The second step in the present study will be to determine which framework is useful in specifying the variable properties of the concept of care dependency as established in the theoretical definition. The following aspects of care dependency were measured in the literature reviewed. Benoniel et al. (1980) developed a social dependency scale, which measures three capacities of patients with chronic illnesses: everyday self-care competence, mobility competence, and social competence. Hardy et al. (1982) examined the effect of care programs on the dependency status of elderly residents in an extended care setting. Among other things, a tool to measure the patient’s nursing dependency status was used. This tool measures requirements for nursing staff time in terms of workload generated by patients’ needs. Miller (1985a, b) studied the dependency of elderly patients in wards using different methods of nursing care. The incidence of dependency in elderly people and patient dependency in relation to nursing care was discussed. Patient dependency was measured by using a scale which rated the patients’ level of physical dependency, apathy, social disturbance, communication difficulties, and incontinence. For policy purposes as well as for the provision of individual care, Maaskant (1993) investigated the care dependency of elderly, mentally handicapped people. Jirovec and Kasno (1993) studied predictors of self-care abilities among the institutionalized elderly. Self-care abilities were measured using the Appraisal of self-Care Agency (ASA-A) scale (Evers 1989). Dijkstra et al. (1995) compared the need for care in three types of Dutch institutions: nursing homes, old people’s homes, and home care. For that purpose, the authors measured the degree of dependence for self-care activities, incontinence, and mobility. In all these studies, the care dependency concept was used to search for a method by which the dependency of a population can be measured. Similarly, George (1991, p. 178) concluded that “researchers and planners have attempted to define the quality of dependency in ways which will help them to assess the need for, and calculate the workload entailed in providing, continuing or long-stay accommodation for the elderly population.”

In contrast to a medical orientation, the ideas of the “needs theorists” may be characterized as based on Maslow’s hierarchy of needs and influenced by Erikson’s stages of development (Fitzpatrick and Whall 1989; Riehl 1989; George 1990; Meleis 1991). Maslow (1970) identified basic human needs as physiological needs, safety needs, belongingness and love needs, esteem needs, and the need for self-actualization. The influence of Maslow is evident in the work of Abdellah, Henderson, and Orem. Although their formulations are different, each of the three “needs theorists” identifies need requisites which correspond to Maslow’s basic human needs.

In Abdellah’s model (1960), the concept of nursing is expressed in a typology of 21 nursing problems which encompass the physical, sociological, and emotional needs of the patient. The nursing activity typology of 21 nursing problems represents the categories or classifications of nursing action that can influence responses in the patient condition (Fitzpatrick and Whall 1989).

Henderson (1966, 1985) specified 14 components of basic nursing care. They remain comprehensive, complete, and consistent with various hierarchies and levels of human need (Yura and Walsh 1983). The components start with physiological functioning and move to the psychosocial aspects, which may convey that bodily operation takes priority over emotional or cognitive status (George 1990). These basic needs address not health problems of the patient, but areas in which actual or potential problems might occur (Gordon 1994). According to Fitzpatrick and Whall (1989), assessment of Henderson’s 14 components of care helps the nurse move the patient from a state of dependence to a state of independence.

Orem (1985, 1995) identified three types of self-care requisites: universal, developmental, and health deviation. Each type of requisites represents a category of deliberate actions to be taken by or for the patient because of his or her needs as a human being. Universal self-care requisites are common to all human beings. Developmental self-care requisites are associated with human developmental processes, or they are new requisites derived from a condition or associated with an event. Health-deviation self-care requisites are associated with genetic and constitutional defects. Orem’s eight universal self-care requisites, common to all human beings, more or less coincide with Henderson’s 14 human basic needs (Meleis 1991).

Characteristics of basic human needs cover a broad range of physical and psychosocial needs. In the frameworks presented, physical needs dominate. “Needs theorists” associate these needs with air, food, elimination, sleep, exercise, and temperature. As long as these physical needs are unsatisfied, all other needs get low priority in need fulfillment. “Needs theorists” identify psychosocial needs such as self-concept, role function, interdependence, education, and family.

For the following reasons, Henderson’s framework provides a good starting point to specifying the variable aspects of the concept of care dependency.

So Henderson’s components of nursing care are used to specify the 14 variable aspects of the concept of care dependency. To allow them to be useful in the context of the research project, Henderson’s 14 human needs have been translated into 15 care dependency items (see Table 17.2).

According to Challis et al. (1996), it is widely agreed that the best way to address the patient’s care needs is by thorough and systematic assessment. The importance of regular assessments is evidenced by the frequency of acute and subacute changes in health status which may occur in patients in long-term care settings (Bernadini et al. 1993). Iyer et al. (1986) identified four types of assessment data: subjective, objective, historical, and current data. Here, where patients with cognitive and communicative dysfunctions are unable to share reliable information about their care dependency with their nurse, the focus is on objective data. Cox et al. (1993) define objective data as those facts that are observable and measurable by the nurse.

When selecting observable and measurable indicators, Waltz et al. (1991) suggest that it is important to determine whether the concept represents an either-or phenomenon or one that varies. Care dependency can be defined as variable in intensity. The described theoretical definition represents one end of a continuum, ranging from total patient dependency to total independence, in activities related to the specified 15 variable properties of the concept of care dependency.

In order to measure the patient’s degree of care dependency, the number of indicators must be determined. Nursing literature refers to a number of indicators, varying from three to five. For example, Cox et al. (1993) mention five dimensions for rating areas of self-care: completely independent; requires use of equipment or device; requires help from another person, for assistance, supervision, or teaching; requires help from another person and equipment device; and dependent (does not participate in activity) (Code adapted by NANDA from E. Jones et al., Patient Classification for Long-Term Care: User’s Manual. HEW Publication No. HRA-74-3107, November 1974). For each of the 15 dimensions of care dependency, it was decided to conceptualize five written indicators, ranging from totally dependent to totally independent. With these indicators the patient’s care dependency can be evaluated.

Structured assessment instruments can assist in screening for problems that often remain undetected in older patients, and they can be adopted as part of everyday practice (Applegate et al. 1990). Assessment instruments may be helpful to complete the measurements of patients’ indicators. Two instruments have been designed as means for measuring the 15 dimensions of nursing care dependency. Each version consists of the following components: (1) a label, (2) a description of the given label, and (3) five indicators to determine the degree to which patients depend on nursing care. The difference between the two versions is the way in which care dependency is assessed.

Responses on the clinical scale are rated on the basis of five written criteria (e.g., see Table 17.3), whereas all ratings of the research version are on a five-point Likert-scale, ranging from 1 (completely care dependent) to 5 (almost independent) (e.g., see Table 17.4).