Jourml of Advanced Nursing, 1993,18, 20-24

Quality of care in nursing homes: from theresident's perspective

Alan Pearson RN ONC RNT DipNEd DipAdvNursStud MSc PhD FRCNA FRCNProfessor of Nursing

Susan Hocking BA(Hons) MAPreviously Senior Research Officer

Sarah Mott RN RPN Dip T (NEd) BAppSa(Nursing)Research Fellow

and Anne Riggs BA(Hons)Research Fellow, Deahn Institute of Nursing Research, E)eahn University, Geelong,Australia

Accepted for publicahon 28 Apnl 1992

PEARSON A, HOCKING S, MOTT S & RIGGS A (1993) Jourml of Advanced

Nurstng 1 8 , 2 0 - 2 4

Quality of care in nursing homes: from ihe resident's perspectiveThis paper derives from a study conducted by the Deakin Institute of NursingResearch between 1988 and 1990, v»?hose major objective was to determine theimpact of staffing mix on nursing residents' quality of care and life Residentsatisfaction with life in the nursing home is a key element m determming thequahty of care and quality of life provided Both the hterature review and thestudy objectives supported the view that resident outcome can be collectedthrough assessing the quality of care and the quality of hfe, through assessmentby informed observers using instruments derived from exphatly statedstandards, and through ehciting the perceptions of residents themselves As d ^ u l e designed to measure satisfaction with care was developed and residentinterviews were undertaken using this measure and the Life Satisfaction Index(A) The majority of responses to the resident satisfaction schedule were positiveThe high percentage of {wsitive responses did not correlate with theobservations of the research assistants and there was some concern that whileresidents were able to assess care they were reluctant to cntiaze the staff or theirbehaviour

INTRODUCTION

This paper denves from a study conducted by the DeakinInstitute of Nursing Research between 1988 and 1990 Themajor obfechve of the study was to detennine the impactc^ staHmg imx on nursing hcsne residents' quality of

Correspondence Professor Alan Pearson School of Health, Umversih/of New England,Anmdak New SmOh Waks 2351, Aastraba

care and life as measured against the outcome standardslaid down m Living m a Nursing Home (Commonwealth/State Woriang Party on Standards 1987) Resident satis-faction with life m the nursing home is a key elementin detomining the quality of care and quahty of life

& Wakkn (I9d4) desnbe the ideal nursinghome as a place where people live their lives with as little

Quahty of care in nursit^ homes

physical or psycho-soaal discomfort as possible, withdignity and a good quality of life The life of the nursinghome resident, they suggest, should be as similar aspossible to the life he or she would choose to lead at home

Consensus view about nursmg homes

Much of the literature focuses on the nature of nursinghome care, and on approaches which emphasize domes-ticity and normality, and rejects the histoncal stereotypeof nursing homes as total institutions which focus onroutine and attempt to replicate hospitals There seems tobe consensus on the view that nursing homes in the futureshould aim at providing 'normal' living environmentswhich promote autonomy and soaal independance inresidents Nursing homes for aged people are consideredto enhance the quality of life of the resident when theyprovide a warm, home-like environment, allowing thegreatest potential for independence and self-direction indaily activities In this respect, nursing home care is viewedwithin a philosophy advocating normalization of hfe, incontrast to the former hospital-style accommodation run inaccordance with a medicalized view of aged care

In a study of 26 nursing homes m the United States,Greenwald & Lmn (1971) found that, as a nursing homegets larger, patient satisfaction and activity declme, andcite a study by Townsend (1962) m the United Kingdom,which revealed similar results

Conversely, in a study which investigated the relation-ship between life satisfaction m residents and the size of anursing home. Curry & Ratliff (1973) found no significantrelationship between the two They did note, however,that residents m larger homes were substantially moreisolated than those m small homes

Institutional environment

The impact of the institutional environment on lifesatisfaction is not fully understood, but Schultz (1976)attnbutes the negative effects of mstitutionalization to theloss of control expenenced by the resident A number ofresearchers argue that the personal charactenstics of theelderly person admitted to a nursing home are the primaryfactors contnbuting to low levels of life satisfaction

