BMC Health Services Research volume 25, Article number: 819 (2025) Cite this article
AbstractSection Background
Long term care facilities, as an integral part of the current social nursing service system, bear the important function of providing nursing services for the older adults. This study conducts an in-depth analysis of the nursing service needs of the older adults, to offer a scientific basis for the improvement of nursing services in long term care facilities.
AbstractSection MethodsD
A questionnaire survey was conducted among the older adults of 24 long term care facilities in Hangzhou, China from March 1 to June 30, 2024. The needs scale of older adults nursing service was used for survey. Bivariate and multivariable linear regression analyses were performed to identify factors associated with nursing service needs in long-term care facilities.
AbstractSection Results
The study sample comprised 1,242 older adults from long-term care facilities. The mean total score for nursing service needs was 162.15 ± 14.38, suggesting a relatively high demand for nursing services among older adults in these facilities. Multivariable regression analysis identified age, self-care ability, educational level, and average monthly income as significant factors associated with nursing service needs (all p < 0.05).
AbstractSection Conclusion
The nursing service needs of older adults in long-term care facilities are substantial and influenced by a range of factors. Healthcare providers and long-term care facilities should develop and implement targeted interventions to effectively address these needs.
With the advancement of medical technology, there has been a significant extension in life expectancy, which has directly led to a continuous increase in the older adults population, thereby giving rise to the issue of aging [1]. It is projected that by 2025, the number of individuals aged 65 and above in China will increase to 257 million, and by 2029, this figure is expected to peak at 344 million [2, 3]. This demographic shift poses a challenge to the traditional family-based older adults nursing model, which, while effective in providing support in the past, is now struggling to meet the needs of an aging society [4]. The accelerated aging process has raised the bar for both the quantity and quality of nursing services for older adults. Against the backdrop of increasingly prominent supply-demand contradictions, the older adults care model is transitioning towards a more societal approach, with the provision of nursing resources gradually shifting from families to individuals and society at large [5, 6]. Long-term care facilities are institutions that provide a range of services, including medical and personal nursing care, to individuals who are unable to care for themselves for extended periods [7]. These facilities cater to people with chronic illnesses, disabilities, or the frailties associated with aging [8]. In China’s 14th Five-Year Plan, there is an emphasis on the continued development of long term care facilities that integrate medical services, to foster a deep integration of medical care with older adults nursing services [9]. However, the current older adults care system in China is still facing numerous challenges, including an incomplete public older adults nursing system, insufficient service quality, a shortage of supply, and a lack of professional personnel [10, 11]. The existence of these issues not only affects the quality of life of the older adults but also poses a threat to the sustainable development of society [12, 13]. Therefore, it is necessary to approach the construction of a more comprehensive and efficient older adults care system from multiple aspects.
Nursing services encompass a comprehensive range of healthcare provisions delivered by a team of registered nurses, licensed practical nurses, and other nursing staff, aimed at fostering health, preventing disease, and facilitating patient recovery and rehabilitation [14]. These services involve direct care, including medication administration and vital sign monitoring, as well as health assessments to identify and track health issues [15]. They also extend to health promotion and education, equipping patients and their families with knowledge about health conditions and self-care practices, and disease prevention strategies to safeguard overall well-being [16]. Due to the limitations of the family-based older adults care model in ensuring the living and medical care needs of the older adults, long term care facilities that integrate medical care with personal care have gradually become the preferred choice for many older adults. These long term care facilities are not only capable of providing professional medical nursing services but also effectively alleviating the loneliness of the older adults [17]. The long term care facilities have garnered significant attention from the government and academia for offering more comprehensive and specialized services to the older adults [18]. Research indicates that after entering long term care facilities, the older adults may face a reduction in social support and the physiological and psychological challenges of adapting to a new environment, which could lead to an increased level of needs [19]. If the needs of the older adults are not met over the long term, it may trigger adverse psychological issues such as loneliness, depression, and low self-esteem [20]. The primary objective of this study is to conduct a comprehensive assessment of the nursing needs among older adults residing in long-term care facilities. Furthermore, this study aims to identify and analyze the factors influencing these needs, providing a reliable basis for optimizing nursing services for this population. Based on this objective, we hypothesize that there is a significant association between the demographic and health status characteristics of older adults in long-term care facilities and their specific nursing needs.
This study employs a cross-sectional survey design, and the survey protocol has been rigorously reviewed and approved by the Medical Ethics Committee of our institution (Approval Number: 20240112). Informed consent was obtained from all participants in the form of a signed paper consent form, clearly indicating their agreement to participate in this research. All collected survey data was strictly confidential and used solely for the purposes of this study’s analysis and research objectives.
