Exploring Preference Fulfillment Among Older Adults Receiving Long-Term Care: Consistency of Satisfaction Ratings

Recent work has called for a culture change in long-term care (LTC) that shifts away from a medical model to one in which a resident’s values, past history, and current preferences become the center of care delivery.^1,2 Such a shift in practice principles has been advocated for by residents, families, and professionals as the right thing to do, and a developing empirical record supports the benefits of individualized person-centered care (PCC).^3-12  Within this frame, an assessment of resident preferences serves as the cornerstone to care planning with reported preferences guiding care.^13,14 For example, when a person indicates listening to music is very important, providers can ensure recreational support is provided.

Equally important as ratings of preference importance are ratings of satisfaction. How satisfied a resident is with the fulfillment of important preferences can guide quality improvement in care delivery. When the same resident described above is highly satisfied with how her preference for music is being met, no change in care is required. But when she is dissatisfied, new strategies to honor her preference may be needed. Research supports the validity and reliability of reports of satisfaction with care and links care satisfaction with health and well-being outcomes.^15-19 In addition, research identifies factors of the person and the environment that can enhance satisfaction.^20-22 Less addressed is the reliability of reports of satisfaction with preference fulfillment in LTC. Understanding whether recipients of LTC are consistent in their reports of satisfaction is critical. Inconsistent reports make it difficult for staff to use preference fulfillment satisfaction ratings as benchmarks for care planning. On the other hand, consistent reports of satisfaction with preference fulfillment validates their use as meaningful indicators for designing PCC quality improvement programs.

Preference-Based Care

While definitions of PCC vary, all maintain the importance of placing the person at the center of care delivery.^1,23-25 This includes psychological, social, spiritual, and physical attributes. Care that centers on the person honors his or her goals, values, and preferences, as well as unique history, sense of choice, autonomy, and dignity. A cornerstone to the delivery of PCC, therefore, is the assessment of preferences (ie, expressions of how one would like his or her needs met) and integration of individual important preferences into care planning. Recent work by Van Haitsma and colleagues has demonstrated the utility of preference assessments.¹⁴ By leveraging assessments of preferences in care planning, such as those asked in the Preferences for Everyday Living Inventory or Section F of the MDS 3.0, care can be tailored to the individual’s likes and dislikes.^26-28 Assessment in any LTC setting upon initiation of the care services can result in integration of preferences into the plan of care. The National Nursing Home Quality Improvement Campaign (NNHQIC, formerly the Advancing Excellence Campaign) has promoted such a practice to support facilities in achieving PCC through the development of tools specifically designed to accomplish this goal (the NNHQIC PCC tool).²⁹ Nursing home (NH) regulations for Self-Determination and Participation (§483.15[b]), further specify the rights of residents to “choose activities, schedules, and health care consistent with his or her interest, assessments, and plans of care” and to “make choices about aspects of his or her life in the facility that are significant to the resident.”³⁰ Studies examining the integration of knowledge of individual psychosocial preferences into care have specifically shown improved decision making, enhanced quality of care outcomes, and positive quality of life.^3-5,9-12

Satisfaction With Care

Satisfaction reports are commonly employed to assess quality of care in LTC.³¹  Research links care satisfaction with health and well-being outcomes and also identifies factors that can enhance satisfaction.^17-22 For example, higher levels of choice in NHs have been linked with greater satisfaction.²⁰ However, satisfaction ratings may capture more than just a reflection of current care outcomes.^18,32 Reports of satisfaction may pick up on a history of care delivery, such as organizational practices and policies that limit delivery of care in a specific way (eg, facility schedules that limit the number of showers) or recipients’ subjective appraisal of the quality of the program. 