Fawcett elal (1980) found that the life satisfaction scoresof 56 mstituhonahzed elderly women related significantlyto a belief m personal influence, and that they relatedmversely to perceived mshtutional restraint Reid et al(1977) found that elderly people who had a low sense ofcontrol, whether mstitutionalized or not, had a more

negative self-image and reported themselves to be lesshappy and content than did those with a high sense ofcontrol

Chang (1979) found that residents had a higher moralewhen they perceived they had control over daily activities,regardless of whether or not they had extemal or internallocus of control Felton & Kahana (1974) found that anextemal locus of control was significantly related tosuccessful adjustment among institutionalized elderly

In a study of 113 residents drawn from a sample ofintermediate and skilled care faalities in the United StatesRyden (1984) found that functional dependency, healthand socio-economic status had a significant, direct effect onthe morale of residents in intermediate care settings andthat the resident perception of situational control had asignificant effect on morale m skilled care facilities Moralewas measured using the Philadelphia Genatnc CenterMorale Scale, Chang's Situational Control of Daily Activi-ties Scale and a resident questionnaire The instruments,though well tested, were lengthy and the study, whichinvestigated residents in four nursing homes, proved tobe very time-consuming The fmding that those m sblledcare facilities were affected only by their perception ofsituational control seems to be of importance

Skilled facilities in the United States closely resembleAustralian nursing homes, and increasing control byresidents has been found to increase overall morale m otherUnited States studies related to such facilities In a study onincreasing morale by lnfluencmg control, Langer & Rodin(1976) and Shultz (1976) report findings which supportRyden (1984), who concludes

Caregivers who consistently communicate a clear belief m thenght and responsibility of the resident to be self-directing, andwho offer choices whenever possible, may alter not only theobjective extent of control by residents but also the subjectiveperception of control

Life satisfaction

Sherwood (1986) found little difference in life satisfactionrates between elderly people being cared for m nursmghomes, day hospitals, senior citizen centres and amongthose cared for by visiting nurses, in a reasonablehomogenous sample of the elderly They found, however,that nursing homes and hospitals were both the mostrestnctive and the most expensive to run

Minkler (1984) argues that the goals of promotingmdividual autonomy and enhancmg the quality of hfe willonly be attamable m nursing homes when the dependency-producing nature of nursmg homes undergoes major

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A Pearson et al

change Such change, he argues will only come aboutthrough a reversal in the attitudes of nursmg home stafftowards care giving, the elderly and the purpose of nursinghomes In reviewing patients' nghts in the United StatesWilson (1978) argues that the only way they can beenforced is by instituting a atation system of monetarypenalties for violations of residents' nghts

Storlie (1982) discusses the constraints and limitations oflife m a nursmg home and reports that residents expen-enced difficulties m adapting to the change in lifestyleimposed on them by these constraints Knapp (1977) foundthat life satisfaction m a sample of elderly people livmg mthe United Kingdom was directly related to the degree ofsoaal interaction or level of activity by the mdividual andates a range of studies with similar results There is also alarge literature on the nature of activities and their realrelevance to the quality of life expenenced by residents

THE STUDY

Both literature review and study objectives supported theview that resident outcome can be collected throughassessing the quality of care and the quality of life,through assessment by informed observers usmg instru-ments denved fi-om explicitly stated standards and througheliatmg the perceptions of residents themselves

To ensure a balanced view of resident outcomes and toaddress the problems raised in the literature on residentoutcomes based on the observers' point of view, the studyalso 'measures' resident outcomes using a resident satis-faction scale developed for the study and a widely usedquality of life scale Both of these scales were administeredthrough interviews v«th residents of the nursing homesstudied

Data

Two data sets were collected m order to gather thisinformation

1 quality of care/life as asessed by informed observers —from a quality of care/life observation schedule,

2 quality of care/life as perceived by residents — from aresident interview schedule

In terms of the design the factors essentially beyondcontrol such as size of home and type of home (chantableor pnvate-for-profit) were included in the design asmdependent vanables, and controlled for the analysisVanables such as size and type of home can be controlledmore ngorously if they are included as strata m the selectionof the sample and replacement for refusals is undertakenwith each relevant stratum Figure 1 illustrates the overall