In this study, the sample size was calculated based on established methodologies from previous research [21, 22]. The formula employed was N = Z² × [P × (1 - P)]/E², where N indicates the required sample size, Z represents the confidence level, E is the margin of error, and P is the estimated probability value (set at 10%). With a confidence level of 95% (Z = 1.90) and a margin of error of 5%, the initial calculated sample size (N) was 1066. Thus, a minimum of 1066 older adults were determined to be necessary for inclusion in this study.
Between March 1, 2024, and June 30, 2024, a questionnaire survey was conducted among the older adults of 24 long term care facilities in Hangzhou, China. The 24 long-term care facilities included in this study were selected through a stratified random sampling method. Initially, all registered long-term care facilities in Hangzhou were categorized into three strata based on facility size and geographical location. This stratification aimed to capture the diversity in facility characteristics and resource availability across different regions and scales. Within each stratum, facilities were randomly selected using a computer-generated random number sequence, ensuring an equal probability of selection for each facility within its respective stratum. This approach helped minimize selection bias and ensured that the sample of facilities was representative of the broader population of long-term care facilities in Hangzhou. Inclusion criteria required that participants be residents of long-term care facilities aged 60 and older, capable of clear communication, and willing to participate. Exclusion criteria precluded individuals with mental health or communication disorders, as well as those with terminal illnesses who could not participate.
We collected following information from the included older adults: age, gender, body mass index (BMI), number of children, marital status, self-care ability, educational level, average monthly income. The needs scale of older adults for nursing service was used to evaluate the nursing service needs of included older adults in long term care facilities. The needs scale of older adults nursing service was developed by Xu et al. and has previously been published elsewhere [23]. The scale utilized in this study is grounded in Maslow’s Hierarchy of Needs theory [24] and is specifically designed to evaluate the nursing service needs of older adults in long-term care facilities. It encompasses five dimensions: physiological health needs, safety needs, love and belonging needs, esteem needs, and self-actualization needs. The questionnaire consists of 40 items, each rated on a 5-point Likert scale, ranging from 1 (not needed) to 5 (very needed). The total score for nursing needs is calculated on a scale from 40 to 200, with higher scores indicating a greater urgency for nursing services. The scale demonstrates robust internal consistency, with a Cronbach’s αcoefficient of 0.834. The Content Validity Index (CVI) was calculated based on expert evaluations of the scale items and yielded a value of 0.755. Additionally, the model fit indices obtained from the Confirmatory Factor Analysis (CFA) were 0.756, which supports the scale’s alignment with the expected dimensions [25, 26]. All indicators of reliability and validity indicate that the scale possesses good reliability and validity.
The self-care ability of older adults was assessed using the Barthel Index, a widely recognized and validated tool designed to evaluate basic activities of daily living (ADLs). This scale comprises 10 items, each scored on a scale ranging from 0 to 100, with higher scores indicating greater self-care ability [27]. The items cover essential daily functions, including feeding, bathing, grooming, dressing, toileting, mobility, transferring, continence, and stair climbing. The Barthel Index is structured to provide a comprehensive and objective assessment of an individual’s capacity to perform these fundamental activities independently [28]. In terms of psychometric characteristics, the Barthel Index has demonstrated strong reliability and validity in various populations, including older adults in long-term care settings. It has an internal consistency Cronbach’s α coefficient of 0.89, indicating high reliability [29]. Additionally, the scale has been extensively validated through both exploratory and confirmatory factor analyses, confirming its construct validity as a measure of self-care ability. The Barthel Index is also highly correlated with other established measures of functional status, further supporting its validity and applicability in clinical and research settings [30].
After obtaining formal permission from the older adults of long-term care facilities, we initiated a questionnaire survey targeting the older adults within these facilities. To ensure the accuracy and consistency of the survey, we conducted rigorous standardized training for all personnel involved in the survey prior to its commencement. The training included survey methods, requirements for completing the questionnaire, and effective communication strategies with the older adults and their family members. During the survey, we standardized the instructions to ensure that each interviewer could explain the purpose and significance of the questionnaire to the older adults and their family members in the same manner. We also emphasized the importance of accuracy in information and the protection of privacy when filling out the questionnaire. The questionnaire could be completed by the older adults themselves if they possessed adequate literacy skills, or it could be filled out by family members on their behalf, especially for those with poor vision or writing difficulties. Regardless of whether the questionnaire was self-completed or completed by a proxy, we ensured that the process respected the older adults’ wishes and accurately reflected their needs and opinions.