A component of the NNHQIC PCC tool is satisfaction ratings of fulfillment of important preferences.¹³ The inclusion of such questions allows the voice of the individual resident to be heard  about whether care is meeting desired preferences.^33,34 Yet, little is known about how consistent these reports of satisfaction by individuals receiving LTC services are and whether they can be used as a valid metric for care-planning purposes.^35,36 

Consistency of Preference Ratings and Ratings of Satisfaction

Research has found importance ratings of preferences are generally consistent over a 1-week period, particularly for personal care preferences of NH residents.²⁷ However, research also finds some variability in reports of leisure preferences.²⁷ Shifts in preference importance ratings can be due to within-person (eg, functional ability), facility environment (eg, facility schedule), social environment (eg, quality of interactions), or global environment (eg, weather) factors.³⁷ We have not developed a full understanding of how consistent individuals’ reports of their satisfaction with preference fulfillment are. Studies in other areas have demonstrated that scales assessing satisfaction can achieve high levels of consistency, such as satisfaction in activities of daily living, satisfaction with homecare services, family satisfaction with cancer care, mealtime satisfaction in LTC, and satisfaction with assistive technology services.^15,16,38-40 Yet, research has not explored if ratings for how satisfied older adults are with the fulfillment of important everyday preferences are reported consistently over time. Understanding the rating consistency of satisfaction is critical to validating the use of such pragmatic measures in care practice.

Current Study

This study aimed to determine if older adults’ satisfaction ratings for everyday preference fulfillment are consistent over a short period (ie, 3 days). We interviewed LTC recipients about their satisfaction with preference fulfillment 2 times: at baseline (time 1, or T1) and then 3 days later (time 2, T2). The time frame of 3 days was chosen to ensure as little contamination as possible of intervening events that could influence satisfaction.⁴¹ In other words, we sought to reassess satisfaction prior to adjustments by the care team to better align with the individual’s preferences or any changes in health status. 

Methods 

Participants

This study included 49 older adults (aged 62-104) receiving care from a single LTC organization in the Northeastern United States that provides skilled nursing care, short-term rehabilitation, assisted living, and adult day health services. To be eligible, participants had to: (1) speak English; (2) have received care through the organization for at least 1 week with continued care expected for at least 1 more week; (3) be medically stable (ie, not at end of life); and (4) be cognitively capable of completing 2 short 10- to 15-minute interviews about their everyday preferences. Cognitive ability was considered appropriate for participation with a Brief Interview for Mental Status score of 13 to 15, a Mini-Mental State Examination score of 22 or higher, or clinical judgment that the older adult could participate in 2 short interviews. Eligible individuals were referred in one of 2 ways: (1) the director of nursing reviewed a list of participants in an ongoing research project assessing individual preferences in the skilled nursing facility (SNF) and indicated if the individual was eligible for participation in this study, or (2) the director of the personal care/adult day program identified potential participants. 

While the majority of participants were recruited from the organization’s SNF, individuals were also eligible from the personal care home (assisted living), short-term rehabilitation program, or adult day services program. Ninety-one older adults were identified for possible participation (n=61 from SNF, n=15 from personal care, and n=15 from adult day services). Of those referred, 49 completed a T1 interview and 45 completed both a T1 and T2 interview; 25 were not eligible due to lack of medical stability, cognitive capacity, availability for both interviews, or death; and 17 were referred but not contacted before recruitment goals were met. 

Procedures

Study procedures were approved by a federally assured institutional review board. Upon receiving confirmation of cognitive ability and medical stability, a trained research assistant approached each referral, reviewed study procedures, and sought informed consent. 

Upon agreement to participate, the research assistant conducted the T1 interview, which consisted of a demographic questionnaire and a preference importance/satisfaction questionnaire. 

Three days after T1, the research assistant returned and completed the T2 interview, which consisted only of the satisfaction questions. If the participant was not available exactly 3 days after the first interview, efforts were made to reach the participant the day prior or the day after.

Interviews lasted, on average, 6.53 minutes (SD=2.58) for T1 and 4.70 minutes (SD=1.66) for T2. Forty interviews were completed 3 days apart, 4 were completed 2 days apart, and 1 was completed 4 days apart (m=2.93 days, SD=0.33).

