their ongm m socio- economic causes, with resultant differentials between social classes, such as deaths from accidents, cancer, alcoholism, suicides and hypothermia. Acci- dents are a major problem for the elderly in both the developed and the de- veloping world. The "unsteadiness" of age, loss of balance, bewilderingly fast traffic and hazards in the home can all result in a high incidence of death and disability. Nutritional problems among old people are also encountered in all parts of the world. In the more affluent nations, persons of all ages may eat an unbalanced diet, while in both developing and developed coun- tries poverty in old age can result in malnutrition and even hunger. Other heavy tolls on the functioning of elderly persons are said to be chronic pain, decreased mobility and chronic bronchitis . Several enquiries are being conducted in the Region to ascertain the more common conditions and diseases found in elderly people, and the Conference heard about a typical cross-sectional epidemiological study conducted among a representative sample of nearly 2000 people aged 60-90 years living in Belgrade (2). It was found that the main diseases prevailing were those affecting the musculoskeletal, cardiovascular, digestive and nervous sys- tems. Injuries, accidents, and poisoning affecting activities of daily living also occurred frequently. While fmdings on the level of functioning among some aged people are often encouraging, the participants believed that they should not be allowed to obscure other, less optimistic findings. A substantial group of aged people, perhaps small in proportion but large in number, fmds it difficult, and some- times impossible, to perform common physical tasks related to their mobility and personal care. This group requires a large amount of care related both to so-called "medical" needs (nursing, treatment, rehabilitation and terminal 6 care) and to those ''basic living" needs, the meeting of which may also involve medicosocial workers (adequate maintenance including food, shelter, clothing and warmth, and contact with friends and family). The participants considered that measurement of the capacity for self- care among the elderly was an important aspect of overall assessment. They reaffirmed the belief contained in recent reports of studies in the United Kingdom and elsewhere, which had emphasized the advantages of these being undertaken in the person's own home. Questions were raised regarding these assessments. What do we actually need to know? What is the best way to obtain this information? What should we do with it when we have got it? With whom should we share it and not share it? What about confidentiality? Whom and how do we educate to undertake assessments? When and where and by whom should this education take place? Screening is a very controversial subject and the group appreciated that participants at several previous meetings had devoted much time to discuss- ing the comparative advantages of multiphasic screening and regular medical examinations performed by the elderly person's own doctor. It was noted that no conclusions had been reached at these and therefore no universally accepted recommendations had been made. While little time was spent in discussing comparative merits, the participants supported the practice of tactful surveillance by the elderly person's friends and neighbours. They emphasized that it should always be backed by a sympathetic, knowledge- able, alert and interested primary health care team. The Conference also discussed early impairments. How could these and the difficulties they cause for many in the performance of daily activities be brought to the attention of health workers? How and where should the public be taught to recognize the development of early impairment and when to seek help or advice? Finally, when such needs are identified have countries the resources to meet them? It was agreed that assessment of disability at any age should be made in order to : - predict the future course and management; - identify pathological processes, especially those that may be partly reversible; - consider possible changes that should be made in the individual's support system. It was considered that this support system was the major concern. It was important to determine how, in what form, and by what mechanisms nurses and medicosocial workers could give backing to the care and assist- ance of family and friends. Equally, people, including the elderly them- selves, must know how and where to obtain help and information when 7 they require it. They must also be confident that prompt, appropriate and acceptable aid will be forthcoming when they need it. Rehabilitation and continuing care These needs of elderly individuals are subject to change however and "once- only" assessments are not enough. Because aging is a process that continues throughout old age, surveillance must also be continuous. It was agreed that often it is the people who need a health service most who use it less than they should. Finance is not the only barrier to its use. There are others, such as lack of knowledge about what is available and where to find it; the attitudes of those who work in the service; and the very structure of the system itself. A social service should be adequate, acceptable and accessible. It should also be appropriate. While it would ap- pear an obvious requirement, workers should have received suitable train- ing and be knowledgeable of the field (i.e. care of elderly people) in which they practise . Behind many of the problems and some possible answers lie several general principles that must be observed if services are to be comprehensive, effective and flexible in both scope and depth. First, the elderly themselves should know of the services available to them and how to use them. Each person will have strengths as well as weaknesses and therefore a main aim is to see that these are made the most of. This is likely to require an advisory service readily accessible to everyone , and backed up by sufficient resources to allow the production of simple manuals, leaflets and reference handbooks. Also highly desirable is an adult education and leisure programme, and this should be within the context of a lively community and not in a specialized organization. Everyone should be able to maintain a variety of enjoyable and worthwhile relationships with individuals and groups of all ages in their own vicinity. Such activities may have to begin as a deliberate initiative - probably on the part of one or more voluntary organizations - but in time they should become part of the general provision for everyone and by everyone so that they provide possibilities for continuing personal fulfilment. In this context a member of the group observed that often the present system produces a need for an old person who has spent two weeks in hospital to be "re- integrated into society". What younger person requires a social worker to help him to pick up his neighbourhood relationships after a two weeks' holiday? Just in terms of maintaining wellbeing and preventing deterioration, the investment required (mostly time) must be acceptable. In the face of the cost of alternatives it is essential. Another important service to enable elderly people to help themselves is adequate support for those with whom they live. Encouragement and some- times a "listening post" may be all that is required, but much can be gained by providing advice and guidance on everyday problems and exasperations. 8 While a number of books on the subject have been published, few are reaching the right people at the right time. Adult education for main- taining health remains superficial and not enough publicity is given to it. The mass media should be invited to participate in planning and their help (as colleagues and not as passive listeners) enlisted at the earliest possible stage of discussion . Another principle to be observed is that the services should know the elderly in their area. This should mean that people who are providing services will know those who need their help as soon as the need becomes apparent. It should also enable all providers - including the community - to gain a better understanding of aging and the aged. It is only when this has been achieved that attitudes are likely to change, myths disappear and parity of esteem be established. Unfortunately, societies, and especially welfare states, have tended to find it easier to group people as "the elderly", in the same way as they group "the handicapped", '41:he mentally ill" or "the young" and then provide services that they think each group wants. In the majority of countries a fundamental change of attitude and a new concept of old age are urgently required . The Conference recognized that at all ages life requires challenge , a motivating force (maybe even anxiety), interrelationships and an appreciation of the fact that no aspect of living is without risk . This concept of life in old age has many implications for the education of professional and auxiliary workers as well as of the public. The third general principle identified concerned crisis prevention or the reduction of secondary disabilities. When something goes wrong, old people often have little in the way of reserves so help must be swift and effective, but it must also be acceptable. The removal of old people from their homes is especially traumatic , and placement without adequate thought is often in- appropriate; such a step should therefore be taken only after sound and thorough assessment of the help required and when no other solution can possibly be found. Well-established links are vital in old age - many are inevitably broken by death - and they should be carefully fostered for as long as possible . It was recognized that most emergencies in this field are usually either "social" or "medical" and that appropriate intervention teams of either the social worker/home help or the ''hospital at home" type should be available at short notice , receiving back-up support from the primary health care team. The fourth principle concerned coordination of activities and the pro- viders of services , and was mentioned frequently by the Conference par- ticipants. Few attempts, it was said, have been made to merge or ration- alize the "mix" of people , professions, sectors or indeed ministries concerned in the comprehensive services required by the elderly in general, and by those who need rehabilitation and continuing care in particular. 9 Rehabilitation While the pathology of many chronic diseases remains irreversible, this does not mean that the physical , emotional, social and vocational sequence of these diseases must also remain irreversible. Research and technical progress have provided many new methods of treatment that have brought about a re-evaluation of the concept of disability. All these developments , together with the dedicated philosophy of treating "the total individual", is summed up in the term "rehabilitation". Experience has shown that, with modem dynamic rehabilitation, much of the undesirable sequence of chronic dis- eases and disabilities can be minimized, alleviated or even eliminated. Thus, rehabilitation constitutes the essential part of so-called ''tertiary prevention" in terms of preventing the development of adverse persistent effects of diseases leading to permanent disability. While emphasis on the rehabilitation of younger persons has strong appeal because it may result in a longer productive life, a strong case can be made economically for rehabilitating the increasing numbers of older disabled people. Frequently, older people who are handicapped have few or no re- sources and are most likely therefore to become dependent on public aid for support. Rehabilitation of these patients often pays the maximum return on the public funds invested by enabling them to resume independent living; certainly it always achieves social and personal gains that in economic terms are beyond measurement. An essential part of the rehabilitation of older disabled people is the follow-up service at home, after they leave either hospital or the rehabilitation centre. Rehabilitation is an essential aspect of therapy, bearing in mind that the aim is to restore the elderly person to as healthy and as mobile a state as possible. Rehabilitation of the aged can be summarized as reactivation, re- socialization and reintegration . Reactivation means that an aged patient, who may be passive, lethargic and physically and socially immobilized, is encouraged to live again an active life in his own surroundings. Re- socialization means that an aged person, after or during illness, again makes contact with family, friends, neighbours and others. Reintegration means that the old person is restored to society, participating fully in normal life and, in many instances, resuming a full-time or part-time occupation accord- ing to ability and capacity. From their own personal experiences, several participants observed that even when the elderly patient is helped to develop his capacity for self-care, often what seemed easy in hospital becomes difficult at home. Also, while an elderly husband or wife may be able to care for a convalescing spouse for a time, after several weeks or months standards of care may deteriorate . Again, a follow-up service can often prevent a disastrous or irreversible condition from developing. Nursing management includes maintaining and caring for the person who is caring for the patient, as well as for the patient himself. Aging and aged patients constitute perhaps the largest single group able to benefit from an extension of home~are services that provide them with the necessary rehabilitation procedures after discharge from hospital. The addition of these medical rehabilitation procedures to the conventional services has enabled many elderly men and women, previously considered hopelessly crippled, to regain their functional independence and continue to live without being a burden to themselves or to others. Continuing care The participants were made aware that the very proliferation of services for elderly people in some countries had contributed to the confusion surround- ing both rehabilitation and continuing care. No one person had the responsi- bility and the authority to see that the activities and services agreed on by the multidisciplinary team were actually carried out. This responsibility was seen as a vital necessity of enormous consequence. Where a coordinator or liaison officer did not exist, a member of the team should be made responsible for relating all the activities concerning the patient. This had particular im- portance in relation to the discharge of an elderly patient from hospital. In an acute care setting an aged person can find his life taken over by staff who have little or no knowledge of the aging process and the changes it brings. Often discharge from the hospital ward is abrupt, without adequate preparation for continuing care at home. Early planning for discharge is a pre- requisite of an effective continuum of care, and for this both nurses and medicosocial workers share outstanding responsibilities. What appears to be lacking very often - and this has been found in studies in various coun- tries - is coordination among and between hospital and community staff. In some hospitals, time is allowed for transfer home and the transition is made gradually, the arrangements being supervised by social workers, public health or community nurses, and therapists; sometimes the patient is able to experiment with living at home again for one or two days. Others return for a few hours each day to day hospitals or day centres, thus en- abling their families to continue their own lives, including employment, while at the same time providing the elderly person with someone "in at- tendance" at night. Primary health care teams, where they exist, often cannot or do not follow up the old person when he is transferred between levels of care. This immobility on the part of primary health team members often contributes to a lack of continuity of care. Good opportunities to teach the patient and his future carers are pre- sented while he is in hospital but they are not always taken. If lay people, however, are to be responsible at home for measuring medicine, renewing dressings or performing other self~are tasks, learning under supervision will considerably facilitate the rehabilitation programme. 11 The Conference participants expressed regret that time did not allow for discussion of the responsibilities of nurses and medicosocial workers in the care of dying elderly people. They considered it to be a very important subject and reaffirmed that nurses and medicosocial workers should con- tribute to providing continuous human care to a dying person of any age. The last days of life should not be a period of humiliation, deprivation and suffering but rather a valuable and learning experience for those who provide the care. In relation to the latter, it was regretted that dying people are rarely given the opportunity to talk about what they are thinking and ex- periencing, and so health and medicosocial workers rarely add to their know- ledge and understanding of dying. SOME PROBLEMS AND CONSTRAINTS AND SUGGESTIONS FOR DEALING WITH THEM One participant stated that, although in her country many different measures had been taken to help elderly people, there had been little real improvement in their lot. Services offered were often inappropriate or too late. The Confer- ence therefore considered that three main questions arose from the regional review. Are the right services being provided? Even where sophisticated government structures and extensive manpower networks exist, is a high quality of services ensured? How can standards of care be measured? Assessing needs accurately The Older Americans Resources and Services (OARS) Multidimensional Functional Assessment Questionnaire To assess the adequacy of current approaches it was agreed that valid and reliable information must be gathered in a standardized manner. Partly in recognition of this and partly in response to other concerns, a number of assessment questionnaires have been developed over the past decade or so. One was presented to the Conference and discussed briefly by the participants. The OARS Multidimensional Functional Assessment Questionnaire (OMFAQ) (3,4) was developed because the Center for the Study of Aging and Human Development at Duke University in the United States was chal- lenged to examine "alternatives to institutionalization". Instead of doing the conventional thing and setting up a classical experimental design to deter- mine the effect of a particular alternative on the likelihood of institution- alization, the Center opted for a model that would not only answer the 12 original question but would also permit examination of the impact of any set of services on persons of any functional state. So, instead of looking at persons at risk for a particular event or state, they looked at the entire spectrum of elderly people. The model had three crucial elements. Element l required valid and reliable information on overall functional status, of value at an individual level and also providing a "sorting mechanism" to define groups according to functional state . Element 2 required a breakdown of services into their generic components and a re-massing of them into service packages according to use. Element 3 was a transition matrix, permitting examination of change in functional state over a period and determination of the impact of the specific service package used. Thus, the model capitalizes on naturally occur- ring events and meets the requirements of a quasi-experimental design. To bring this model into operation it was necessary to have a means of assessing personal functional status, and of assessing service use (services again being defined generically). Based on theory and experience , a decision was made to include information in five areas: mental health, physical health, activities of daily living, social resources, and economic resources. Because measures of generically defined services were notably lacking, a two-part questionnaire was developed. The content of part A, Functional Assessment, was based on valid scales in the literature and basic clinical requirements; part B, Services Assessment , was an original venture. After testing in dif- ferent settings (institution , clinic, and community) to ensure that it was relevant to the entire range of elderly people , the OM FAQ was obtained. The validity and reliability of part A have been examined and the results pub- lished (5, 6) and there are plans for similarly examining part B. The whole structured questionnaire consists of 101 questions , some with multiple parts. Information is sought directly from the individual; where this is not possible owing to incapacity a knowledgeable informant gives adequate information . While information from any one of the questions can be used separately, the OMF AQ also provides a rapid means of summarizing infor- mation separately for each of the five areas, in each case on a 6-point scale. Thus, it is possible to determine the level of functioning in each area (I , ex- cellent; 2, good; 3 , mildly impaired; 4, moderately impaired; 5, severely impaired; 6, totally impaired). Based on these five 6-point scales, a functional classification system can be developed. In part B there are definitions for each of the 24 generic services , the definitions being in terms of purpose, activity, relevant personnel and units of measurement. The combination of generi- cally defined services used by any one person is a service package. Since the possible number of different service packages is substantial, attempts are currently being made to develop a services classification system. To use the entire model it is necessary to have initial and re-evaluation information on functional status and service use. The OMFAQ can be, and frequently is, used independently of the model. 