This study utilized SPSS 26.0 software for data processing and statistical analysis. Qualitative data were described using counts and percentages (%); quantitative data that conformed to a normal distribution were expressed using the mean ± standard deviation (x ± s). To comprehensively evaluate the factors associated with the need for nursing services among older adults, both bivariate and multivariable linear regression analyses were employed. Initially, bivariate regression analyses were conducted to examine the individual relationships between each independent variable and the dependent variable, thereby identifying potential associations. Subsequently, a multivariable regression model was utilized to adjust for potential confounding variables, thereby offering a more nuanced and comprehensive understanding of the factors associated with nursing service needs. Given the clustered nature of our sampling design, which included data from 24 long-term care facilities, we implemented a mixed-effects regression model to account for potential within-facility correlation. Specifically, we used the unique identifier (ID) of each long-term care facility to incorporate random effects into the regression models. This approach adjusts for the non-independence of observations within the same facility, thereby reducing the risk of bias in our estimates and providing more accurate coefficient estimates. The fixed effects in the model included the primary predictors and covariates of interest, while the random effects allowed for variation in intercepts across different facilities. This methodological adjustment ensures that our results are robust and not confounded by the clustering of participants within facilities. The significance level for this study was established at α = 0.05.
A total of 1242 older adults in nursing long term care facilities were included. As shown in Table 1, Among the older adults residing in long term care facilities, a pronounced trend of aging is observed, with individuals aged 70 and above accounting for 61.03% of the total. In terms of gender composition, there is a slight predominance of male over female older adults. The majority of the older adults exhibit good self-care abilities, being capable of independently performing activities of daily living. Regarding educational background, the majority of the older adults have completed junior high school and high school education.
As shown in Table 2, the average total score of nursing service needs in long term care facilities was 162.15 ± 14.38, indicating the older adults in nursing long term care facilities exhibit a relatively high demand for nursing services, with the average scores of the top three needs being physiological health needs, love and belonging needs, and safety needs. These requirements reflect the fundamental aspects of care that are prioritized in such settings, aligning with the holistic approach to nursing services that encompasses physical well-being, emotional support, and a secure environment.
As presented in Table 3, multivariable regression analysis revealed that age, self-care ability, educational level and average monthly income were the associated factors of nursing service needs of older adults in long term care facilities (all p < 0.05). Specifically, the adjusted coefficient for age quantifies the change in nursing service needs associated with a one-year increase in age, holding all other variables constant. For example, an adjusted coefficient of 0.5 for age indicates that, on average, nursing service needs increase by 0.5 units for each additional year of age, assuming other factors remain unchanged. The adjusted coefficient for self-care ability reflects the impact of a unit change in self-care ability on nursing service needs, independent of other predictors. A negative coefficient suggests that higher self-care ability is associated with lower nursing service needs, indicating that individuals with greater self-care capabilities require fewer nursing services. Regarding educational level, the adjusted coefficient represents the effect of a change in educational level on nursing service needs, after accounting for other variables. We have carefully reviewed the findings and verified the data. The initial crude coefficient for educational level was negative, while the adjusted coefficient is positive. This discrepancy likely arises due to the influence of other covariates in the model. The positive adjusted coefficient indicates that, when other factors are held constant, higher educational level is associated with increased nursing service needs. Finally, the adjusted coefficient for average monthly income illustrates the relationship between income and nursing service needs. A positive coefficient suggests that higher income is associated with greater nursing service needs, after adjusting for other variables. This finding may reflect differences in the ability to access or utilize nursing services based on financial resources.
Our study of 1,242 older adults in long-term care facilities shows a high demand for nursing services. Multivariable regression analysis identifies age, self-care ability, educational level, and average monthly income as significant factors influencing nursing service needs. Older individuals, those with limited self-care abilities, lower educational attainment, and lower incomes demonstrate greater reliance on nursing services. These findings highlight the complex interplay between demographic, functional, and socioeconomic factors in shaping nursing care needs. Future interventions should prioritize enhancing self-care capabilities, improving health literacy, and addressing financial barriers to healthcare access to better support this vulnerable population.