Demographic questionnaire. Participants reported on their birthdate, race/ethnicity, marital status, and highest level of education, as well as their ability to see and hear. Ethnicity was coded as 1 (yes, Hispanic/Latino) and 0 (not Hispanic/Latino). Race was coded as 1 (Asian), 2 (Black/African American), 3 (White), 4 (American Indian/Alaskan Native), or 5 (Native Hawaiian/Pacific Islander). Marital status was coded as 1 (married/partner), 2 (widowed), 3 (divorced), 4 (separated), or 5 (never married). Education was coded from 1 (less than high school) to 6 (graduate degree). 

Ability to see and hear were asked in accordance with the Minimum Dataset 3.0 (MDS 3.0) and coded as 0 (adequate) or 1 (impaired). In the case of impairment, follow-up questions determined the degree. Sensory ability was assessed to provide the interviewer with a sense of each participant’s capacity to hear and see the questions and answers and to ensure sensory deprivation would not impact consistency in reports. 

Preference interview with satisfaction. SNFs that are Medicare- or Medicaid-certified routinely provide comprehensive clinical assessments of residents’ functional capabilities through the MDS 3.0.28  Included in this clinical assessment are 16-items in Section F (Preference Assessment Tool, or PAT) that ask clients to rate the importance of everyday preferences. PAT items were informed, in part, by the Preferences for Everyday Living Inventory (PELI).^26,42 The PAT has been found to capture variation in preference patterns in NH residents and has been adopted by the NNHQIC to advance quality care delivery as a component of their PCC goal.⁴³ 

This study used the NNHQIC 16-item PAT, which covers a variety of topics from leisure pursuits to personal care preferences. Respondents were asked to rate these items on “How important is it to you to…(insert preference)” with a 4-point Likert scale of 1 (very important), 2 (somewhat important), 3 (not very important), or 4 (not important at all). Respondents could also select 5 (important but no choice or cannot do). Scores were reverse coded to indicate higher scores as greater importance and lower scores as lower importance. 

If a participant said a preference was very important, somewhat important, or important but cannot do, they were asked how satisfied they have been with their preference being met in the past week. To respond, participants used a 3-point Likert scale from 1 (mostly or completely satisfied) to 3 (not satisfied at all). Satisfaction scores were reverse scored to ease interpretation of findings, with higher scores indicating higher levels of satisfaction and lower scores indicating lower levels of satisfaction with preference fulfillment.

Analyses

In line with prior work examining test-retest reliability of older adults’ responses regarding care satisfaction, we used Pearson correlations to assess the consistency of responses on satisfaction with preference fulfillment.^15,38 Correlations examined the association between T1 and T2 reports for each preference. 

Results

In the final sample, 28 older adults participated from the SNF, 12 from the personal care home, and 9 from the adult day services program. See Table 1 for sample demographic characteristics.

Test-retest reports of satisfaction with preference fulfillment were consistent over a 3-day time frame (Table 2). Correlations between responses at T1 and T2 for each satisfaction item were significant for 13 of the 16 items (r=.46-1), indicating consistency in reported levels of satisfaction at T1 and at T2. The association of T1 and T2 reports was not significant for 3 items: choosing what clothes to wear, taking care of one’s own personal belongings or things, and listening to music you like (r=.23-.28). 

Discussion

This study sought to determine if ratings for how satisfied LTC recipients were with important everyday preferences being fulfilled were consistently reported over 3 days. Results indicate that participants in this sample were consistent. This finding carries key implications for research and practice, most pointedly that ratings of satisfaction with preference fulfillment are reliable indicators to use in care planning. 

While test-retest reliability over a short period (eg, few days, 2 weeks) has been established for reports of satisfaction with other aspects of care such as activities of daily living, homecare services, LTC mealtimes, cancer care, and assistive technology services, this study is the first to our knowledge to consider the consistency of reports of satisfaction with fulfillment of preferences being met for LTC recipients.^15,16,38-40 Results demonstrate a high level of consistency in reports of satisfaction across an average of 3 days for most (13 of 16) preferences.