13 To ensure that the questionnaire is administered and interpreted in a standardized manner, and that it will be possible to compare information from different sites, training in OMFAQ administration is offered on a regular basis and potential users are encouraged to discuss their projects and seek help. Assessing nursing needs: the Belgian trials Attempts to produce an instrument for assessing nursing needs have been reported from several countries of the Region, and the multinational re- search study that forms part of the medium-term programme in nursing/mid- wifery also aims to identify a common core of knowledge required for each patient/client. Participants at the Conference briefly discussed progress made in the development of such a tool in relation to the assessment of needs of elderly people. In 1978 Belgium joined the WHO epidemiological study on the health of the elderly (2). Oosely related to this was a complementary study by a Belgian nurse, Miss A. de Baets, which took a closer look at the nursing needs of the elderly. The aims of the project were (a) to obtain information on nursing needs as defined by elderly people themselves and as defined by nurses , the amount and type of nursing demands identified, and the possi- bilities for developing self-care ; (h) to compare results of the nursing project with those of the "parent" questionnaire ; and (c) to formulate directives for home care , based on results from the project. The questionnaire was developed from Henderson 's Basic principles of nursing care (7) , with some amendments and additions. While final analyses and interpretations were not available for the Con- ference , it was reported that the interviewers - all retired nurses - had been made more aware and appreciative of the preventive aspects of nursing care and also of the nursing and medicosocial needs in relation to the promotion of self-help. Four groupings had been identified: - elderly people who want to practise self-help but do not have the necessary information ; - elderly people who want to practise self-help and have the necessary information; - elderly people who do not want to practise self-help and do not have the necessary information; - elderly people who do not want to practise self-help although they have the necessary information to do so. It is hoped that the final analysis will provide valuable information for the development of supportive nursing services. 14 Some problems in the clinical and medicosocial fields Feeding demented old people In the terminal phase of care, elderly long-stay patients with dementia be- come difficult to spoon-feed. They may bite, spit, swallow the wrong way or refuse to eat. With the restrictions on the use of tube-feeding and in- fusions (because of the limited length of time .these can be continued and because of the distress and even pain they may cause), feeding demented old people has become distressing for those looking after them . There are demands that conflict with the need to keep the patient alive: not to cause pointless suffering; not to force the patient to eat; and not to speak about any difficulties or conflicts. This was one of the findings of a recent Swedish study (8). It was suggested that it is because this kind of ethical conflict is so distressing that nurses find that they cannot talk about it to others or even allow themselves to think about it. They therefore behave as though they are not aware of what is happening. The natural reaction to conflicting demands is to flee but usually, of course, these nurses cannot do that. Instead, they have to continue to make the patient's bed, clean and feed him. The use of defence mechanisms in this kind of situation can result in distancing oneself from the cause (in this case from the patient) or in finding a scape- goat - a role that, in this instance, is likely to fall upon a member of another discipline, probably medicine. The aim of the Swedish study was to identify these conflicts and also to explore what actions could help nurses in long-stay wards. From the study, it was concluded that group discussions could reduce the pressure, because they provide a kind of catharsis for nurses experiencing this kind of stressful situation . Feeding dying patients In another study undertaken in Sweden (9) it was found that "feeding a disabled patient is an intimate and vulnerable activity, and for the patient to 'submit' [to being fed] she must trust the care worker". If patients do not, they may protest or firmly refuse to take what is being offered. This can lead to a degree of forced feeding that , in turn, results in greater distrust and more protests . When the ability to speak is lost, spitting and fighting may be an attempt to communicate this refusal to the feeder. It was found that both a skilful spoon technique and an emotional rapport between feeder and patient are essential to successful feeding . Spoon-feeding may fail if the nurse is distressed, worried , tired or irritated. Sometimes the patient may feel humiliated by the procedure, while his spitting and spilling of food or liquid may embarrass the nurse. The latter then feels unsuccessful and the patient senses this and again refuses the food. 15 It was evident from these studies that relationships between patients who are fed and those attempting to give them food are both complicated and reciprocal. When spoon-feeding becomes impossible, at least three forms of conflict may be identified : (a) conflict between the nurse's responsibility to feed the patient and the patient's unwillingness to be fed; (b) conflict between the nurse's duty to keep the patient alive and her duty not to prolong suffering; and (c) conflict between the nurse knowing the inevit- ability of death and her reluctance to accept death. The researchers had pointed out that patients admitted to long-stay geriatric wards are usually waiting to die; they had a right to expect kind and careful nursing and to be allowed to die naturally. Denying the bio- logical reality of approaching death may create a paradoxical relationship, inducing anxiety in both patient and nurse and affecting the quality of emotional contact between them. Incontinence in demented old people Other work undertaken in Sweden (10-14) has related to incontinence in demented old people. The majority of these patients have urinary incon- tinence and some are doubly incontinent. This causes problems for the patients themselves, for their families and friends , for other patients , and for those looking after them, including nurses. For many years patients with urinary incontinence have been given indwelling catheters, but frequently these have led to infections of the urinary tract, bladder stones and distressing smells because of the infec- tions. It was reported by the researchers that marginal improvement had been achieved by the use of methenamine hippurate (in high doses cur- atively and low doses prophylactically). It was agreed, however , that further study in this field was still very much needed and reference to the development in Sweden of a bactericidal incontinence pad was noted with interest. The particular crises of incontinence imply a need to trust someone who may be able to help : many incontinent patients try to hide this impair- ment. It is believed that this is because a child learns to be ashamed when he does not control his bladder and bowel , and that this emotion can re-emerge in later life. Incontinent old people need to be encouraged to take initiatives to deal with the impairment without experiencing feelings of guilt and inferiority. Sometimes they have to be helped to acquire and accept their new identities - those of incontinent people . This fact has to be integrated into their living, but without causing a loss of self-respect. Incontinence may also increase the risk of isolation : the smells, wet skin and wet clothes can all contribute to this. To be incontinent can be not only a matter of losing control over the bladder and bowel; it can also cause loss of self-respect and even raise doubts about the value 16 of continuing to live. Nursing plans for incontinent old people therefore have to take all such reactions into consideration. Memory impairment (15-21) Memory is not an isolated function. It depends on many factors such as good physical and mental health, as well as stimulation from the environ- ment. Many factors reinforce it or impair it. Memory disorder is one factor in the vast range of criteria of dependency. Research workers in Grenoble believe that to improve memory all three aspects - emotional, mental and cognitive - must be considered. Their work and progress in this field were briefly presented to the Conference. At the Geriatric Centre of the University Hospital in Grenoble, memory stim- ulation exercises have been devised : - to stimulate those activities that have become lethargic; - to teach the use of any available resources that have lapsed into disuse; - to fight against "special senses" deficiencies; - to liberate inhibitions. The ultimate aim is to promote the active participation of the patient through the acquisition of new attitudes towards himself and the tasks to be performed. In addition, through certain exercises in which rhythm or timing is introduced , further actions are anticipated, such as improving emotional reactions, promoting better self-control and reducing anxiety. This should improve the performance of everyday chores, such as remembering messages and shopping lists, or where belongings have been put. Loneliness and frailty Loneliness is not synonymous with being alone . Many old people who live alone are rarely, if ever, lonely whereas others living with family or friends are. Even those living with many people - such as residents of homes and other institutions - can be surrounded by company yet feel very lonely and neglected. Four main factors that contribute to loneliness are poor health, poverty, having little interest in other people (very often all through life), and the death of the person with whom one has been living. Unmarried or ''un- partnered" people who have kept up a wide circle of friends {which pre- supposes interest in them), have adequate income , and are reasonably active and well are the least lonely, even though they may live alone all their lives . Implications for prevention, therefore , are to a large extent in the hands of the individual. Health and social workers can only help in assisting the elderly 17 person to keep active and well; to take notice and do something about pre- venting impairments or difficulties; to concentrate on strengths and abilities rather than on weaknesses and disabilities; and to give psychological and practical help at times of bereavement or other great loss. This may mean stimulating the help of neighbours and other members of the community, as well as acting and assisting more directly. "Health by the people" includes elderly people, and ways in which they can be helped to help themselves need to be identified and implemented . Those who are particularly vulnerable should be known to the health and social workers of their district. For example, in many European countries at present a number of middle-aged people are being made redundant or forced to take early retirement. Because it is known that memory impair- ment may more often be associated with retirement than with age, these people have become a new vulnerable group and should, therefore, receive this kind of attention. For those who are already old and lonely, specific services may be required. Lack of transport, for example, is often a two-way impediment to meetings and other social occasions. Homes and hospitals may be sit- uated a long way away from public transport, making it difficult for friends and relatives of old people to visit them regularly. Some voluntary organ- izations and agencies run a transport service to take elderly, frail or infirm old people to clubs and on special expeditions or outings. Thought should be given, however, to the obvious preference of some people to have trans- port to visit their own families and friends, rather than be transported to spend time with people with whom they have little in common other than a handicap or disability. Thus, services supplied should, as always, reflect the needs of the people and not represent activities volunteers and others wish to undertake or provide. In relation to all services for an individual, it is important to achieve a compromise between privacy and isolation. Privacy is highly valued by the majority of elderly people and regard should be paid to this. Also, all people need to be alone sometimes. This is one reason why one of the main objec- tives of a social policy or service should be to help not only the family but also the individual to help himself. The preservation and strengthening of family and social bonds and tra- ditions were also considered to be of great importance. Care should be taken to ensure that whatever is done in the name of "progress" - such as re- housing elderly people - does not imperil the existing patterns of care and support for old people. Environmental conditions are extremely important in old age, and there is no doubt that rapid urbanization can produce great stresses in elderly people. The corner shop or the village post office, which were once meeting points, have now disappeared and nothing has replaced them; few cashiers at the tills of city supermarkets - even if the old person can get to them - will be pleased to spend time in chatting. 18 Dr Norberg reported on studies that found that among those old people to whom loneliness was a major problem, there was a high demand rate for medical attention and drugs. During 5 years of observation it was further found that they were not, in fact, suffering from definite diseases to a greater extent than other old people. Cognitive functions were also tested and again no difference was found between those complaining of loneli- ness and the control group. The conclusion was reached, therefore, that those individuals to whom sitting alone and doing nothing is a large part of their day, are creating physical problems for themselves, mainly constipation, sleep disturbance, anxiety and depression. Because the problem of social isolation is one of the most difficult to solve, it is a frequently discussed topic. Like alienation, poverty and other poor environmental conditions, it can lead to manifestations of stress, commonly in the guise of somatic symptoms. The danger is that medical therapy may be prescribed, especially psychotropic drugs, which not only do not help the primary condition but also draw attention away from the underlying cause, and may expose the old person to all the hazards associated with drug usage . To create a society in which such needs of the elderly have a good chance of being met more appropriately, a determined educational drive is required, aimed at ensuring a better understanding of the process of aging, of the needs of the elderly, and of the most effective and relevant ways of supporting them. Such an educational effort is now a matter of worldwide urgency. The work of medicosocial workers in hospital The hospital is a medical framework and often a highly technical institution. Because of this , some participants suggested that while doctors and nurses may feel important and confident in such an environment, they tend to view social work in that setting as a second-class discipline . Consequently, medicosocial workers are often called on only in times of an emergency, such as to arrange an immediate discharge. The majority work in wards or units, ''under" medical or nursing staff, and therefore are restricted to helping only those patients who are referred to them. Because of manpower short- ages they may even have to reject some of these , preferring to give a high standard of service to a few rather than a low standard to many. It was felt that tlie value of the social worker as a member of the ward team , although gradually being recognized in some Member States, is still not fully appreciated and there is an urgent need for clarification of their function. It is because this is often lacking that the majority of health workers have little knowledge of their area and level of competence. In relation to the care of the elderly, this ignorance is of great concern because disease, even when present and known , is not necessarily the most important factor in the lives of old people. Many of their most pressing problems are of 19 a socioeconomic nature and can be fully discussed and solved only when each member of a multiprofessional team contributes his specific skills and know- ledge. While some overlapping of activities is inevitable, and even in some in- stances desirable, clear delineations have to be set and every team member al- located tasks according to his professional experience and competence. Often the social worker is the link between the patient and his home environment. Because of this it may be desirable to have some medicosocial workers based in the community but able to follow their patients into hos- pital. Some participants thought this would result in a more efficient and continuing plan of care for patients after discharge from hospital, as well as giving them a sense of security and of "belonging" when first admitted into acute care. This could lessen their confusion on such occasions. It might also cut down on the liaison work of ward staff. This suggestion obviously