Allison R. Heid
2949 Oakford Road
Ardmore, PA 19003
Phone: (703) 727-6570
This study sought to understand the consistency of ratings over a 3-day test-retest period for how satisfied long-term care recipients were with the fulfillment of important everyday preferences. Pearson correlations were assessed for reports of satisfaction on 16 everyday preference items by 49 older adults (aged 62-104). Participants received services from skilled nursing, assisted living, or an adult day health program provided by a single long-term care organization. Results indicate that participants in this sample were consistent in reports of satisfaction of preference fulfillment over 3 days on 13 of 16 preferences. This finding indicates that ratings of satisfaction with preference fulfillment are reliable indicators to use in care planning.
Key words: test-retest reliability, care preferences, care satisfaction
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.
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.
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.
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.
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.
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.
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).
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.
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.
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