Consistency may mark that one’s feelings of satisfaction are not likely to change over the course of a few days and are therefore important to target in goal planning. It may also mean that care over 3 days is consistently delivered, leading to consistent responses in satisfaction. Either interpretation means that the level of reported satisfaction could be targeted for care planning goals to align care with important preferences. More specifically, low ratings of satisfaction of preference fulfilment could act as triggers for targeting resources in the care delivery process. Staff could think about how to best accommodate unsatisfied preferences in their work flow. If it were shown that satisfaction ratings were variable over 3 days, clinicians may have struggled with creating goals for clients. But with high levels of consistency, clinicians can be assured that their efforts to modify care are meaningful.

Yet, a few preferences did show greater variability in satisfaction ratings over 3 days. Lower test-retest associations were found for choosing what clothes to wear, taking care of one’s own personal belongings or things, and listening to music. Prior research demonstrates importance ratings for preferences for choosing what clothes to wear and taking care of one’s own personal belongings or things are highly consistent.²⁷ A reason for the differences in T1 and T2 satisfaction reports could be that older adults’ satisfaction for these preferences changes slightly from day to day, perhaps depending on a care experience or a change in mood. For example, the shift in rating may reflect that one day the caretaker allowed the resident to choose what clothes to wear, but the caretaker on the following day did not. Meanwhile, importance ratings for the preference of listening to preferred music have been found to be more variable over a 1-week test-retest period.²⁷ The variability in satisfaction ratings for this preference may fluctuate in response to changing feelings about music. To better understand these findings, open-ended questions could be added to the assessment to determine how care has been delivered recently or if the resident has recently participated in specific activities that influenced preference importance and satisfaction. Such additional data would inform our understanding of satisfaction ratings for these items. Overall, findings encourage the use of assessments of resident satisfaction with fulfillment of important everyday preferences. 

This work is not without limitations. First, the study was completed as a pilot examination of the consistency of preference satisfaction ratings. Generalizability is limited by the small sample from a single organization. Participants were highly educated with minimal cognitive impairment. In addition, participants were predominantly referred by the director of nursing or the director of the adult day program, which may have resulted in a biased sample of participants actively involved in their care. Additional work should explore whether these results hold up in a larger, more diverse sample. Second, this project assessed consistency over 3 days to avoid contamination of care events that could influence feelings of satisfaction. This time frame may be too short to draw meaningful conclusions about consistency; testing across additional time frames may prove more informative. Additional research is needed to see how far apart satisfaction can be rated to understand the sensitivity of preference satisfaction ratings. Third, this study did not explore the impact of personal or care environment characteristics on reports of satisfaction with preference fulfillment. Prior research indicates that personal and contextual characteristics can impact satisfaction beyond current circumstances and, therefore, additional research should examine this in relation to ratings of satisfaction with LTC preference fulfillment.^18,20,32 Finally, participants were individuals who could self-report their preferences and satisfaction. The perspectives of individuals unable to communicate due to severe cognitive impairment are not represented. Additional assessment tools are needed to understand satisfaction among these individuals.

Conclusion

This novel work explores the consistency of a pragmatic clinical assessment tool that can be used to inform the delivery of PCC. Findings support the use of satisfaction ratings as reliable indicators for informing preference-based care delivery. Care planning approaches that consider how satisfied a person is with having his or her preferences met can honor the individual and move the LTC industry away from a medical model of care to one centered on the person. 

References

1. American Geriatrics Society Expert Panel on Person-Centered Care. Person-centered care: A definition and essential elements. J Am Geriatr Soc. 2016;64(1):15-18.

2. Edvardsson D, Varrailhon P, Edvardsson K. Promoting person-centeredness in long-term care: an exploratory study. J Gerontol Nurs. 2014;40(4):46-53.

3. Cohen-Mansfield J, Marx MS, Thein K, Dakheel-Ali M. The impact of past and present preferences on stimulus engagement in nursing home residents with dementia. Aging Ment Health. 2010;14(1):67-73. 