has implications for curricula planning and the inclusion of practical community experiences in educational pro- grammes. It could well represent a core content for multidisciplinary edu- cational programmes . Some other problems and constraints Many other problems and constraints to good practice were touched on during discussion, but unfortunately time did not allow for a full explora- tion of the possible solu lions. First , the lack of communication, collaboration, cooperation, and there- fore coordination exists not only between health and social services - ex- acerbated perhaps when these are the responsibility of different sectors and even ministries - but also between the levels of the health system itself and between different, or even the same, disciplines. Adequate communi- cation and coordination is also lacking in connection with other sectors such as housing, transport, environment and education . Consequently, poli- cies adopted by these sectors are not always helpful to the implementation of policies of the health sector. Many participants stated that one of the greatest problems concerned the attitude of the general public, as well as those of professionals and mem- bers of other disciplines; the need for change was urgent. Current attitudes towards old people contribute to the low priority afforded to programmes for health care of the elderly. This in turn has led to health and social staffing problems. There is a lack of interested professionals and inadequate numbers of home-helps, as well as a dearth of other categories of essential workers in this field. Many countries also lack enough educators of health and social service students. In considering high-risk groups, participants realized that these were not only people with physical impairments. Socioeconomic deprivation also re- sults in high risk. The Conference was reminded that today 's unemployed are 20 tomorrow's elderly. In this connection insufficient attention is paid to the immediate post-retirement or post-redundancy period - a time when there is a specific need for mental stimulation and cultural activities. Many members of the primary health care team give little time to counselling, or just listening when it is most needed, such as after retirement or bereavement. SOME NEW PRACTICES AND SCHEMES Present practices often result in overlap and confusion , even where there is an acute shortage of resources. There is therefore considerable value in experimenting with new ideas and new schemes , for while "new" is certainly not synonymous with "good", enthusiasm and quests for improvement should always be encouraged. New approaches to care and nurse-training programmes in Czechoslovakia It is recognized that doctors and nurses at the primary health care level can play an important part in the prevention of premature aging, morbidity and dependence. In Czechoslovakia records are kept of all old people living within a certain catchment area. These include facts about their state of health, the social position of their family and their own status both within and outside it. Those with an impairment, difficulty, handicap or disease are visited by a geriatric nurse who, in collaboration with staff from the local social service, arranges for their basic needs, including house-deaning, to be met. Recently, student nurses have been participating in this service . Some- times nursing students care voluntarily for old people in their spare time, but this recent innovation represents a positive step towards introducing such practical experience into their training programme. Some have been awarded certificates of special appreciation from local governments for their contributions in this field , but most gratifying is the fact that they are ap- preciated by the old people themselves. Special establishments recently set up by local social services include all-day or all-week accommodation. Nurses working in these have received specific training during training courses and seminars. Old people's clubs, whilst aiming to mitigate feelings of loneliness by contributing to social and recreational activities, are also slanting these activities towards health education. This encourages old people to maintain their self-reliance for as long as possible. Short-stay homes with helpers are also made available, and provide the elderly person with alternative accommodation while his house is being re-decorated or his regular helper is taking a holiday. 21 During their education nurses who are going to work in old people's homes and convalescent homes are taught to derive pleasure from even minor improvements in their patients. They are also helped to develop a moral awareness, a highly humane approach and an appreciation of medical ethics. Student nurses are taught the fundamentals of rehabilitation and aes- thetic education in their basic training programmes. More recently, a new subject, "occupation of sick persons", has been introduced to help nurses initiate activities for bedridden patients. Postbasic courses in nursing care of the elderly are also available . Home care in Denmark In this context ''home care", administered by the social service system, is defined as "the blend of health and social services provided to individuals and families in their places of residence for the purpose of promoting, maintaining, or restoring health or of minimizing the effects of illness and disability" (22). Because it had been found that many elderly people have a greater need for nursing services during the latter part of the day and at night, existing home services in two municipalities in Denmark have been organ- ized to provide care round-the-clock at two levels. The first level consists of maintenance home care. This offers personal care and social services to persons whose conditions are stable but who require visits, either routine or as required , from someone who does not need to be professionally quali- fied. The second level offers intermediate home care. This means that per- sonal care and any social services needed are delivered and coordinated by professional workers. It is care offered to those patients whose condition is not expected to fluctuate widely during a period either of rehabilitation or of gradual accommodation to a progressive disease. The team on an evening shift consists of two nurses and either two home helps or two practical assistants. The night team has one of each category of worker. Each team receives a report from the previous shift and then drives to the homes of patients. Each car has radio contact with the central point. This enables staff to receive up-to-date informa- tion and new emergency calls , and also provides some measure of security for them . During 1978/1979 (the latest period for which figures are available) 82% of routine visits were made in the evenings. Reasons for emergency visit- ing were to change dressings, to confirm observations and to carry out some other basic nursing care. Of the patients visited, 75% were over 65 years old and 29% were aged 80 years or more. Patients pay for this service and, while it is likely that it is no less expen- sive than nursing-home fees, the great advantage is that patients are able to stay in their own homes. However the scheme has yet to be evaluated. 22 It is hoped to extend the service in future to provide a third level of help in the form of intensive home care. This would be concentrated and co- ordinated nursing for those patients with a serious illness but who do not require hospital expertise or equipment. A prerequisite to establishing such a service , however, would be easy access to both , if and when required. Further experimentation is also planned to extend the service to help people who are looking after dying friends and relatives. This is more compli- cated to arrange as it would also involve the payment, by municipal auth- orities, of financial compensation for the relatives' lost hours of work. The contribution of volunteer groups The voluntary contribution throughout the Region is in various stages of development , culture and tradition playing a large part. In some Member States voluntary service has been the backbone of public service for gener- ations, whereas in others it has never existed. In those countries where voluntary work is well established , there is an increasing awareness of the importance of improving the quality of life for elderly people - the need to help them to remain active physically and mentally. One recent trend is voluntary work by the elderly themselves, and some services have been taken over by the very people for whom the service was first intended. These include meals-on-wheels, recreational activities, home help services, staffing of day centres, and manning of telephone exchanges for special help agencies. The main aim is the "desegregation" of old people, and it is believed that the rapprochement established between generations during the Year of the Child is being maintained. Some olde r people are going into schools to speak about history during their lifetimes, particularly in- teresting memories, and about professions and trades that are disappearing. For the "old" old , or those with no choice but to go into an institution, it can be a comfort and help to find volunteers there of an age near their own. Volunteer groups participate in daily events, open up the old people's curiosity about the outside world, and organize activities that require imagin- ation, memory and observation. One Red Cross Society is training elderly people to become comperes for shows for old people, recognizing, as the Red Cross has always done, that some relevant preparation is necessary if volunteers are to do good work. The families of elderly people often have ideas about what volunteers can do, and from discussion of their own needs new services can be conceived and developed . Certainly, those who are looking after very old or incapaci- tated people for most of the year will appreciate temporary accommodation being made available during holiday periods , or other ways of combating an old person's loneliness while they are away. Voluntary work must be a dynamic process, responding sensitively and swiftly to new needs. The needs of elderly people are now the concern 23 of many volunteer groups throughout the world. Volunteers can help to meet these needs by being generally useful and working not in competi- tion, but with, professionals. It was agreed that both groups still have much to learn about working with each other and that collaboration between volunteers and professionals is difficult to achieve without adequate prep- aration on both sides. Geographical proximity alone does not ensure com- munication, and without it coordination and thereby the attainment of common goals are impossible. Once again, this is a field in which attitudes have to change. Day hospitals The aim of a day hospital is to provide for elderly people a daily service that will enable them to live at home. Usually the elderly who attend a day hospital are incapacitated people of advanced age with multiple pathology. A day hospital usually provides medical treatment and nursing, diagnostic tests, a full range of assessments, and active rehabilitation. Maximization of patients' independence is its primary objective. There is frequent liaison with the relevant hospital staff and with community and social services, and close links with family doctors, domiciliary nurses, day centres, sheltered accom- modation and the relevant voluntary agencies in the district. The network should make the maximum use of all available local resources, thus enabling patients to be cared for at home. In the United Kingdom, as in many other countries, the staffing of day hospitals varies greatly. The Conference discussed in particular one that is run in a poor area of east London. This has a team consisting of three nurses , two occupational therapists and one assistant occupational therapist, with clerical and domestic support. A full-time social worker is attached to the day hospital. This team is headed by one of the occupational therapists. The medical team includes two consultants in geriatric medicine and other medi- cal staff who serve the district. When a referral for day hospital attendance is made (usually by a family doctor) a member of the medical team makes a home visit. The referral form used is a record of a comprehensive assessment and also outlines the treatment required. The team members then plan together how best to man- age the patient's rehabilitation. Initially, each patient has a thorough medical check-up, followed by any nursing, occupational therapy, physiotherapy, speech therapy or chiropody required. A complete dental overhaul is made (especially of any dentures worn), and sight and hearing are also tested. Glasses and hearing aids are prescribed or changed as necessary. Weekly case conferences are held between all members of the staff, and the patient's progress and future are fully discussed and planned. The dur- ation of both treatment and day hospital attendance is flexible, and depends on the patient's progress. 24 Factors considered important in the success of day hospitals include: - the development of positive attitudes by all staff members towards patients and their families; - a holistic approach to the planning and implementation of treatment; - careful use of, and coordination with, other departments in the hos- pital so that the widest possible spectrum of treatment is offered; - a comprehensive programme, offering not only medical treatment and nursing care but also a variety of social activities; - an active policy of welcoming visits by families, friends and com- munity organizations, thus encouraging local goodwill, funding and involvement. The involvement and endorsement of the patients themselves at the plan- ning stage of their treatment has resulted in their full cooperation in the programmes offered to them. The use of an occupational therapist as head of the team was discussed, and it was pointed out that few other disciplines complementary to medi- cine offer training in the care of both physical and psychiatric patients. Occupational therapy is concerned with the treatment of physical and psychi- atric conditions through specific selected activities, in order to help people reach their maximum level of function and independence in all aspects. This is also the rationale of day hospitals, and it would seem appropriate, there- fore, for occupational therapists to play a major part in their management and organization. Development of services specializing in psychiatry of old age Though not yet accepted in the United Kingdom as formal policy by the Department of Health and Social Security or by the Royal College of Psy- chiatrists, there has been a trend towards setting up services specializing in the psychiatry of those over 65. These have generally fostered closer links with departments of geriatric medicine and social services to produce more coherent treatment and acute hospital care for elderly people with organic brain disease. Encouragement of earlier referral, improved assess- ment in the community and a facility for acute hospital admission have all led to a shift from predominantly long-term inpatient care to short-term day care and inpatient crisis intervention and rehabilitation. This is helping to reduce the volume of disability carried by the community and also to identify the most severely disabled patients for whom long-term institu- tional care is appropriate. Such units have tended to take a more positive approach towards the functional psychiatric illnesses of old age with en- couraging success rates. In turn, this has promoted a more optimistic atti- tude to their diagnosis and treatment by the primary health care team. 25 Measures to reduce mental disability Medical measures. These comprise the diagnosis and treatment of remediable elements of mental disability: the use of hypnotics and tranquil- lizers to render behaviour compatible with management in the home (in- cluding depot neuroleptics for aggression, restlessness and paranoid symptoms in demented patients). Psychological measures. These comprise the following: (a) reality orientation, which is useful at home and in hospital and emphasizes that recent memory and the capacity to learn are not entirely lost in dementia; (b) reminiscence - making use of older memories in order to focus interest and interaction among groups of elderly people; (c) behaviour modification, which can be in the form of detailed pro- grammes or as a general approach to the management of disability; it is well established in the field of mental handicap and has now been shown to have applications for mental disability in the elderly; (d) psychotherapy, including group therapy, marriage guidance, and limited and supportive psychotherapy, which all require different approaches when used in relation to elderly people. Often the approach needs to be direc- tive and supportive, with emphasis on the themes of dependency and loss. Provisions for disabled elderly people living alone Accommodation. Elderly people with progressive mental disability re- quire increasingly frequent supervision, and they also adapt poorly to new environments. Apart from residential care the emphasis must therefore be on providing extra supervision in the person's own home. Changes of resi- dence should be avoided. Although sheltered housing for the elderly has long been an important development in the United Kingdom, because of the sparcity of warden coverage its relevance for people with dementia has fre- quently been questioned. However, in Southampton, a town on the south coast of England, a housing scheme has been operating for the last five years with 3 wardens for the tenants of 32 flats. Their duties include helping the tenants with medication, shopping and preparation of meals. They also give extra help during illness. Consequently, this unit has maintained some very frail people, including many with mental disabilities who would otherwise have needed residential care. In another town the development of a peripa- tetic warden service, available to any house on request through a standard electronic device, offers close coverage and thus avoids, for many old people, moves to a special sheltered-housing unit. 26 Provision of extra care in the home. Apart from the standard home help and meals-on-wheels services, some areas in the United Kingdom have developed more extensive networks of voluntary neighbourhood schemes to support elderly people living alone. In Kent, for example, the social services department has introduced a scheme whereby social workers may contract people in the neighbourhood to provide specific services and super- vision up to a certain costing level. These contracts have been shown to postpone, or even avoid altogether, the more expensive option of residen- tial care. Similarly, there have been a few instances of the ''hospital at home" approach to the short-term care of elderly people for whom hospital ad- mission would otherwise have been necessary. Support for caring relatives A great deal of the burden of mental disability in the elderly is carried by relatives, and often by spouses of similar age. It is in their interest, and that of the other services, that they should be adequately supported to continue that care. In the case of dementia, such relatives have a 24-hour job, seven days a week. Their ability to carry on can be greatly enhanced if this load is punctuated by periods of relief, such as: (a) day care, in the form of luncheon clubs, day centres and day hospitals; {b) "granny-sitting" services, ranging from a few hours ' respite during the day by volunteers, to professional night sitters or home helps relieving for longer periods such as a weekend; and (c) relief admissions to an old people's home or to a hospital, such as regular two-week breaks, increasing the frequency as the dementia ad- vances. Other methods of supporting caring relatives include: (a) surveillance and help from community psychogeriatric nurses working closely with the primary care service as well as with the hospital unit; they counsel, give practical advice to the family on behaviour man- agement, and alert the hospital staff to needs for extra relief, changes in medication, etc.; {b) support groups for relatives; and (c) short-term admissions (over and above the relief periods) at times of crisis. 