With advancing age, the demand for integrated medical and nursing services among older adults increases [31]. This population requires not only basic assistance with activities of daily living to maintain self-care and comfort but also necessitates professional nursing services to address the diverse health issues that may emerge as a result of aging [32]. The demand for daily living care services encompasses a wide range of essential support areas, including diet, housing, personal hygiene, and mobility assistance. These services are fundamental to the daily lives of older adults. As physical function gradually declines, older adults increasingly depend on these services to maintain their independence and mitigate risks associated with mobility difficulties or cognitive impairments [33, 34]. The management of common chronic diseases and acute health issues among older adults necessitates ongoing follow-up and meticulous care from these services [35,36,37]. The integrated medical and older adults care model, by combining medical and nursing care resources, provides continuous health support and disease management for the older adults, greatly enhancing their quality of life and health status [38, 39]. Therefore, long-term care facilities should systematically optimize their delivery of integrated medical and geriatric services for older adults. This optimization must center on the development and implementation of evidence-based, personalized care protocols that comprehensively address the multifaceted needs of the aging population. Enhancing care delivery systems in this manner is crucial to achieving optimal health outcomes and maintaining quality of life for older adults within these care settings.
Self-care ability is a critical determinant of independent living status among older adults. As this ability deteriorates, the demand for nursing services correspondingly rises. This inverse relationship highlights the necessity of monitoring and supporting self-care capabilities to preserve functional independence and defer the need for more intensive care. Older adults with diminished self-care capacity often encounter substantial difficulties in performing basic activities of daily living (ADLs), such as dressing, bathing, feeding, and toileting [40, 41]. To address these needs effectively, long-term care facilities and service providers should deliver specialized and individualized care interventions. These interventions should extend beyond basic personal assistance to encompass complex clinical support, including medication administration, wound management, and rehabilitative therapies. In response to the progressive decline in mobility among older adults, adaptive measures such as the use of assistive devices (e.g., walkers, canes) and environmental modifications (e.g., handrails, wheelchair-accessible facilities) are necessary to enhance safety and functional independence. Moreover, comprehensive care provision should integrate psychosocial support to address the emotional and social challenges associated with diminished self-sufficiency [42, 43]. Therefore, healthcare professionals are encouraged to adopt a holistic approach that integrates physical care with emotional support and active encouragement. This multifaceted strategy aims to promote psychological well-being and sustained social connectivity among older adults [44].
Our study shows that lower incomes are significantly associated with greater reliance on nursing services among older adults in long-term care facilities. This correlation can be attributed to several interrelated factors. Financial constraints limit the ability of individuals with lower incomes to access private healthcare services or afford additional medical interventions outside of institutional care [45]. As a result, they become more dependent on the nursing services provided within long-term care facilities to meet their basic healthcare needs. Moreover, lower-income individuals may face challenges in maintaining optimal health, such as limited access to nutritious food, preventive care, and medications. These factors can exacerbate health conditions, thereby increasing their need for nursing care [46, 47]. Additionally, lower educational attainment, which is often correlated with lower income, may result in reduced health literacy [48,49,50]. This can further hinder their ability to self-manage chronic conditions, leading to a higher demand for professional nursing support. Long-term care facilities should consider implementing financial assistance programs or partnerships with community health services to help lower-income older adults access additional healthcare resources.
Although this multi-center study employed a robust sample size, several methodological limitations should be acknowledged. First, the geographic concentration on long-term care facilities in specific regions may introduce selection bias, potentially limiting the external validity of our findings to other populations or healthcare settings. Second, our analytical model did not account for certain potentially confounding variables that may significantly affect care needs, such as comorbidities, functional status trajectories, or caregiver-related factors. These limitations highlight the need for future research to adopt more geographically diverse sampling frameworks and incorporate a wider array of biological, psychological, and social determinants to better elucidate the unmet nursing care needs of older adults.
In summary, this study has identified substantial unmet nursing care needs among elderly residents in long-term care facilities. Empirical evidence demonstrates significant associations with key demographic and socioeconomic factors, including age, functional independence, educational attainment, and financial status. While identifying the needs of older adults is a crucial first step, future research should focus on exploring effective interventions and elucidating the role of healthcare professionals in addressing these needs.
The data associated with the paper are not publicly available but are available from the corresponding author on reasonable request.
This study was funded by the Major Project of Hangzhou City Health Science and Technology Plan (ZD20230068).
In this study, all methods were performed in accordance with the relevant guidelines and regulations. Our study adhered to the Declaration of Helsinki. The study has been reviewed and approved by the ethics committee of The First People’s Hospital of Lin ‘an District (approval number: 20240112). And written informed consents had been obtained from all the participants.
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The authors declare no competing interests.
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Wu, H., Lu, P., Wu, C. et al. The nursing service needs of old adults in long term care facilities: current status and associated factors. BMC Health Serv Res 25, 819 (2025). https://doi.org/10.1186/s12913-025-12927-y