4. Gerdner LA, Schoenfelder DP. Evidence-based guideline. Individualized music for elders with dementia. J Geront Nurs. 2010;36(6):7-15. 

5. Lawton MP, Van Haitsma K, Klapper J, Kleban MH, Katz IR, Corn J. A stimulation-retreat special care unit for elders with dementing illness. Int Psychogeriatr. 1998;10(4):379-395. 

6. McCormack B, McCance TV. Development of a framework for person-centred nursing. J Adv Nurs. 2006;56(5):472-479. 

7. Radwin LE, Alster K. Individualized nursing care: an empirically generated definition. Int Nurs Rev. 2002;49(1):54-63. 

8. Robinson JH, Callister LC, Berry JA, Dearing KA. Patient-centered care and adherence: definitions and applications to improve outcomes. J Am Acad Nurse Pract. 2008;20(12):600-607. 

9. Simmons SF, Schnelle JF. Individualized feeding assistance care for nursing home residents: staffing requirements to implement two interventions. J Gerontol A Biol Sci Med Sci. 2004;59(9):M966-M973. 

10. Thompson DL, Smith DA. Continence restoration in the cognitively impaired adult. Geriatr Nurs. 1998;19(2):87-90. 

11. Van Haitsma KS, Curyto K, Abbott KM, Towsley GL, Spector A, Kleban M. A randomized controlled trial for an individualized positive psychosocial intervention for the affective and behavioral symptoms of dementia in nursing home residents. J Gerontol B Psychol Sci Soc Sci. 2015;70(1):35-45.

12. Whitlatch CJ. Person-centered care in the early stages of dementia: honoring individuals and their choices. Generations. 2013;37(3):30-36.

13. Van Haitsma K, Crespy S, Humes S, et al. New toolkit to measure quality of person-centered care: development and pilot evaluation with nursing home communities. J Am Med Dir Assoc. 2014;15(9):671-680.

14. Van Haitsma K, Abbott KM, Heid AR, et al. Honoring nursing home resident preferences for recreational activities to advance person-centered care. Ann Longterm Care. 2016;24(2):25-33.

15. Archenholtz B, Dellhag B. Validity and reliability of the instrument Performance and Satisfaction in Activities of Daily Living (PS-ADL) and its clinical applicability to adults with rheumatoid arthritis. Scand J Occup Ther. 2008;15(1):13-22.

16. Pizzola L, Martos Z, Pfisterer K, de Groot L, Keller H. Construct validation and test-retest reliability of a mealtime satisfaction questionnaire for retirement home residents. J Nutr Gerontol Geriatr. 2013;32(4):343-359. 

17. Crogan NL, Dupler AE, Short R, Heaton G. Food choice can improve nursing home resident meal service satisfaction and nutritional status. J Gerontol Nurs. 2013;39(5):38-45.

18. Kane RL, Maciejewski M, Finch M. The relationship of patient satisfaction with care and clinical outcomes. Med Care. 1997;35(7):714-730.

19. McNeill JA, Sherwood GD, Starck PL, Thompson CJ. Assessing clinical outcomes: patient satisfaction with pain management. J Pain Symptom Manage. 1998;16(1):29-40.

20. Bangerter LR, Heid AR, Abbott K, Van Haitsma K. Honoring the everyday preferences of nursing home residents: perceived choice and satisfaction with care. Gerontologist. 2017;57(3):479-486.

21. Melchiorre M. Relationship of hospitalized elders’ perceptions of nurse caring behaviors, type of care unit, satisfaction with nursing care, and health outcome of functional status. Int J Human Caring. 2016;20(3):134-141.

22. Shippee TP, Henning-Smith C, Gaugler JE, Held R, Kane RL. Family satisfaction with nursing home care: the role of facility characteristics and resident quality-of-life scores. Res Aging. 2017;39(3):418-442. 

23. Dementia Action Alliance. Living with Dementia: Changing the Status Quo. https://daanow.org/wp-content/uploads/2016/04/Living_Fully_With_Dementia_White-Paper_040316.pdf. Accessed April 27, 2018.