27 FUTURE PLANNING The Conference went on to consider briefly some of the demographic trends likely to influence the type of services that will be required in the future, and also some pointers thought to be of special note from the country review that had been presented. Some demographic trends and facts A phenomenon that has appeared in many of the more developed countries of the Region is the presence of a third, or even fourth, generation: many 60-year-olds (the "young" old) have a living parent (the "old" old). This may add to the difficulties of social contact and to the responsibilities of the 40- and 20-year-old generations of such families. In fact, one family could need support (practical and/or psychological) in providing care for two generations and this, together with other changes in family structure, is likely to add considerably in the future to the demands made on both nursing and medicosocial personnel. The distinguishing general demographic characteristic of this older popu- lation group in the coming 25 years or so will be the new "very old". A characteristic of this older section of the population will be the predominance of women: two thirds of those over the age of 80 years will be women. It can also be assumed that, if present trends continue, the majority of these women will be either single or widowed, live in one-person accommodation, and suffer from a chronic illness or condition and, in many cases, from multiple pathology. As the very old, and particularly very old women, already use welfare services for the elderly more than other groups, this knowledge certainly has implications for both disciplines. In a number of the Member States represented at the Conference many national and local surveys have been undertaken, and from these it is known that about 90% of old people live at home, and one in three live alone. Just over half of those aged 65 - 74 years have some form of disability, and this number rises to over three quarters for those over 85 years of age. Of those over 75 years, approximately 17% are appreciably handicapped while less than half of the "older old" are able to get out without assistance. It would appear, therefore, that an adequate number of surveys has been undertaken to demonstrate that a considerable problem already exists. Despite the growth of such facts and figures, however, information is not always inter- preted and used; planners need to understand what the results of studies actually mean in terms of future needs. Certainly, a rigid categorization of needs by age group should be avoided. Just as individual old people vary in their personal and environmental circumstances, so the problems they face and the range of support they require will also vary considerably. Services, 28 both statutory and voluntary, have to cater for the vast differences between old people as individuals, the wide variations in the impact of growing old, and the rapidly changing social and economic features in the society in which we all live. The last of these can present enough difficulties for younger people, and it is little wonder that older people quickly feel bewildered, left behind , and sometimes inferior. In a few countries of the Region the range of services already available is considerable , but needs can change and few services are carefully monitored and amended when necessary. Ideally, they should be based on a careful assess- ment of what each particular person requires, bearing in mind what he/she can provide or obtain from family, friends or community. Considerably more than the inefficient use of resources is lost if a generalized approach is used or the maximum degree of flexibility is not built into the system. Some priorities for the future It was agreed unanimously by the participants that long-term care and psycho- geriatric units and wards should be given high priority in all health services of the Region . Generalizations, while providing some insight, are not an adequate basis for remedial action. More precise information is needed on the prevalence and depth of particular attitudes and behaviour of staff working in this field, and therefore the services being provided by them. These staff need help and encouragement themselves to support old people who have a variety of problems, including loneliness and apathy, incontinence , bereavement and, indeed , problems in managing their lives during these last years. It was suggested that the responsibility of nurses in relation to these patients could be summarized as being: - to provide an atmosphere that helps elderly people to maintain choice, independence and mobility to their optimum ; - to help implement treatment as prescribed and in accordance with the guidelines laid down by the professional bodies of the country ; - to provide a safe environment in which people can live and meet the needs of daily living while undergoing treatment. In addition, the nurse has a responsibility to members of other disciplines and should help them to use their knowledge and skills for the benefit of patients, and also of students . The latter should be encouraged to utilize their training and educational experience to the full. It was stated that constraints which impede and sometimes prevent nurses from attaining these goals include : - inadequate facilities or inefficient equipment; - poor layout of accommodation (sometimes even overcrowding); 29 - lack of management of auxiliary services ( domestic, catering and portering); - disciplines working in isolation and not practising the multidisciplinary teamwork to which they give lip-service; - unrealistic and sometimes dangerous ratios of trained staff to aux- iliaries or students; - general shortages of staff. "Long-term care" often means "final-stay services", and therefore homes , institutions, units and wards should be centres for life and living as well as for care and nursing. For those with severe disability who are unable to feed, wash and dress themselves, or in some way are permanently dependent, and for whom reha- bilitation offers no prospects, prolonged nursing care is inevitable. Wherever it is given, the aim should be to provide the highest possible standards of care. These will depend largely on the personal qualities, experience and training of the staff. Some Member States have undertaken studies in this field, assess- ing the quality of care by the way tasks are carried out. The four levels of evaluation used were: - dangerous - safe - appropriate - optimal From these workload studies it has been found that the majority of tasks are carried out at the lower levels of the scale, that is, between danger- ous and safe . Evaluation scales such as these can be used to assess care given in a particular setting (nursing home or hospital), for a specific condition (in- continence), or during a certain procedure (admission or discharge). In assess- ment for services, whether medicosocial or nursing, the strengths as well as the weaknesses of patients should be measured and their existing capacities developed. This implies that prescribed therapy must be relevant and appro- priate for each individual; attitudes such as those that result in prescriptions for "basket work for all residents" must undergo fundamental change. Those looking after old people should be aware of their ethnic, historical and cultural background and have an understanding of the social history of their time. Music, books, films, entertainment - whatever amenities are provided - should also be to their liking, and probably of their era. Blaring contemporary music in residential homes and hospitals is likely to be enjoyed only by the younger members of staff and not by those whose interests they are supposed to be protecting and promoting. 30 The need to adapt community services according to social change was also emphasized. Meals-on-wheels services, for example , now often needed to include appropriate diets for the different ethnic groups in the area. Although there is much talk about involving the community and using volunteers , little is done to help them to organize themselves and to give them the necessary information and advice. Health and social workers need to learn to work with them, and sometimes should initiate collab- orative action . Participants emphasized the outstanding need for long-term plan- ning of services for the future elderly. All service and manpower planning of health systems should include them. In the first instance, what is re- quired is political will , married to administrative action to reallocate exist- ing resources. If this is not realized and heeded, the burden will become in- tolerable to the community and result in misery for millions of old people, including, in time, ourselves. EDUCATION OF WORKERS IN BOTH DISCIPLINES IN HEALTH CARE OF THE ELDERLY The complementary roles of nursing and medicosocial work Time and time again the need for coordination between the health and social services was brought into the discussion, and participants defined the important differences between the two. Unfortunately, these are not always recognized. Partnership between the services and therefore between the professions, on which so much depends, should be viewed against a back- ground of understanding of their complementary responsibilities. In an attempt to describe these , the following definitions were agreed by participants :0 Nursing is a fundamental human activity and in its organized form a discrete health discipline . Its primary responsibility is to assist individuals and groups (families/co mmunities) to optimize function throughout the life span as well as to care during acute and protracted illness and dis- ab ility. It also makes social contributions maintaining, promoting and protecting health, caring for the sick and providing rehabilitation. It is concerned with the psychosomatic and psychosocial aspects of life as these affect health, illness and dying. a These two definitions are adapted from: Hall, D.C. A position paper on nursing. Unpublished document EU RO/NU RS 75.1 Rev. I , 1979 . 31 Social work focuses on person and environment interaction. To this end medicosocial workers: - help people to develop competence in, or increase, their own problem-solving and coping abilities; - help people to obtain appropriate resources when in need ; - help to improve the awareness and responsiveness of organiz- ations to people's needs; - help to facilitate interaction between organizations and institutes; - influence social and environmental policy. Participants saw these complementary responsibilities of the two dis- ciplines, when organized and channelled, as having an important impact on health care of the elderly. It was recognized that health cannot be attained by the health sector alone and medicosocial workers in particular could be- come a vital link between health workers and those sectors that are respon- sible for relevant aspects of social welfare, such as environment, housing, transport and education. The proper use of this group of workers, and an in- crease in their numbers where necessary, could have far-reaching consequences not only throughout all levels of the health sector but also for social and economic sectors at the community level of development. Education for professional workers It is obvious that no one educational programme will suit all countries of the Region: each must develop its own services, and therefore its own pro- grammes of education for its workers , according to the needs of its popu- lation. For many Member States, however, much of the education of their health workers will be based on certain principles. Standards of care, for example, are everywhere the tripartite responsibility of clinical practice, management and education. Without one, each of the others will be Jess effective. Oinical management and education allow good practice. First, the majority of countries need to assess what they are already providing. Is highly sophisticated technology the highest priority? Are some services destroying the very cultural fabric of traditional community care? Help within families and communities has been a natural happening for centuries: what are we doing to it by talking about it as though we are establishing something new? Secondly, what is the first priority cited by old people themselves? Some of the representatives of nongovernmental organizations present referred to the Age Concern Manifesto ,a which offers a definition of the a Manifesto on the place of the retired and the elderly-in modern society. Mitcham, Age Concern England (undated). 32 overall needs and aspirations of all elderly people . Parts of it were seen by participants as being relevant cross-nationally, and also as having im- portant implications for both educational and service programmes . One example given was as follows: The elderly need to have sufficient income to meet their needs for social, physical and emotional well-being; accommodation which en- sures their right to privacy and the retention of their own material possessions ; and the freedom to exercise those preferences and pre- judices which express their individuality and sense of the past. They need easy access to transport to enable them to supply many of their own wants and to pursue their personal inclinations. They need the security of knowing that, in the event of any emergency, they will not be put at risk through the failure of essential domestic supplies or the shortage of basic foodstuffs. Whether living in residential in- st itutions or their own homes, they need the kind of health care and domiciliary support which will help them to retain the maxi- mum degree of independent living in spite of increasing infirmities or disabilities. In terms of educational programmes this raised many questions, for few participants had been able to report that their countries ran special courses or programmes on health care of the elderly. Should appropriate theory and practice be included in all basic education? If so, what should be the focus? What clinical experience should be offered? How can we ensure that comprehensive assessments are made , without violating the individual's privacy? How can we develop in studen ts an appreciation of the importance of protection of the liberty of the individual, so that each old person is able to retain maximum control and choice over his own lifestyle and over his own dying? How can we practise the principles of rehabilitation to attain the original aim of maintaining optimum physical, social and mental functioning in each elderly individual? Last, how should teachers , managers and research workers be prepared? Suggestions for curriculum development All curricula for the basic education of nursing and social service students should provide some gerontological theory to prepare them for work with the elderly at primary, secondary and tertiary levels of care. The matrix of such curricula should focus on theories of human development, aging, self-care, health promotion and community health , and include the development of disease, disability and social dysfunction , specific treatments and rehabilitation . Opportunities should also be provided for students to engage in clinical and social experience with elderly persons 33 in all settings and to participate in interdisciplinary work, in order to gain knowledge and an appreciation of the roles of other health and social ser- vice workers and of disciplines in other sectors. The current practice of using ancillary heal th workers who must rely on their more skilled colleagues for guidance and training requires the development of communication skills, supervision, and teaching tech- niques at an early stage in the careers of all professional nursing and medicosocial workers. Postbasic education should include the development of courses for clinical specialists, teachers , managers and researchers in this field. These should encourage a humane and positive attitude towards old people and develop the satisfaction and fulfilment that can come from professional involvement with the elderly and their families. The special features of disease in old age, the dangers of overdiagnosis and overprescription, and the problems of therapy, especially those of drug therapy, should be given special consideration. Courses should be provided to enable the principles of rehabilitation to be practised and applied, in order to attain and maintain optimum physical, social and mental functioning for each elderly individual. Teacher models are important to students everywhere. Competent teachers with a suitably critical and questioning approach to their work could, by undertaking research , contribute to raising the regard in which health care of the elderly is held. Finally, the elderly are not rehabilitated, supported and nursed by beds and bricks. They need people with aptitude , sympathy and edu- cation, but often the people with these attributes (such as head nurses on long-term wards) are those who themselves have considerable personal needs . Frequently, they work with untrained staff and without adequate support. These staff members are the most important tools in health care of the elderly and should be treasured by their governments and other employers as such. Education of auxiliaries At present, much of the day-to-day care of elderly people in institutions is given by ancillary personnel, often well motivated but with very little train- ing. They also urgently require imaginative involvement and learning ex- periences if their motivation and interest are to be maintained. Programmes of training for present and future personnel should include inservice experience under the supervision of professionals. While proliferation of this level of worker should be avoided, those who already exist should be given oppor- tunities to develop themselves as persons and also their individual careers. In relation to the latter, the use of audiovisual material has been found to be especially appropriate and effective for teaching this category of nursing 34 personnel. More work is needed to develop such aids, and the development of a mechanism for the exchange of educational aids and information among countries of the Region would be invaluable. Regular testing for safety and competence was also recommended. Often machinery and equipment were serviced for safety far more frequently than the staff. Both groups, professional and auxiliary, should take man- datory refresher courses and further education should be made available to all categories at all levels of responsibility. Education of volunteers The low prestige attached to the care of tl1e elderly is sometimes reflected in a preference by volunteers for other work. Often this is due to lack of know- ledge and understanding, but it can also be due to fear: the fear of being with mentally confused, incontinent , aggressive and immobile people . Once again, training programmes are required that emphasize realistically the positive aspects of aging, and learning experiences with well old people should be made available. Volunteers should be members of the health or social ser- vice team, having the support, encouragement, supervision and backing of professional staff, as well as the confidence and welcome of patients and families. Education of other members of the public Fear of the unknown is real , and studies have revealed that many members of the general public are frightened by tlle physiological and psychological changes brought about by the processes of aging and dying. It would appear tllat national campaigns to improve the public's level of knowledge are urgently needed for all age groups. As one participant observed, aging may be more stressful to a 40-year-old tllan to someone in his eighties. Information on both aging and dying is rarely made readily available at low cost. While dying in relation to children and younger people has been frequently studied and documented, little work has been published on dying among old people. Voluntary organizations associated witll nursing and social welfare, such as the Red Cross, should be encouraged to publish such literature, lead discussions on the subjects of aging and dying, and organize relief services to enable relatives to attend demonstrations of the skills they need to acquire in order to look after tlleir elderly relatives compe- tently and knowledgeably. There is a current trend in some Member States for younger people to return to rural areas to look after their parents and grandparents. Often, as well as practical assistance, they need support to cope with guilt feel- ings. At the same time, information could be given to them so that they know about tlle statutory and voluntary services available to them locally. 