A Comparison between Independently Living Elderly Individuals and Residents in 25 German Nursing Homes Following the Group-Living Principle

Special Article - Geriatric Care Nursing

Gerontol Geriatr Res. 2021; 7(3): 1058.

A Comparison between Independently Living Elderly Individuals and Residents in 25 German Nursing Homes Following the Group-Living Principle

Simon A*

School of Health Sciences & Management, Baden-Wuerttemberg Cooperative State University, Stuttgart, Germany

*Corresponding author: Anke Simon, School of Health Sciences and Management, Baden-Wuerttemberg Cooperative State University, Stuttgart, Germany

Received: May 21, 2021; Accepted: June 18, 2021; Published: June 25, 2021


Objective: The purpose of this study was to analyses the subjective Quality of Life (QoL) perceived by older people in German nursing homes following the group-living principle.

Methods: The Nottingham Health Profile (NHP), a health-related QoL measuring instrument, was employed in 25 nursing homes (n=404 participants). A comparison with a national German representative subsample of independently living elderly individuals (age group over 75) was conducted. Psychometric properties and appropriateness were analyzed.

Results: Our findings indicate an acceptable perception of residents’ QoL. The mean NHP scale scores show that except for the NHP subscale physical ability, the perceived QoL of residents in group-living nursing homes reached nearly the same level as that of independently living elderly individuals (national German reference values, age group over 75 years). QoL-related results on life satisfaction and feeling of happiness confirm the NHP findings. The protocol from a preliminary pilot study could be replicated according to good scientific practice.

Conclusions and Implications: The report presents the first major investigation in the field of subjective quality of life in group-living nursing homes. The study focused on people over 75 years of age with age-specific reduced physical and mental abilities. The NHP should also be considered a reliable, valid and appropriate instrument for older people. Due to the lack of research on residents’ perspectives, further studies should establish age-specific and care setting specific reference data for nursing home residents. In particular, more research is needed to answer the question of which care setting best meets people’s essential needs in older age.

Keywords: Quality of life; Empirical study; Nursing homes; Group-living principle


Diff: Difference between Mean Values; EL: Energy Loss; ER: Emotional Reaction; EQ-5D: Euro Qol-5 Dimension; f: Female; FH: Feeling of Happiness; HUI: Health Utility Index; LS: Life Satisfaction; M: Mean Value; m: Male; NHP: Nottingham Health Profile; OECD: Organization for Economic Cooperation and Development; P: Pain; PM: Physical Mobility; QoL: Quality of Life; S: Sleep; SD: Standard Deviation; SF-36: Short Form Survey 36; SF-6D: Short-Form Survey Six-Dimension; SH: Status of Health; SI: Social Isolation; a: Internal Consistency (Cronbach’s alpha); rtt: Split-Half-Reliability (Spearman- Brown).


Group-living care settings have evolved as a reaction to critical public opinion regarding the hospital-like environment of traditional nursing homes. The concept originated in Sweden and was later introduced in other countries, such as the Netherlands [1], Great Britain [2], France [3], and Japan [4]. Although group-living, home-like nursing homes have been established as an alternative to traditional nursing homes (settings) for many years, there is no generalized definition of the term “group-living nursing home”, but common principles and concepts related to this model include:

• Archetypical nursing homes consist of several group-living units with up to 15 residents living together in each unit.

• Nursing homes provide home-like environments as much as possible.

• An individual space, either a small private apartment or a one-room unit, is provided for each resident. Additional large dayrooms/lounge kitchen areas serve as a shared space, where the majority of daytime is spent together with other residents.

• The idea of ‘active ageing’ is implemented, allowing as much privacy and independence as possible. Comparable to the residents’ former homes, no centralized food and no centralized washing service are provided.

• A mixed care team (an educated care-giver per unit and nursing staff and voluntaries per nursing home) compensates for declining ability and vitality in the residents and lowers the burden for family care.

• A mix of residents (with psychogeriatric complaints, i.e., dementia, and with somatic, physiological ailments) live together.

In public opinion, conventional nursing homes are often associated with single-sided thoughts, such as the last stage before death, poor Quality of Life (QoL) and loss of independence. The implemented German standard assessment instrument for external mandatory evaluation of nursing homes, based on the German Care Transparency Act (§ 115 Abs. 1a SGB XI), mainly focuses on the evaluation of objective quality indicators, primarily structure and process quality attributes. Critical discussions among health scientists, health professionals and health politicians about methodological issues and the lack of outcome criteria led to a recent revision that was introduced in December 2019 [5-9]. Although the newly revised German assessment instrument covers essential outcome quality criteria such as the prevention of mobility loss, independent maintenance of daily activities, and unintended weight loss, and solves most of the mentioned issues, the viewpoint of the residents is still not included.

Current research proposes the implementation of quality of life measurements to cover residents’ viewpoints on care [5,10-16]. To date, only a few studies investigating subjective quality of life in older people can be found. They mainly focus on older, multi-morbid patients without dementia [5,17,18], address patients with dementia partly in special settings [14,15,19-23], and consider care-related measures for nursing home residents [10,16,24]. According to our research, there is still a complete lack of studies on group-living nursing home residents in Germany and elsewhere, apart from one preliminary pilot study published in 2013. In Simon et al. [25], we researched certain quality of life measurements according to the following criteria: a) dimensions that included aspects of physical and mental well-being, social relations and daily life appropriate for the tar-get group of nursing home residents [26], b) validation as paper & pencil questionnaires and face-to-face interviews, and c) the availability of nation-wide age-specific reference values. The selection process included generic profile-based instruments (i.e., Short Form Survey 36/SF-36 and Nottingham Health Profile/NHP) and preference-based measures with a single-dimension index score (i.e., Short Form Survey Six Dimension/SF-6D, Health Utility Index/HUI, EuroQol-5 Dimension/EQ-5D). During the preliminary investigation in 2013, a questionnaire appropriate for elderly individuals could be validated. Descriptive findings in seven nursing homes indicated an acceptable quality of life.