Figure 1 Design of the study

design of the study which encompassed a range of van-ables grouped in the category of organizational vanableswhich included size of home, type of home and location ofhome

Residents

It was required that individual residents be selected for anexamination of the nursing plan and other observations onthe outcome standards, residents' perceived life satisfac-tion, and Resident Classification Instrument This wasundertaken by selecting five individual residents for theoutcome standards, one in four individuals for life satisfac-tion with a minimum of five residents and a maximum ofeight residents (individuals who were unable to respondwere replaced), and 50% of residents for the ResidentClassification Instrument

Residenis' perception ofqualiiy

A number of approaches to measure residents' perceptionof the quality of life have been reported on m the literatureIn the pilot instruments, a senes of broad, 'global' questionswere addressed to individual residents m an interviewearned out by a research assistant These questions were

1 What do you like most about living m this nursmghome?

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Quality of care in nursing homes

Table 1 Responses toresident satisfaction schedule(percentage of respondents)

'Denotes items where a response ofdisagree is a positive response aboutthe home

12345678

9101112131415

It IS noisy here*I hke the foodThe meals are boring*If I need help from the staff they come quicklyThe staff are interested in meThe home organizes outingsI enjoy going on organized outingsI enjoy doing the activities organized inside

the homeI have enough say in what I do with my timeI can vary my daily routineIt IS boring in this home*I feel I have enough privacyThere are interesting people to talk toMy family and fnends are welcomeSometimes language is a barrier between the

staff and myself*

Agree

29 777 426 874 176 080 448 7

62 383 768 029 986 863 096 3

161

Disagree

64 914 466 314 311515 243 2

31411126 664 611429 3

16

79 0

Undecided

54826 9

11612 5448 1

6452545518772 1

4 9

2 What do you like least about living in this nursing

home?

3 What things do you do in this nursing home?

4 What things would you like to do?

RESULTS

The results were disappointing The Resident InterviewSchedule was found to be difficult to use and analyse, andnot as effective as required for the study Some of theresidents selected randomly for interview were confusedand unable to participate It was felt that this instrumentneeded to be supplemented with a more objective, quantifi-able schedule, and that the number of residents interviewedshould be increased so that a greater number of responsescould be elicited from articulate residents

Measurement of satisfaction

From the responses to the questions, a schedule designedto measure satisfaction with care was developed (Table I)Resident interviews were undertaken using this measureand the Life Satisfaction Index (A), developed by Neugartenetal (1961) Data were collected from 1374 residents

It IS acknowledged, however, that such an approachIgnores the perceptions of residents who are confused ordisonented There is insufficient evidence in the literaturethat the use of advocates is a valid alternative for con-

fused residents, and utilizing such an approach would beprohibitive in terms of time It was reasonable to assumethat quality of care/life for the confused resident would,however, be assessed through the observation schedulewhich looked at quality of care/life

In terms of resident perception of the quality of care,the literature is less helpful, with much of it arguing thatthe consumer is often unable validly to assess careSome reports suggest, however, that if structured, non-judgemental questions are used, resident perception ofquality of care can be measured

Positive responses

As can be seen from Table 1, the majonty of responsesto the resident satisfaction schedule were positive Theresponses to question 7 'I enjoy going on organized out-ings' and question 8 'I enjoy doing the activities organizedinside the home' were more evenly divided between thosewho stated they disagreed and those who agreed The highpercentage of positive responses did not correlate with theobservations of the research assistants and there was someconcern that while residents were able to assess care theywere reluctant to criticize the staff or their behaviour

Rhys Heam (1986) also found that the majonty ofresponses tended toward the bland, 'very nice really'variety Similarly, the research assistants reported that theresidents were reluctant to complam about their 'home' tothe interviewers

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Acknowledgement

This paper was based on a study of optimal shils mix fordesired resident outcomes in non-government nursinghomes, funded by The Commonwealth Department ofCommuruty Services and Health, 1988

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Fawcett G, Stonner D & Zepelin H (1980) Locus of control,perceived constrant, and morale among institutionalizedaged International Journal of Agtng and Human Development

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Felton B & Kahana E (1974) Adjustment and situationally-bound locus of control among institutionalized aged Journal of

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