35 Family help, community care and voluntary organizations all require support from the formal and statutory services. Professionals have a responsi- bility to pass on their knowledge and skills to those who need them. En- listing the help of experts in the mass media as partners in such endeavours could be of great mutual benefit and is long overdue. Education for teamwork and work with the community Manpower development in the planning of services often receives little at- tention. In many Member States no manpower policies and plans exist. Where they do , they often contain no relevant programmes of education for teamwork. If personnel are to be prepared to perform tasks directly related to identified service requirements, cooperation will be needed at all levels between decision-makers in health and education, as well as in other sectors that are concerned directly or indirectly with health development. At present, frequently little or no cooperation exists among professionals, between levels of the health service, and between other sectors (such as housing and trans- port) and the health system. Sometimes, participants reported, there was even a lack of cooperation between members of the same discipline, such as nurses at the primary and tertiary levels. Throughout the Conference, poor communication and lack of know- ledge regarding each other's objectives were identified as irnportan t impedi- ments to effective teamwork. This inevitably resulted in a lack of collabor- ation and coordination of effort. No sector, and likewise no profession or discipline, can function properly in isolation. Activities of one impinge upon the goals of another - hence the need for constant consultation to ensure the development and implementation of planned programmes of care. Coordinated planning at the community level should make it possible to link primary health care closely with other sectors in joint efforts for educational and service programme development. Health personnel form part of the community in which they live and work, and a continuing dialogue between them and the rest of the community is necessary for harmony of views and activities. There are many ways in which the community can participate in care of the elderly, but it must first be in- volved in assessing the situation, defining problems and setting priorities. A clear, rational policy is needed that will promote community cohesion and foster the coordination at local level of all relevant sectoral programmes, that will build up the capacity of communities, and that will ensure control of funds invested in services and the personnel providing them. Community par- ticipation also requires mutual support between government and community, reinforced by mutual feedback. It is the responsibility of government to stimulate this kind of support, to set up the necessary coordinating mech- anisms to pass or amend legislation and, whenever applicable, to provide sufficient human, material and financial resources. 36 To plan and manage appropriate services, the right kind of infor- mation is essential, but the collection of information should always be kept to a minimum. Any information gathering and analysis should be an integral part of teamwork and should not be carried out separately. Com- petence in observation and data collection is a required skill of members of all disciplines. SERVICES RESEARCH Whilst a considerable amount is already known about the nursing and medico- social needs of elderly people and could be put into practice immediately, much still needs to be learned. Are studies being undertaken in the most useful way? What do we need to know to improve current practice? Nurses at the Conference particularly identified long-term and psychogeriatric care as two areas in which improved nursing practice is long overdue; nursing should be based on sound research findings, yet both these areas are neglected fields of nursing research. The full potential of nursing's contribution to health care of the elderly depends on a scientific basis for clinical practice; not only is new knowledge required but mechanisms for ensuring its use in practice need to be identified and developed. Resources are finite and their use must be carefully considered and planned. Attention should therefore be given to the relative cost of various strategies to meet the present and changing needs of an aging world population. Accountability to the public for the humane use of knowledge in pro- viding effective and high-quality services is the hallmark of professions. Other guiding considerations are the anticipated problems, an appreciation of where nursing and medicosocial work can make its most beneficial contribution, and projections regarding decisions that nurses and medicosocial workers will have to make in the corning decades. Nursing research develops knowledge about health and the promotion of health over the full lifespan, about the care of persons with health problems and disabilities , and about ways of improving the quality of life. All have special significance in relation to elderly people. Conference participants suggested that examples of research consistent with practice priorities include the following. 1. Identification of determinants (personal and environmental, in- cluding medicosocial support networks) of health (prevention of disease , disability and premature aging), e.g. avoidance of behaviour such as chemical dependency, successful adaptation to a chronic disability or disease and the conduct of an individual's own dying. 37 2. Development and testing of care strategies to : facilitate an individual's ability to adopt and maintain health- enhancing behaviour; enhance a patient's ability to manage a chronic illness, condition, disability or handicap to minimize dependency and to maximize wellbeing; provide effective care to high-risk groups, including very old and chronically sick people; and design and assess, in terms of effectiveness and cost, models and strategies for delivering nursing care found to be effective in clin- ical studies. The economics and politics of the present or any future health and social service care system cannot be divorced from quality, types of services and control. To ensure care of high quality, there must be practitioners concerned with measuring and maintaining care at a predetermined level. In all coun- tries nurses and medicosocial workers with appropriate advanced education are needed to undertake such studies. CONCLUSIONS Participants emphasized that elderly people do not constitute a homogeneous group; they are active members of the general population and have responsi- bilities as such. The extent to which they are able to meet these should be taken into consideration when health and social services are planned, and elderly people and their families should be represented in this planning. One of the principal needs of elderly people in many societies, and one that the Declaration of Alma-Ata addresses, is that of equity. Conference participants agreed that elderly people are often the poorest and most dis- advantaged members of contemporary society, and that this was unacceptable socially, economically and politically. It was recognized that in the field of health care of the elderly much needs to be done and also undone. Many nurses and medicosocial workers lack an appreciation of how their own education, deep-seated values and beliefs affect their attitudes towards the care of elderly people. Some have never had opportunities to experience the reward that comes from helping people to understand and adopt healthy lifestyles and attain, or regain and maintain, the independence possible within their physical, mental and educational capabilities. 38 The concept of nursing as a hospital-based profession still prevails in most Member States. This, together with the sharp dividing line that often exists between hospital and community, has had a detrimental effect on the development of comprehensive care for elderly people. Nurses and medico- social workers have not always assumed their complementary responsibilities in helping individuals, families and communities to optimize physical, social and psychological functions. Developing nursing and medicosocial services for the elderly l . To achieve health for all by the year 2000, reorientation of health programmes is required in many countries, with activities arranged in three main programme areas: (a) promotion of lifestyles conducive to health; (b) reduction of preventable conditions; and (c) provision of care that is adequate, accessible and acceptable to all. Translated into a health care of the elderly programme for nurses and medicosocial workers (among others), these activities include: - at the primary level, hazard control and health promotion; - at the secondary level, early detection and assistance with treat- ment to stabilize, control or repair, or to prevent an impairment from becoming a handicap; and - at the tertiary level, rehabilitation (including continuing care) and terminal care. High-risk groups are not only those with physical impairment; socioecon- omic deprivation also results in high risk. One major contribution by the providers of nursing and medicosocial services could be to the country's pri- mary health care programme. This is likely to require a shift in emphasis from an individual approach based on the medical model to one related to social structure, health policies and wider socioeconomic issues of present- day society. 2. While a range of health and social services is often indicated to meet the needs of elderly people, resources for formal services are finite. Self- care and voluntary services should never be used as a substitute for pro- fessional care, but effective and imaginative planning to include cooperation with volunteers and other lay people could help to provide supplementary help to old people. Both nurses and medicosocial workers should participate in, and in some instances even initiate, such collaboration so as to achieve concerted action. Both disciplines also have special responsibilities to pro- vide teaching and supervision for such auxiliary and lay personnel who participate in nursing and medicosocial services. 39 3. The longer-term care of elderly people, especially those in geriatric and psychogeriatric wards, should be given priority, and services provided should reflect their needs. In many Member States, long-term care of elderly people is a neglected area, emphasis usually being placed upon acute hospital care. Nurses everywhere need to be convinced that helping people to main- tain optimum health and function is one of the most important services they can provide. Working as independent practitioners able to admit into and discharge from the health care system, nurses are able to take full responsi- bility for providing long-term care in all settings, with members of other disciplines contributing to the care plan as and when required to do so. This is one reason for the urgent need to form a cadre of nurses who are able to function effectively in providing a continuity of health care for elderly people from hospital to community and vice versa. 4. Nurses and medicosocial workers should also take responsibility for contributing to total care services during terminal illness. This is likely to include care of the dying person's family and friends in the form of practical help and psychological support. In turn help, support and counselling should be made available to team members of all disciplines who provide long- term and terminal care. 5. Times of crisis and loss are frequent and highly significant periods in the lives of elderly people. Surveillance, while respecting every individual's right to privacy, should be such that when these events occur the individual is swiftly supported and helped by appropriate members of the primary health care team. 6. At present, inadequate and unconcerned care is often given to the elderly, infirm and disabled since "accepted standards of care" have as yet not been adequately defined. Professional workers in all settings should expect to have to account for their individual actions, and both nurses and medicosocial workers should be prepared to measure and evaluate qualita- tive as well as quantitative standards in the health care of the elderly. 7. Education of the general public is very important. More attention should be paid to this, especially in relation to people of influence, in- cluding political decision-makers. Nursing personnel should assist in educating people about the physiological, social and psychological processes of aging, so that the inevitable changes wrought by them come to be accepted as a normal part of the life cycle. Lay people caring for the elderly in their homes are likely to have special needs for knowledge and help with the development of basic nursing and rehabilitative skills. Nongovernmental organizations should be encouraged to help provide suitable educational programmes for the public. To ensure that elderly people and their families 40 know where and to whom to go for immediate assistance and information when in need, adequate publicity should be given to all available services and forms of aid. Developing nursing and medicosocial manpower for the health care of the elderly 8 . All members of a team should be able to exercise their particular skills and to perform their specific functions within that team. The individual contribution of each team member, which is provided by virtue of his or her special professional expertise, should not (except in exceptional circum- stances when the needed competence is not available) be taken over or supple- mented by team members with different professional backgrounds. Health and medicosocial personnel, both professional and auxiliary, should acquire understanding, knowledge and practical skills, initially through theory and clinical application and subsequently in continuing, supplementary or ad- vanced education, including further practical experience. 9. Basic education for students of both nursing and medicosocial work should include some gerontological theory to prepare them for work with elderly people at the primary, secondary and tertiary levels of care. Curricula for botl1 disciplines should focus on theories of human growth and develop- ment, including the aging process. All health workers should be able to recognize and appreciate the different etlmic, sociocultural and historical backgrounds of those for whom they care. In relation to the elderly iliis is of great importance and all team members should be aware of the social history of the period covering the lifespan of the individuals for whom they are caring. 10. Within the behavioural and social sciences those aspects required for a better understanding of the elderly could be identified and developed for inclusion as core content in multidisciplinary educational programmes. 11. Clinical learning experiences should include participation in inter- disciplinary work so that all students gain knowledge and an appreciation of the roles of all health and medicosocial service workers and of disciplines in other related sectors. This is considered an essential component of edu- cation for teamwork. 12. Postbasic and postgraduate nursing education in the field of health care of the elderly should provide career flexibility, and aim to provide a cadre of nursing specialists able to practise , teach, supervise, manage and conduct research in geriatric nursing, and to act as consultants to their colleagues at all levels of the health care system. 41 13. To obtain the best results from non-institutional services, attention needs to be focused on reviewing current legislation and obtaining relevant amendments. Development of research and studies 14. If nurses and medicosocial workers are to respond effectively to new needs of society, such as comprehensive care of the elderly and the very old, they must continue to add to their professional knowledge by undertaking further qualitative, quantitative and longitudinal research, studies and analyses. 15. Research is urgently needed in all areas - management and education as well as service and practice. It is important that research should first benefit the weaker and more vulnerable groups, and therefore problems in basic nursing should be studied, such as the feeding, cleaning and care of incontinent, confused and dying patients. "Old age" should not be studied in isolation, however. It is important that the conceptual framework of "life- span or development" be used and that ways to strengthen the capacities and abilities of all age groups be sought. 16. The study of relationships, emotions, attitudes, beliefs and prejudices is also likely to yield useful findings that would help to improve the quality of life for elderly people everywhere. Also, delegates urged that research into geriatric nursing problems should be studied at three levels : that of society- organiza tion, that of the individual, and also - to gain knowledge at the international level - transcultural nursing. The last mentioned would also help in the distribution and exchange of knowledge and experience among countries of the Region. I 7. Nurses and medicosocial workers should be able to analyse their own work and identify the general principles inherent in any specific nursing and medicosocial function. They should be able to use research findings to im- prove practices and to formulate policy. Nurses with appropriate experience should carry out studies so that geriatric nursing practice is based on sound research findings. Those who have the inclination and the potential to do so will need educational preparation to carry out independent research work and to make contributions to multidisciplinary studies relating to the care of the elderly. The multinational nursing research project being undertaken in 19 Member States as part of the medium-term programme in nursing/mid- wifery in Europe will help to provide answers to some of the issues referred to during the Conference. It will add to the body of knowledge and skills in nursing practice through dissemination and application of the nursing process. It has also offered excellent opportunities to nurses to gain practical research experience in the field. 