24. Kitwood T. Dementia reconsidered: The person comes first. New York, NY: Open University Press; 1997.

25. Pioneer Network. Defining Culture Change. Pioneer Network website. https://www.pioneernetwork.net/culture-change/what-is-culture-change/. Accessed April 27, 2018.

26. Van Haitsma K, Curyto K, Spector A, et al. The preferences for everyday living inventory: scale development and description of psychosocial preferences responses in community-dwelling elders. Gerontologist. 2013;53(4):582-595. 

27. Van Haitsma K, Abbott K, Heid AR, et al. The consistency of self-reported preferences for everyday living: implications for person-centered care delivery. J Gerontol Nurs. 2014;40(10):34-46.

28. Saliba D, Buchanan J. Development and validation of a revised nursing home assessment tool: MDS 3.0. Centers for Medicare & Medicaid Services websitehttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/downloads/MDS30FinalReport.pdf.. Published April 2008. Accessed April 27, 2018.

29. National Nursing Home Quality Improvement Campaign. Person-Centered Care. https://www.nhqualitycampaign.org/goalDetail.aspx?g=PCC. Accessed April 27, 2018..

30. CMS Manual System: Pub. 100-07 State Operations Provider Certification, Revision to Appendix PP. Centers for Medicare & Medicaid Services website. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R48SOMA.pdf. Published June 12, 2009. Accessed April 27, 2018.

31. Simmons SF, Schnelle JF. Strategies to measure nursing home residents’ satisfaction and preferences related to incontinence and mobility care: implications for evaluating intervention effects. Gerontologist. 1999;39(3):345-355.

32. Klose K, Kreimeier S, Tangermann U, Aumann I, Damm K, RHO Group. Patient- and person-reports on healthcare: preferences, outcomes, experiences, and satisfaction – an essay. Health Econ Rev. 2016;6(1):18. 

33. Paulus D, Jans B. Assessing resident satisfaction with institutional living: developing a tool. J Gerontol Nurs. 2005;31(8):6-11.

34. Vaismoradi M, Want IL, Turunen H, Bondas T. Older people’s experiences of care in nursing homes: a meta-synthesis. Int Nurs Rev. 2016;63(1):111-121.

35. Arling G, Kane RL, Lewis T, Mueller C. Future development of nursing home quality indicators. Gerontologist. 2005;45(2):147-156.

36. Sitzia J. How valid and reliable are patient satisfaction data? An analysis of 195 studies. Int J Qual Health Care. 1999;11(4):319-328.

37. Heid AR, Eshraghi K, Duntzee CI, Abbott K, Curyto K, Van Haitsma K. “It depends”: reasons why nursing home residents change their minds about care preferences. Gerontologist. 2016;56(2):243-255. 

38. Hsieh CM. A client satisfaction measure of homecare services for older adults. J Soc Serv Res. 2017;43:487-497. 

39. Kristjanson LJ. Validity and reliability testing of the FAMCARE scale: measuring family satisfaction with advanced cancer care. Soc Sci Med. 1993;36(5):693-701.

40. Sund T, Iwarsson S, Anttila H, Helle T, Brandt A. Test-retest reliability and agreement of the Satisfaction with the Assistive Technology Service (SATS) instrument in two Nordic countries. Physiother Theory Pract. 2014;30(5):367-374. 

41. Marx RG, Menezes A, Horovitz L, Jones EC, Warren RF. A comparison of two time intervals for test-retest reliability of health status instruments. J Clin Epidemiol. 2003;56(8):730-735. 

42. Housen P, Shannon GR, Simon B, et al. What the resident meant to say: use of cognitive interviewing techniques to develop questionnaires for nursing home residents. Gerontologist. 2008;48(2): 158-169. 

43. Roberts TJ, Gilmore-Bykovskyi A, Lor M, Liebzeit D, Crnich CJ, Saliba D. Important care and activity preferences in a nationally representative sample of nursing home residents. J Am Med Dir Assoc. 2018;19(1):25-32.