The study presented here has two objectives. Our main intention is to measure residents’ subjectively perceived quality of life in group-living nursing homes. The second aim of our investigation is to replicate our preliminary study results as well as to implement a research protocol [25] according to good scientific practice.

Quality of life was assessed by using the Nottingham Health Profile [27]. The NHP is one of the most commonly used generic scales for measuring health-related quality of life and has already been used in nursing home studies with frail elderly individuals [18,28]. The 38 items, formulated as direct statements, aim to identify self-assessed QoL impairments in six dimensions: physical mobility, pain, sleep, social isolation, emotional reaction, and energy level. Gunzelmann et al. [29] confirmed the psychometric validation of the German NHP version [30]. The authors provided age-specific reference values as a representative subsample.


Participants and data collection

This exploratory cross-sectional study included 25 group-living nursing homes in Germany and was conducted in January 2018. The care provider (private, non-profit organization) is one of the first to introduce group-living nursing homes in Germany. All 25 nursing homes in our sample homogenously follow the cooperative groupliving policy (as mentioned above). There-fore, the investigation was conducted in a standardized setting regarding aspects such as homogenous philosophy of care, similar building features and domestic characteristics, 10 to 14 residents per unit, standardized care concept and qualified mix of staff.

According to our study protocol [25], the inclusion criteria for selecting residents were as follows: living in nursing homes for more than three months and willingness and physical and mental ability to participate in the study. Residents with cognitive impairment, i.e., dementia, were not excluded for ethical reasons. Naturally, many of the residents in nursing homes suffer from various stages of dementia in different stages. They do, however, have the human right to freedom of expression. Nevertheless, nursing home head nurses pre-selected the target population regarding the general ability to understand and answer quality of life and health-related questions. As proposed in the preliminary pilot study, patients with severe depressive symptoms were excluded [25].

Data acquisition was accomplished by face-to-face interviews. Due to the special setting of nursing homes with bodily and cognitively impaired older people (including residents with dementia), we replicated our study design’s introduction procedure [25], comprising four well-prepared steps: (1) all investigators underwent a short training session on qualitative re-search methods and the interview guideline; (2) organized groups (two to three interviewers assigned to each nursing home) visited the related group-living units for two days; and (3) to gain natural contact with the residents, the investigators were introduced to the residents by the head care-giver very early with the start of the morning shift, i.e., they helped prepare breakfast and ate with the residents, assisted with the morning toilette and bed making; and (4) the investigators spent the entire two days together with the nursing home residents to create a familiar atmosphere. In this way, time pressure and uncomfortable situations could mainly be avoided. The nursing home residents and investigators decided freely when and where to perform the interview. The length of the interview was not limited. The investigators were allowed to explain the statements and scales if necessary or to read them aloud.


The measurement tool was administered as a self-reported questionnaire [25]. A German version of the NHP [27] validated by Kohlmann et al. [30] and by Gunzelmann et al. [29] was used for the population of independently living people. The scale consists of 38 QoL items related to six dimensions using a binary (yes or no) scale. Residents confirmed each statement with “yes” (when there was a complaint or limitation, entered as 1) and denied it with “no” (when there was no complaint or limitation, entered as 0) regarding his or her (living) situation at the time of the interview. Following the calculation instructions [30], each ‘yes’ was weighed according to its importance in the dimension and scored between 0 (maximum quality of life) and 100 (no quality of life). The dimensions’ score was not calculated when the resident was unable to completely respond to the related items.

To compare our obtained data with the German reference values, we used a representative subsample of independently living people older than 75 years [25,29]. Furthermore, we added two QoL-related scales to the original pilot study protocol: the OECD life satisfaction scale (2017; single item scale from a minimum score of 0 to a maximum score of 10) and the feeling of happiness scale by Inglehart et al. [31] (Likert scale from 1 - not happy at all to 4 - very happy) and compared our findings with reference data provided by the OECD Better Life Index and the World Value Survey.

Following the original pilot study protocol, we included sociodemographic and health-related variables: age, sex, marital status, length of stay, current state of health (five-point Likert scale from 1 - very poor to 5 - very good), grade of dependency (German assessment standard Pflegegrad) and the AMT4 (shortened version of the Abbreviated Mental Test by Swain and Nightingale [32]).

Statistical analysis

The Statistical Package for the Social Sciences (SPSS), version 23, was used for all analyses. The descriptive results comprise the mean, standard deviation, frequency and percentage. Possible differences between the subsample residents older than 75 years of age and the German reference data of independently living older people were sex-specifically verified using the t-test. The NHP reliability analyses (internal consistency, split-half reliability) and the inter-correlation of the scales were replicated and reported according to our pilot study protocol [25]. Significance was set at the 5% level (p<0.05).


Study population

Out of a total of 1577 residents in 25 nursing homes, 615 were physically and cognitively able to answer the questionnaire. A total of 404 of these residents participated in the study (response rate 66%). Reasons for declining were mainly due to a lack of interest, insufficient time, and absence during the time of interviews. Table 1 shows the baseline characteristics of the participating residents. Seventy-eight percent of the participants were female; the mean age was 84.6; the majority were widowed (76.7%). Approximately two-thirds of the respondents had lived in the nursing home for more than one year. Thirty-three percent of those tested had an impaired cognitive status. Most participants had been categorized as grade 2 or 3 de-pendency.