42 International liaison 18. Time did not allow for full discussion of all aspects of nursing and medicosocial work in health care of the elderly, and participants felt that further work in this field was needed at the international level, together with other international bodies concerned. REFERENCES I. Preventing disability in the elderly : report on a WHO Working Group. Copenhagen, WHO Regional Office for Europe, 1982 (EURO Reports and Studies , No. 65). 2. Heikkinen, E. et al. , ed. The elderly in eleven countries: a sociomedical survey. Copenhagen, WHO Regional Office for Europe, 1983 (Public Health in Europe, No. 21). 3. Fillenbaum, G.G. et al. Assessment of individual functional status in a program evaluation and resource allocation model. in: Multi- dimensional functional assessment: the OARS methodology, 2nd ed. Durham, NC , Center for the Study of Aging and Human Develop- ment, Duke University, 1978, p. 3. 4. Maddox , G.L. & Dellinger, D.C. Assessment of functional status in a program evaluation and resource allocation model. Annals of the American Academy of Political and Social Science, 438 : 59 (l 978). 5. Fillenbaum, G .G. Validity and reliability of the multidimensional functional assessment questionnaire. In : Multidimensional functional assessment: the OARS methodology, 2nd ed . Durham, NC, Center for the Study of Aging and Human Development , Duke University, 1978 , p.25. 6. Fillenbaum, G.G . & Smyer, M.A. The development , validity and reli- ability of the OARS multidimensional functional assessment question- naire. Journal of gerontology, 36 : 428 (1981). 7. Henderson, V. Basic principles of nursing care. Geneva , International Council of Nurses , 1961. 8. Norberg, A. et al . Ethical problems in feeding patients with advanced dementia. British medical journal, 281: 84 7-849 {1980). 9 . Norberg, A. et al. Ethical conflicts in long-tenn care of the aged : nutri- tional problems and the patient-care worker relationship . British medical journal, 280: 337-381 (I 980). 10 . Norberg, B. et al. The effect of short-term high-dose treatment with meth- enamine hippurate of urinary infection in geriatric patients with indwell- ing catheters. I. The preparation and morphology of a quantified urine sediment. Uppsala journal of medical science, 84: 67-74 (1979) . 43 11. Norberg, A. et al. The effect of short-term high-dose treatment with methenamine hippurate of urinary infection in geriatric patients with indwelling catheters. II. Evaluation by means of a quantified urine sediment. Uppsalajoumal of medical science, 84 : 75-82 (1979). 12. Norberg, B. et al. Effect of short-term high-dose treatment with meth- enamine hippurate on urinary infection in geriatric patients with an indwelling catheter. IV. Oinical evaluation. European journal of clinical pharmacology, IS : 357-361 (1979). 13. Norberg, A. et al. Randomized double-blind study of prophylactic methenamine hippurate treatment of patients with indwelling catheters. European journal of clinical pharmacology, 18: 497-500 (1980). 14. Norberg, A. et al. Uber die Wirkung kurzdauemder Behandlung mit hohen Dosen Metenaminhippurat bei Harnwegsinfektionen alterer Patienten mit offenem Verweilkatheter. Planung, Methodenentwicklung und statistische Analyse. Aktuel/e Cerontologie, 10: 184-185 (1980). IS. Israel, L. et al. Techniques particulieres adaptees aux personnes agees : leur validation par analyse factorielle en geriatrie. /n: Recherche experi- mentale et investigation clinique de la senescence cerebrale. Basie, Sandoz, 1978. 16. Israel, L. et al. Echelle d'appreciation clinique et tests psychometriques en geriatrie. Recherche de correlations. Therapie, No. 34, pp. 585- 590 (1979). 17. Israel, L. et al. Les troubles de la memoire chez !es personnes agees : sondage effectue aupres d'une population de 782 retraites de la ville de Grenoble. Revue medicale, 4(9): 455 (1979). 18 . Israel, L. et al. Problemes poses par !es essais medicamenteux effectues avec le concours de medecins praticiens. Concours medical, 101: 2075- 2078 (1979). I 9. Israel, L. et al. Batterie d'epreuves psychometriques pour personnes agees ambulatoires. Psychologie medicale, 12(3) (1980). 20. Israel, L. et al. Batterie d 'epreuves psychometriques a !'usage du medecin generaliste pour apprecier !es conduites intellectuelles des personnes agees. Psychologie medicale, 12(4)(1980). 21. Israel, L. & Ohlmann, T. Structure factorielle de la memoire appreciee a travers une batterie d 'epreuves psychologiques chez des personnes agees ambulatoires : son application aux essais cliniques controles. Encephale, 6: 181-195 (1980). 22. A prospectus for a national home care policy. Assembly of Ambulatory and Home Care Services of the American Hospital Association, 1978. 44 Annex 1 GLOSSARY The following concepts from the International classification of impairments, disabilities, and handicaps were used throughout the Conference. Impairment. In the context of health experience, an impairment is any loss or abnormality of psychological, physiological, or an- atomical structure or function. Two aspects of this definition need to be stressed. First, the term "impair- ment" is more inclusive than "disorder" in that it also covers losses; e.g., the loss of a leg is an impairment, but not a disorder. Secondly, in reaching agree- ment on terminology with other international agencies , it has been necessary to make certain modifications to the definitions included in a preliminary draft of this manual. In the draft, functional limitations were regarded as being elements of disability, whereas they have now been assimilated with impairments; this alteration helps to resolve boundary distinctions that originally lacked clarity. Impairment represents deviation from some norm in the individual's bio- medical status, and definition of its constituents is undertaken primarily by those qualified to judge physical and mental functioning according to generally accepted standards. Impairment is characterized by losses or abnormalities that may be temporary or permanent, and it includes the existence or occur- rence of an anomaly, defect, or loss in a limb, organ, tissue, or other structure of the body, or a defect in a functional system or mechanism of the body, including the systems of mental function. Being concerned to describe identity at a particular point in time, impairment is neutral in regard to a number of associated features , and this needs to be stressed. Thus impair- ment is not contingent upon etiology, how the state arose or developed; both ascribed and achieved status, such as genetic abnormality or the con- sequences of a road traffic accident, are included. Use of the term "impair- ment" does not necessarily indicate that disease is present or that the in- dividual should be regarded as sick. Equally, the deviation from the norm does not need to be perceived by the impaired individual. On the same grounds , a concept of latent impairment constitutes a contradiction in terms - the individual exposed to or harbouring an extraneous etiological agent of disease is not impaired; impairment ensues only when the agent has initiated a reaction by the body so that pathological processes develop. 45 Disability. In the context of health experience, a disability is any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being. In providing the link between impairment and handicap, it is fairly easy for the concept of disability to appear somewhat vague, variable, or ar- bitrary. As already noted, however, functional limitation is now regarded as an aspect of impairment, and this should resolve most of the diffi- culties. Impairment is concerned with individual functions of the parts of the body; as such it tends to be a somewhat idealistic notion, reflect- ing potential in absolute terms. Disability, on the other hand, is con- cerned with compound or integrated activities expected of the person or of the body as a whole, such as are represented by tasks, skills, and behaviours. Disability represents a departure from the norm in terms of perform- ance of the individual, as opposed to that of the organ or mechanism. The concept is characterized by excesses or deficiencies of customarily ex- pected behaviour or activity, and these may be temporary or permanent, reversible or irreversible, and progressive or regressive. The key feature relates to objectification. This is the process through which a functional limitation expresses itself as a reality in everyday life, the problem being made objective because the activities of the body are interfered with. In other words, disability takes form as the individual becomes aware of a change in his identity. Customary expectations embrace integrated func- tioning in physical, psychological , and social terms, and it is unrealistic to expect a neat separation between medical and social aspects of activ- ity. For instance, physical incapacities and socially deviant behaviours equally transgress what is expected of the individual - the important differences between them concern the value that is attached to such de- viations, and any sanctions that may be applied as a result; such valuations relate to the concept of handicap, rather than to that of disability. In attempting to apply the concept of disability, there is a need for caution in how the ideas are expressed. By concentrating on activities, disability is concerned with what happens - the practical - in a relatively neutral way, rather than with the absolute or ideal and any judgements that may attach thereto. To say that someone has a disability is to preserve neutrality, nuances of interpretation in regard to his potential still being possible. However, statements phrased in terms of being rather than having tend to be more categorical and disadvantageous. Thus to say that some- one is disabled, as if this were an adequate description of that individual, is to risk being dismissive and invoking stigma. 46 Handicap. In the context of health experience, a handicap is a disadvantage for a given individual, resulting from an impairment or a dis- ability, that limits or prevents the fulfilment of a role that is normal (depending on age, sex, and social and cultural factors) for that individual. Three important features of this concept should be borne in mind: (a) some value is attached to departure from a structural, functional, or performance norm, either by the individual himself or by his peers in a group to which he relates; (b) the valuation is dependent on cultural norms, so that a person may be handicapped in one group and not in another - time, place, status, and role are all contributory; (c) in the first instance, the valuation is usually to the disadvantage of the affected individual. The state of being handicapped is relative to other people - hence the in1portance of existing societal values, which , in turn , are influenced by the institutional arrangements of society. Thus, the attitudes and responses of the non-handicapped play a central role in modelling the ego concept, and defining the possibilities, of an individual who is potentially handi- capped - the latter has a very limited freedom to determine or modify his own reality. In this context it is relevant to take note of differences in societal responses to visible as opposed to invisible impairments, and to serious as opposed to trivial disadvantages. Handicap is characterized by a discordance between the individual's performance or status and the expectations of the particular group of which he is a member. Disadvantage accrues as a result of his being unable to con- form to the norms of his universe. Handicap is thus a social phenomenon, representing the social and environmental consequences for the individual stemming from the presence of impairments and disabilities. The essence of an adverse valuation by society is discrimination by other people, but the concept is , nevertheless, essentially neutral as regards its origins. Thus the individual's own intention is of no immediate concern; disadvantage can arise when the individual deviates in spite of his own wishes, but it can also develop when the deviation is inadvertent or the product of his own choice. The concept also assimilates phenomena such as invalidism or excessive dependence upon an institution. 47 Annex 2 LIST OF PARTICIPANTS Austria Mrs O.H. Fach , Vienna Ms H. Rachinger , Bad Isch! Belgium Dr M. Draps, Chief Medical Officer , Ministry of Public Heal th and Family Affairs , Brussels Bulgaria Dr N.A . Matei , Director , Department of Social Affairs , Ministry of Public Health , Sofia Czechoslovakia Dr M. Kvasova , Chief Nursing Officer , Ministry of Heal th of the Czech Socialist Republic , Prague Denmark Mrs I. Hakansson, Post basic School of Nursing , Aarhus Mrs H. Teilmann , Director of Education, Postbasic School of Nursing, Copenhagen Finland 48 Miss S. Luisennierni, Chief Social Worker , Meil ah ti Hospital , Helsinki Miss R. Uusitalo, Chief Director of Nursing , Koskela Geriatric Hospital , Helsinki France Mr G. Brun, Chief Nursing Officer, Paul Brousse Hospital , Villejuif Mrs C. Patron, Cabinet of the Secretary of State, Ministry of Health , Paris Hungary Miss M. Nosza, Chief Nurse , Municipal Hospital Balassa, Budapest Luxembourg Mr G. Bosseler , Ministry of Health , Luxembourg Miss C. Greisch , Gerontological Service, Ministry of Family Affairs, Luxembourg Netherlands Mr F. Booj, Nationale Ziekenhuisraad, Utrecht Poland Mrs K. Gumowska, Ministry of Health and Social Welfare , Warsaw Mrs K. Koronka , Chief, Nursing Division , Ministry of Health and Social Welfare, Warsaw Portugal Mrs M.I. Monteiro de Barros , Directorate-General of Hospitals , Lisbon Sweden Miss A.IM. Hollo , National Board of Health and Welfare , Stockholm Switzerland Miss M.L. Jeanneret , Chief Nursing Officer , Medicosocial Office of the Canton of Vaud , Lausanne 49 Union of Soviet Socialist Republics Dr O.S. Bojtsova, Assistant Professor, Chair of Social Hygiene and Public Health Organization, Central Institute for Advanced Medi- cal Studies , Moscow United Kingdom Mr R. Halliwell, Department of Health and Social Security, London Mrs R. Manley, Royal College of Nursing, Royston Miss A. Seelig, Department of Health and Social Security, London Yugoslavia Mrs V. Silvo, Acting Director, Home Care Service, Health Centre, Maribor Mrs M. Slajmer-Japelj, Dean , Higher School for Health Workers, Ljubljana Temporary advisers 50 Miss I. Hamelin, Planning Officer, Helsinki City Heal th Department, Finland (Chairman) Miss L.K. Hollaender, Head Nurse, Home Nursing Care Department, Copenhagen, Denmark Mrs C. Imfeld, Information and Coordination Centre for the El- derly, Department of Social Insurance and Public Health , Gen- eva, Switzerland Mr H. Kurtenbach, Federal Ministry for Youth, Family Affairs and Health , Bonn , Federal Republic of Germany Mrs K. Lister , The City and East London Area Health Authority (Teaching), Tower Hamlets Health District, London, United Kingdom Mrs H. Manteuffel, Director of Nursing, Stadt. Altenheim St. Josef, Munich , Federal Republic of Germany Professor A. Norberg, Department of Advanced Nursing, University of Ume~, Sweden Dr M. Peltramova, Head, Department of Medical Education and Further Education, Ministry of Health of the Czech Socialist Republic , Prague , Czechoslovakia Mrs B. Pomykala ,0 Institute for Nursing Care of the Elderly and Dis- abled, Frankfurt-Hochst, Federal Republic of Germany Dr W. Rueckert,0 Head, Social Economic Department, German Founda- tion for the Care of the Aged, Cologne, Federal Republic of Germany Dr A. Salgado , Head Consultant, Geriatric Department, Red Cross Central Hospital, Madrid , Spain Miss R. Stephan , Division of Psychogeriatrics, Free University of Berlin, Berlin (West) Mrs M. Str¢m, School of Social Work , Trondheim, Norway Mrs G.C.A. van der Veen, Director, "De Rustenburg" Nursing Home, Bergschenhoek, Netherlands Mrs I. Witte ,0 Editor, Deutsche Krankenpflegezeitschrift, Stuttgart, Federal Republic of Germany Representatives of other organizations Belgian Catholic Nurses' Association Miss A. de Baets , President , Brussels , Belgium European Centre for Social Welfare Training and Research Dr J. Hartmann , Head of Research, Vienna, Austria a Participation expenses not paid by WHO. 51 European Nursing Group Miss F. Dittrich, Chief Nursing Officer, Department of Health of the Government of Styria, Graz, Austria International Association of Gerontology Professor M. Bergener, Director, Rheinische Landesklinik, Cologne, Federal Republic of Germany International Committee of Catholic Nurses Ms L. Fiori, General Secretary, Rome, Italy International Council of Nurses Miss R. Reimann, Bildungszentrum Essen, Fortbildungsinstitut fur Pflegeberufe des Deutschen Krankenschwesternverbandes, Essen, Federal Republic of Germany League of Red Cross Societies Miss M. Esnard, Chief Social Welfare Adviser, Geneva, Switzerland Northern Nurses' Federation Mrs K. Johansen , Ullevfil Nursing School , Oslo, Norway Norwegian Nurses' Association Miss M. Karoliussen, Lecturer, Graduate Studies of Nursing Education, University of Troms¢ , Norway WHO Regional Office for Europe 52 Mrs A. Chokrieh, Short-term Consultant (Secretary) Dr W. Fritsche , Chief, Coordination with other Organizations Mr J.M. van Gindertael, Public Information Officer Miss M. Skeet, Short-term Consultant (Rapporteur) PART 2 WORKING GROUP ON MEDICOSOCIAL SERVICES IN HOSPITALS Helsinki 1 -4 September 1981 INTRODUCTION The Working Group on Medicosocial Services in Hospitals,0 convened by the Regional Office in collaboration with the Government of Finland, was at- tended by 19 temporary advisers from 16 countries and a representative of the International Council of Nurses. A list of participants is given as Annex I. This was the first meeting on the subject to be convened by the Regional Office as part of the medium-term programme in nursing/midwifery in Europe and its purpose was: (a) to study existing hospital-based medicosocial services provided for patients and their families; (b) to discuss the means of communication between medicosocial workers in hospitals and members of other disciplines in the health service; (c) to identify future trends in the field of medicosocial services; (d) to identify the education needs ofmedicosocial workers; (e) to make suggestions regarding the development of medicosocial services and the education of medicosocial workers; and (f) to relate the present situation to health service needs and resources and make suggestions for solving the main problems. The participants were welcomed by Dr S. Takki, Deputy Director of the Ministry of Social Affairs and Health, Finland and, on behalf of the Regional Director, by Miss Elisabeth Stussi, Acting Regional Officer for Nursing. a In the WHO Regional Office for Europe, medicosocial work is the responsibility of the nursing unit. 53 GENERAL DISCUSSION As defined in the preamble to the WHO Constitution, health embraces physical, mental and also social wellbeing. Man's needs must be recognized as a complex of physical, psychological and social components, and ser- vices designed to meet those needs must form a coherent system rather than a series of largely unrelated activities. It was realized at the first session of the Working Group, therefore, that its scope, as suggested by its title, was unrealistic and constrictive. At the outset it was decided that, although emphasis would be placed on medicosocial work in hospitals, discussion would not be confined to this but would cover as far as possible the medico- social needs of people in all settings. An attempt was also made to iden- tify some of the general issues relating to the development of medicosocial work as a discipline. Welfare and social services It was agreed that services are essentially the same whether provided by "welfare" or "social service" departments, but that the term "social services" is usually used in a broader sense to include not only health and welfare services but also all other provisions by society for the betterment of people's wellbeing. These provisions can be grouped under three headings : social wel- fare, fiscal welfare and occupational welfare (1) . As used by a United Nations committee of experts and adopted by a committee of the International Social Security Association , social ser- vices are defined as "an organized activity that aims to help towards a mutual adjustment of individuals and their social environment" (2) . This gives a concept of social services that includes health care and a concept of health services that includes social welfare. Social workers see health as one - but only one - component of many social problems, while health workers are aware of the need for their services to be supplemented, on occasion , by social services. In fact, of course, the work of both the social worker and the health worker covers only part of the larger objective of promoting human wellbeing, other parts including education, employment, recreational services and many others. The picture that emerges, therefore, is of the social and health services forming interacting components of a far larger system. Nursing and social work have complementary responsibilities in helping individuals, families and communities to optimize physical, social and psychological functions in society. Social work focuses on the interaction of the person and the environ- ment. To this end social workers : 54 - help people enlarge their competence and increase their problem- solving and coping abilities; - help people obtain appropriate and needed resources; - encourage the response of organizations to people's needs; - facilitate the interaction of individuals with others in their environment; - influence interactions between organizations and institutions; - influence social and environmental policy. Taking this as the "core" of all social work, medicosocial workers could provide an important link between the health sector and all other sectors involved in primary care and services to improve the living and working con- ditions of individuals , families and communities. Social goal of health for all by the year 2000 While it recognized that the individual approach to needs, based on the medical model, was essential in many instances , the Group agreed that all health and medicosocial workers have an additional responsibility to effect far wider changes when necessary, both in social structure and in elements of the environment. In this context they endorsed the WHO definition of health and the concepts inherent in the Declaration of Alma-Ata (3). They gave unanimous support to the suggestion that in all countries the work and education of providers of medicosocial services should be reorientated to help achieve the social goal of health for all by the year 2000. The development of teamwork in the health care system has fundamental implications for all related professions and disciplines. To date, each has con- centrated on identifying its individual role . This preoccupation has been of little interest or benefit to patients and clients: it is their needs and those of the communities they form that have to be identified. There is a notable absence in many Member States of a definition of deprived groups and those categories of people who are unable to provide for their own needs. MEDICOSOCIAL SERVICES IN THE EU ROPEAN REGION The medicosocial services provided in Member States differ widely through- out the Region. Medicosocial work has a variety of meanings, and it is a matter of some urgency that a clear definition be formed and agreed on. People and institutions involved in social welfare programmes have all too often worked in isolation both from other sectors of public con- cern and from each other. This situation can be remedied only if medico- social workers are able to contribute and participate as full partners in decision- and policy-making. 55 Medicosocial workers are responsible for studying, analysing and solving, within existing means, the social problems caused by or causing the patient's disease or condition. Together, health workers and social workers constitute a body of professional people that contributes, through its activities, to the wellbeing of patients or clients. The Group recommended the standardization of terminology in order to avoid confusion between the two professions; the International Federation of Social Workers has clearly defined the role of the social worker and this should be accepted by all other international bodies. The role of the medicosocial worker should also be clearly defined and accepted at local, national and international levels. In the development of a definition three points should be borne in mind. I. The goal of medicosocial workers is to help individuals with social problems so that they become aware of and use their own potential. 2. The "core" function of the medicosocial worker in all settings must be clearly set out. 3. Additional special skills and knowledge relevant to a particular setting (hospitals being only one of many) should also be set out. Organization of medicosocial services In some countries the social needs of a patient or client are the responsi- bility of nurses, especially of public health nurses working in the com- munity. In others, medicosocial workers are a professional group of highly qualified people specially trained to undertake medicosocial work in hos- pitals. The category and level of workers required obviously depends on the needs of the people but it must be recognized that, while self- assessed need and effective demand are virtually unlimited, resources are finite. "Needs" also change because what is considered "normal" changes. For example, our classical notion that deafness and toothlessness are "normal" features of old age has been challenged; we now consider them as handicaps calling for treatment or aids. This increasing tendency for self-assessed needs and effective demand (as inevitable consequences of "self- care" teaching) applies not only to the provision of medical care, but also affects patterns of sick-leave from work. Although by accepted standards the population of Europe is becoming healthier, rates of sick-leave have risen in most Member States over the past two decades. It could be that the threshold of "disease" thought to justify absence from work is lower, but often it is because it is nowadays economically easier for people to re- main away from work (4). This characteristic of our time must be reflected in the educational programmes for all health and social workers. 56 The first priority is to obtain a clear view of the medicosocial needs in each country. Only when a national profile has been obtained can the ways and means of meeting medicosocial needs be planned. A pragmatic approach is needed, as called for in the global and regional strategies for attaining health for all by the year 2000 (5,6). Although there has been considerable improvement in the health of people in the countries of Europe, often much more could have been done within the resources available. Services are poorly distributed, with the result that some population groups are grossly underserved and often have no effective access to services. Even in the wealthier countries of the Region improvement is often uneven and not always commensurate with the vast increases in manpower and financial input. Preventing illness and providing help for those with a chronic or disabling condition are frequently given low priority. Many illnesses are self-inflicted, and the provision of remedial services is an imbalanced and sometimes inappropriate response to health-destroying lifestyles. There is a failure to recognize the extent to which health policy depends on the policies of other sectors and ministries, particularly those with respon- sibilities for the economy, agriculture, transport, the environment and edu- cation. An effective health and social service policy depends upon a coor- dinated effort of all sectors and all segments of society. Structure should facilitate function but in some systems of social service, particularly those of social security, it often impedes it. In the past, social research has tended to concentrate on the behaviour of the individual and, while this is both right and necessary, valuable in- formation could also be obtained from the study of social systems and organ- izations. Such research might provide reasons why available services are not used by those in need . The formal administrative and statistical evidence supplied by governments is not adequate for this purpose. In several coun- tries of the Region, studies conducted outside the health sector have docu- mented the experiences of patients and potential patients in their encounters with health and social services. These are often cogent and of immense value. Supplementary information to the so-called ''hard" epidemiological material is required for medicosocial services, and this should be based on qualitative as well as quantitative data. In relation to the voluntary sector and other lay agencies, contacts between informal groups and formal organizations sometimes reveal a tend- ency for the latter to dominate, to colonize or to absorb the former. Because professionals are accountable to a bureaucratic structure they tend to take over or supplant lay help, rather than to support it. Planning of medico- social services should be in conjunction with nongovernmental organiz- ations and indigenous local leaders, and there should be mutual under- standing that only the teaching and supervision of lay people should be in the hands of professional workers. 57 Dependency groups and their needs The term "dependency groups" is taken to mean those categories of people who are recognized as being unable to meet their own minimal needs and who therefore have claim to some form of social assistance . Often they are the elderly, the mentally ill, the chronic sick, and the handicapped or disabled members of society. They are not identified in terms of a medical diagnosis and it is one of their common characteristics that ''they are of little scientific or professional interest". They are also said to be : - relatively resistant to curative medicine ; conventional medicine may ameliorate their condition, delay its progress or reduce the trauma, but it is unlikely to eradicate the condition and restore the individual to healthy, "normal" functions; - potentially costly as long-term users of heal th and social services; - economically unproductive and socially dependent because of their condition. Not all individuals within each category have all these characteristics , but they are thus grouped because their status makes them potentially vulnerable to illness and dependency. They are called "dependency groups" because they are more likely than other major categories to require special assistance from families , or from health and social services. The wording, therefore, is intended to identify them in terms of care and management implications rather than of their physiological condition. Current concern with dependency groups stems from a number of changes that have appeared in recent decades (7) . 1. Their increasing numbers , not only in absolute terms but as a pro- portion of tl1e population and as a proportion of the patients on the books of the medical and social services. To a large extent this increase is the un- intended consequence of technological advance and social improvement. People live longer and become more liable to the diseases of age, and indi- viduals who would previously have died from acute disease live on, some- times with the residual effects of their earlier illness. 2 . The potential cost of caring for these groups while maintaining the same humane standards regarded as desirable for the remainder of the popu- lation. (It is necessary to say "potential cost" rather than "actual cost" because older custodial standards are still prevalent in many countries and be- cause actual costs per head in residential institutions/hospitals and in the com- munity are still relatively low compared with those of most oilier categories of patient.) The indications are iliat, despite policy guidelines, resources 58 devoted to acute conditions continue to increase in proportion to those spent on the management and care of dependency groups. 3. There is a persistent argument that in modem industrialized society the traditional care given to dependency groups by family members and the community has diminished and is made less possible by social and geo- graphical mobility. This argument requires better documentation. It tends to ignore changes in affluence that enable more vulnerable individuals to live independently. 4. Technological changes may require levels of competence unattain- able by impaired/handicapped/chronically sick persons. The argument is that such higher competence requirements create dependency in individuals who would have been able to function in the simpler societies of the past. Again, this requires examination: appropriate assessment for and supply of aids and appliances may well compensate for the disadvantages of modern living. 5. The increasing costs of medical technology and the consequent need to evolve different forms of care for the various categories of the population whose needs are not primarily "medical". This is an argument that can be formulated and stressed in different ways by lay, professional, administrative and political groups with different roles in relation to a national health service. Administrators faced by these pressures point to the high incidence of unnecessary treatment and medication; social workers speak of the frequent occasions when medicine hives off its less interest- ing responsibilities to the social services; while sociologists blame the medical model. Underlying such dissatisfaction in the United Kingdom, for example, has been the ideological assumption on which the National Health Service was founded - that with a comprehensive health service accessible and free to all, illness would either disappear or diminish to the extent that costs, as a proportion of gross national product (GNP), would be reduced. For some time the failure of this forecast has been hidden by increases in the GNP itself but now, with little or no economic growth, it is becoming clear. 6. Allied to these issues is the organizational argument that, in the past, human needs were categorized in professional/organizational terms, each set of defined needs being grouped as the responsibility of particular segments of the welfare system. Such structures are no longer appropriate but are entrenched and difficult to change. The interface between medicine and social services is therefore being increasingly perceived as a barrier to efficiency and efficacy, rather than as a convenient mechanism enabling medicosocial needs to be assessed and met. 59 Lifestyles in the community "Lifestyle" is a word often used in a restricted sense; it relates to much more than a few problem areas identified by medicine. It covers patterns and components of daily living that are characteristic of, and sometimes dependent on, the cultural environment. In some countries of the Region much is already known about the upbringing , the expected behaviour and the major life events of large segments of the population. Even in those Member States where intense sociological research has been undertaken, however, it is not always possible to obtain complete descriptions of the characteristic patterns of major subgroups. It is not possible to document systematically, for instance, such influences as upbringing, values absorbed in childhood and adolescence, education, level of knowledge, social relation- ships, family networks, the working environment , and many other compo- nents of ''living". All are influenced by, and in turn influence, the environ- ment in which the individual exists. Even if such a series of studies were possible, it is doubtful whether one could collect the kind of information that could be usefully related to health experiences. Among sociologists there exists a feeling that, in the research context, ''lifestyle" requires a much finer conceptual definition. Above all, in order to supply the depth and quality of data required it is necessary to go back to basic and descriptive fieldwork. It is dangerous to assume that the needs and objectives of service pro- viders are the same as those of patients or clients. The imaginary diagrams and pathways produced by professional workers often bear little relation to, and may even conflict with , the reality as experienced by people in need. Re- search should therefore be directed towards documenting the perception of people rather than beginning with the input of services provided. Medicosocial services in hospitals Such services vary not only between countries but also between hospitals in the same country. In many instances they include some aspects of dealing with the financial arrangements of patients: social insurance, retirement pen- sions or other benefits , as well as payments for care, therapy and other ser- vices. Other areas of work include responsibility for the rehabilitation of people after accidents, young unmarried mothers, drug addicts and those with sexually transmitted diseases. In a few instances, specialties in medicosocial work have been developed in the fields of psychiatry and care of the elderly. The Group identified some hospital situations calling for priority medico- social intervention. These included : 60 (a) serious non-acceptance of needed medical treatment; (b) illness causing alterations in lifestyle; (c) medical diagnosis suggesting progressive disease; (d) alteration of "body image" or physical mutilation, either by acci- dent, disease or treatment; (e) the need for rehabilitation and reintegration into society (par- ticularly for psychiatric patients) ; (f) the need for help with continuing care plans; (g) manifestation of anger, frustration or other strong emotional upset; (h) breakdown of family or other important relationships; and (i) the need of family or friends for help or information . One common problem identified was the lack of continuous support among the different levels of care. This was of particular concern when vulnerable people were discharged home with little or no preliminary warning or preparation. Those who required services such as home-help, meals-on- wheels, mobile therapy or a visiting nurse service, either did not receive them or received them late. No one person in the multidisciplinary team, either in the hospital or the community, assumed responsibility for the necessary communication and coordination. The ratio of patients to providers of medicosocial services varies from hospital to hospital. On the whole, the larger specialized hospitals employ the highest number, yet their patients are not always those with needs. Frequently this acute remedial or curative medicine is practised for the bene- fit of young, affluent and articulate people. It follows that not all medico- social workers feel this to be the most satisfying area in which to work. In some general hospitals only one or two social workers are on call, and they therefore do not become integrated into any one team. In those specialized hospitals where "resocialization" plays a central role, it is more evident that the medicosocial worker is, and works as, a member of the inter- disciplinary team. The importance and therefore the number of social workers is often much greater in these institutions. Some Member States have recognized that people with long-term illness or disability entering nursing homes from hospital (as well as from home) require preparation for admission , and appropriate counselling is often made available to them. The number of medicosocial workers employed to provide this service, however, can be far from adequate for the large and increasing numbers of people who require it. For a decade or more , many teaching hospitals in the Region have had departments of social service. These usually have a coordinating head or director and a secretariat. Each medicosocial worker has his/her own ward, specialty or outpatient clinic and undertakes work as a member of a multi- disciplinary team that includes the patient and his family or friends. These 61 medicosocial workers are often involved in the teaching of medical and nursing students and participate in courses for ancillary staff. COMMUNICATION: METHODS AND MEANS Three interrelated and interdependent aspects of medicosocial work were also discussed by the Working Group. These were relationships, com- munication , and the nature of teamwork. Social work can take pride in the fact that from the beginning it recognized the importance of human relationships and attempted to employ that concept in a conscious and deliberate way for the benefit of the people it served. Relationships are a vital factor in the development of a human or social system, improving the capacity of the individual to cope with tasks and realize aspirations. In addition, medicosocial workers enter into other types of relationship : with people close to their clients {family or friends); with representatives of other helping agencies; and with members of the team in or with which they work. It is impossible for any element or level of a health or social service system to operate effectively without efficient communication. A work- ing definition given to the Group was "communication is an interactional process which gives and receives messages and checks out meanings" (8). Social workers make use of the communication theory concept in their relationships with clients as professional practice requires , through the technique of interviewing. They also use their knowledge and skills of com- munication theory at all levels of interaction with other individuals and groups in their working relations. Medicosocial workers work directly with individuals or groups of patients to help them with their personal and social problems. This includes helping them to adapt to situations complicated or changed by illness, im- pairment, disability or handicap . Medicosocial workers then share their understanding of the patients ' difficulties or concerns with others involved in the plans for care. To do this they must be able to relate to members of many different disciplines, both inside and outside the hospital. Medico- social workers are also dependent on members of these other disciplines for referrals, and one of their main aims is to help other members of the health team - at all levels - to recognize when they cannot meet patients' needs and when a medicosocial service is required . Teamwork can mean giving up, as well as acquiring, responsibilities. If their education has been appropriate and has included the social sciences and human development, medicosocial workers will know some 62 of the terminology used by other professionals. This provides a basis for effective communication within the team . Means of communication in hospital identified by the Group included : - taking part in ward or unit rounds ; - taking part in regular ward meetings; - having direct contact with doctors, ward sisters , therapists and others as appropriate; - making own ward rounds; - writing reports for inclusion in patients' records; - holding formal and informal discussions; - supporting exchanges of health and social workers inside and out- side hospital; - participating in inservice training programmes; - teaching medical, nursing and other health care students; - promoting interprofessional courses or sessions; - writing about the role and function of medicosocial workers in hos- pital newsletters and encouraging others to write about theirs; - providing information on areas of need ; - drawing the attention of others to unintentional and undesirable consequences of hospital routine or procedures as these are revealed during discussions with patients , families or other members of staff. It would be unrealistic to expect everyone included in the treatment and care of a patient to work together in complete harmony. Teamwork has a competitive as well as a collaborative element. Communication is not only verbal; emotions and attitudes are also eloquent. There is also the vexed question of leadership . Which member has overall responsibility? Who is accountable, and to whom? The quality of teamwork could be measured by the way in which such problems and conflicts are acknow- ledged and dealt with. Through their specialized knowledge and skills in group work, and from experience of dealing with the difficulties of relationships, medicosocial workers should be able to contribute to the solving of team problems. They, in turn, will sometimes need an advisory or counselling service themselves. This is especially true of those health and social workers involved in long-term and terminal care. At least one Member State in the Region (Belgium) has already set up such a service, which is proving to be of enormous value. 63 EDUCATIONAL NEEDS OF MEDICOSOCIAL WORKERS In both developing and developed countries, manpower development in the planning of health and social services often receives little attention . In many Member States no manpower policies exist. Where they do, they often have little relevance to either the long-term or the changing needs of the health systems and the communities and individuals within it. Political will is necessary to change the manpower development process and make it relevant to health development plans aimed at attaining health for all through primary health care. Existing gaps and problems are likely to be compounded as countries base systems on primary health care with its integral components of self- care and community involvement. Medicosocial workers will increasingly be required to provide intelligent guidance and encouragement to communities and individuals in the prevention of social problems and the illnesses and disabilities caused by them. Career structures and working conditions will have to provide the necessary incentives, and technologies appropriate to community action will have to be developed and incorporated into training programmes. One main approach should be the promotion of community educational pro- grammes with team- and problem-oriented methods of teaching and learn- ing. This will demand cooperation at all levels among decision-makers in all sectors and in all the relevant ministries . The overall aim of all health and social service teams is to meet the needs of populations or to help them to meet their own needs. Different disciplines have different approaches but the goal is common to all. This is an important consideration in the development of all manpower for health systems. Organization Because medicosocial work has not as yet been clearly defined in the Region, the preparation of those who provide medicosocial services varies widely and ranges from no training at all to university courses of three years . In a few countries there are also postgraduate courses of 1-2 years for specialties such as psychiatry and geriatric medicine . Some Member States that have had training schemes have discontinued them in recent years, transferring responsibility for providing the service to nurses. Of these a few, but by no means all , have programmes of further education. One country has terminated social work positions in its mental hospitals and created more psychiatric nursing posts in their place. The Working Group saw this as concrete evidence of the current confusion of roles between the two disciplines. Adequate supervision of new students was considered a high priority, but this is missing in the majority of Member 64 States. There is a need for continuous monitoring of the content of cur- ricula to ensure that medicosocial workers receive appropriate education to meet the changing needs of society. The present monetary inflation and economic recession, for example, not only has direct and far-reaching physical and mental effects on people but also means that the health and social services have to find ways to use their finite resources to the best possible advantage. TI1e latter has resulted in the combination of several hospitals in some countries, and to the centralization and auto- mation of advanced technology and equipment. For patients this means such things as more extensive outpatient investigation and treatment (with corresponding transport needs); shorter admissions to hospital; and continuation of care at home under the supervision of the family doctor. Many of these physicians have moved into group practices, health centres or mobile dispensaries and now work in closer collaboration with home nurses, therapists and medicosocial workers. Relevant theory and practice for each team member in preparation for such teamwork are vital to its success. In some countries medicosocial services are subsidized by more than one ministry, and this further complicates the planning of education pro- grammes for medicosocial workers. Curriculum content Consideration should be given to a common introductory programme in the social and human sciences to students of all health disciplines and related professions. This should include practical learning experiences and intersectoral work in the community. Educational programmes for medicosocial workers are also required at basic and postbasic levels. Con- tinuing and further education should be available throughout the Region and country exchanges facilitated. Intercountry cooperation Cooperation should be effected between countries, and with the appro- priate international and nongovernmental organizations, to improve living and working conditions, job security, labour relations, job satisfaction and social motivation. This requires the planning and implementation of national career development schemes, and practical and continuing education sys- tems for all categories of health and social service manpower, including medicosocial workers. Cooperation among countries is very important for the development of comparative studies and teacher training schemes, and for the production and exchange of learning materials. 65 CONCLUSIONS The participants emphasized that conclusions and recommendations of the meeting, the first of its kind, should be regarded as being of a preliminary and general nature and as representing an initial attempt to delineate and identify major issues and questions of internst. "Medicosocial work" has a variety of meanings throughout the Region and there is an urgent need for the term to be more clearly defined. Appropriate steps should be taken to help medicosocial workers to identify the content of this service. This would enable the formulation of more concrete suggestions regarding the organization and management of medicosocial services, including resource planning and the education of medicosocial workers. The major contribution of the providers of medicosocial services should be to the country 's primary health care programme. This is likely to require a shift in emphasis , from an individual approach based on the medical model to one related to social structure , health policies, wider socioeconomic issues and decision-making in present-day society. Records of patients are not always made available to medicosocial workers, and this militates against teamwork . However , the possibility of developing common documentation that could be made available to all team members requires careful consideration and discussion , since con- fidentiality is often involved. The setting up of a small task force by the Regional Office could facili- tate and expedite these actions and also help to identify ways in which medicosocial workers might develop their own system of assessment , plan- ning, implementation and evaluation of care , using documentation similar to that currently being developed in nursing. RECOMMEND A TIO NS National level 1. In order to provide a coherent system of social and health services that would enable a continuum of appropriate care to be made available in all settings and at all levels, Member States should take appropriate steps to : (a) obtain information on the present medicosocial needs of their pop- ulations; the ways these needs are being met; the range of workers currently being deployed for the purpose; the systems of communication and co- ordination between the workers; the levels and types of preparation of the 66 workers; and the likely future needs and resources for medicosocial ser- vices, taking into account demographic , epidemiological , socioeconomic and technological trends and resources ; (b) identify which of the existing categories of worker should be respon- sible for medicosocial work; (c) identify the functions and duties of providers of medicosocial ser- vices, taking into account the concurrent changes in medicine, nursing and other related health disciplines; (d) integrate providers of medicosocial services into all health care teams; (e) improve coordination of the work of all members of the health care team; (J) improve communication and exchange of information (including the provision of appropriate documentation) between providers of medico- social services in hospitals and related institutions, and members of other relevant disciplines in all settings; and (g) identify and further develop desirable trends and successful new practices in this field. 2. Member States should identify the educational needs of providers of medicosocial services , and plan and organize programmes that provide train- ing for teamwork and preparation in the organization of work , and that also give attention to the psychosocial aspects of care. 3. At the postbasic level, educational programmes should include sessions in modem disciplines such as computer science, industrial technology and management (with attention to theories of and practical experience in communication), in addition to advanced education in the human and social sciences. 4 . University and continuing education should be made available , especially for those appointed to specialized or senior positions in teaching, administra- tion or research. 5. Opportunities for shared learning experiences among members of the health care team should be taken wherever appropriate. International level 6. Effective liaison should be established and maintained between WHO and other relevant organizations, such as the International Association of Social 67 Workers, the International Federation of Social Workers and the Inter- national Association of Schools of Social Work, in order to discuss, clarify and promote developments of mutual interest in the field of medicosocial work, such as the establishment of terminology and the contribution of medicosocial workers to the attainment of common goals. WHO level 7. The Regional Office should plan and assist Member States in undertaking the national studies , especially with regard to development of a common protocol in order to facilitate comparative research and the exchange of information and expertise. 8. The Regional Office should give consideration to the further develop- ment of medicosocial work throughout the Region, recognizing the important contribution the discipline could make to achieving the social goal of health for all by the year 2000. REFERENCES 1. Titmuss, R.M. Essays on "the welfare state''. London, Un win, 1963. 2. Concluding report on the work of the roundtable. In: The role of social services in social security: trends and perspectives. Geneva, International Social Security Association, 1974 (Studies and Research, No . 6). 3. Alma-A ta 1978: primary health care. Geneva, World Health Organiza- tion , 1978 ("Health for All" Series , No . 1). 4. Kohn, R. Coordination of health and welfare services in four countries: Austria, Italy, Poland and Sweden. Copenhagen, WHO Regional Office for Europe, 1977 (Public Health in Europe, No. 6). 5. Global strategy for health for all by the year 2000. Geneva, World Health Organization, 1981 ("Health for All" Series, No. 3). 6 . Regional strategy for attaining health for all by the year 2000. Copen- hagen, WHO Regional Office for Europe, 1980 (document EUR/RC30/8). 7. Amann, A. The status and prospects of the aging in western Europe. Vienna , European Centre for Social Welfare Training and Research, 1981. 8. Satir , V. Conjoint family therapy. Palo Alto, CA, Science and Behavior Books, 1964. 68 Annex 1 LIST OF PARTICIPANTS Temporary advisers Miss R. Delaune, Louis Pradel Hospital for Cardiovascular Diseases and Pneumology, Lyon, France Mr M. Feraa, Inspector-General, Ministry of Public Health, Rabat, Morocco Dr J. Hamp!, Rehabilitation Centre, Faculty Hospital II, Prague, Czecho- slovakia Mrs B. Hokkanen,0 Social Department T-6, Children's Castle Hospital, Helsinki, Finland Miss E. Horgan, Chief Community Nursing Officer, Eastern Health Board, Dublin, Ireland Ms S. Juhlin, Chief Medical Social Worker, Uppsala University Hospital, Sweden Mr M. Keirse, Head, Patient Counselling Department, St Raphael Uni- versity Hospital, Leuven, Belgium Mrs R. Keller, Individual Health Care, Department 12, Municipal Coun- cil, Vienna, Austria Dr S. Kut, Institute of Child Health, Hacettepe University, Ankara, Turkey Ms A. Leppo,0 Supervisor, National Board of Social Welfare, Helsinki, Finland (Chairman) Ms S. Luisenniemi, Chief Social Worker, Social Service Department, HYKS - Meilahti Hospital, Helsinki, Finland (Vice-Chairman) a Participation expenses not paid by WHO . 69 Mrs M. Nelissen, University Hospital, Utrecht, Netherlands Ms K. Nojonen,0 Director, Nursing Services, Central Mental Hospital, Pitaniemi, Finland Mrs N. Novakovic, National Gerontology Centre, Subotica, Yugoslavia Professor H. Perroti , Director, School of Health Services, KATE Project, Ministry of Education, Heraklion, Crete, Greece Miss L. Plojoux , Oncohaematology Centre , Cantonal Hospital, Geneva , Switzerland Dr M. Sokolowska, Chief, Department of Medical Sociology, Institute of Philosophy and Sociology, Polish Academy of Sciences, Warsaw, Poland Mrs M. Str~m, School of Social Work, Trondheim, Norway Mrs T. Wilson, Faculty of Human Sciences , North-East London Poly- technic , Stratford , United Kingdom (Rapporteur) Representatives of other organizations International Council of Nurses Miss M. Sorvettula ,0 National Board of Health , Helsinki , Finland WHO Regional Office f or Europe Miss M. Skeet, Short-term Consultant Miss E. Stussi , Acting Regional Officer for Nursing (Secretary) a Participation expenses not paid by WHO . 70 WHO publications may be obtained. direct or through booksellers, from: ALGERIA ARGENTINA AUSTRALIA AUSTRIA BANGLADESH BELGIUM BHUTAN BOTSWANA BRAZIL BURMA CANADA CHINA CYPRUS CZECHO- SLOVAKIA DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA DENMARK ECUADOR EGYPT FIJI FINLAND FRANCE GABON GERMAN DEMOCRATIC REPUBLIC GERMANY. 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Organisation mondiale de la santé (OMS) · Publications
Medicosocial work and nursing: the changing needs: report on two WHO meetings, Cologne, 16–19 November 1981, Helsinki, 1–4 September 1981
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