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How "real" is your resident satisfaction survey? High "satisfaction" levels are wonderful, aren't they? Not necessarily.

High "satisfaction" levels are wonderful, aren't they? Not necessarily.

Many nursing facilities conduct satisfaction surveys, but few do it well. How can you determine whether your facility is evaluating satisfaction effectively?

One way is to examine the results of your facility's most recent satisfaction survey. First, did you survey residents, their family members, or both? A typical approach is to interview the family members, friends and/or healthcare representatives of residents as proxies for the residents' opinions. Recent research has clearly demonstrated, though, that satisfaction information collected from the direct customers of nursing care, i.e., the residents, is different from satisfaction information collected from any other group.

Specifically, other proxy groups tend to rate care more positively than residents do, and they rate specific aspects of care differently in terms of order of importance. Thus, if you want the opinions of nursing home residents with respect to satisfaction with care, you have to ask the residents themselves. Second, if you have collected satisfaction information from residents, examine the results to see if a majority responded favorably to most questions. If so, your satisfaction instrument probably needs revision.

Don't get us wrong. We're not saying you aren't doing a good job and residents don't know it. What we are saying is that it is relatively easy to conduct a satisfaction survey of nursing home residents that produces inflated satisfaction levels, There are several reasons for this.

First, many residents suffer from cognitive and/or emotional conditions that might distort their perceptions and/or reduce their expectations of the care they receive. In addition, older adults - women in particular - tend to report higher rates of satisfaction with healthcare services than younger groups; thus, there is a good chance that extremely old and frail nursing home residents, who are predominantly female, will report high rates of satisfaction with substandard or inadequate care. The fact that nursing home residents are dependent on staff for daily care can only decrease their willingness to express truthful dissatisfaction.

A further complication is that the format of many satisfaction questionnaires invites positive responses - what investigators call an "acquiescent response bias." Nursing home residents will tend to respond favorably to questions of this sort regardless of the quality of care they are receiving.

We propose, in this article, to address ways to more effectively evaluate resident satisfaction using methods designed to temper potential acquiescent response biases. First, however, we should explain why you should want to avoid inflated satisfaction levels. ("What," you might ask, "is wrong with persistently positive satisfaction results?" Absolutely nothing, if your sole intent is to collect data for public relations purposes.) We believe that satisfaction data, as opposed to just making your services look good, should be used to improve services so, in fact, your services are good.

To do this, satisfaction data must reveal both your facility's strengths and weaknesses. You can't identify areas that need improvement if resident responses to all or most of your satisfaction questions cluster at the "highly satisfied" end of the scale. Therefore, you need to ask questions that are sensitive to differences in satisfaction levels.

To identify these types of questions, we tested three methods of measuring satisfaction with 111 residents of three nursing facilities. Focusing on two important care areas, incontinence and mobility, we first determined the daily frequency with which these care activities were provided. These data provided an objective measure of care frequency that could be compared with residents' subjective ratings.

We then conducted personal interviews with residents using an instrument that included the three methods of measurement. The methods differed from each other in the degree to which a direct response about satisfaction was required of residents. We categorized the methods as follows:

1. Global satisfaction questions about specific care areas, which required the most direct responses (e.g.,"Overall, are you satisfied with how often someone helps you to walk?");

2. Direct questions about preferences within specific care areas (e.g., "Would you like to walk more?" "Would you like to walk less?" and "How many times during the day would you like someone to help you walk?"); and

3. Open-ended comments about care activities, spontaneously provided by the resident during the interview.

Based on findings from previous methodological studies of satisfaction, we hypothesized that the methods requiring less direct responses (methods 2 and 3) would produce different response patterns, which might reflect higher rates of dissatisfaction, Higher rates of "dissatisfied" responses would, as we've suggested, be more useful for evaluating efforts to improve care. With few exceptions, we were right.

Consider the results from the questions pertaining to mobility assistance. When asked the global satisfaction question, "Overall, are you satisfied with how often someone helps you to walk?" only 19% of respondents said "no." based on this result, many nursing facilities would conclude that most residents are "satisfied" with their current level of walking assistance; thus, this care area is not viewed as a weakness in the facility. Methods 2 and 3, however, revealed that this would be an erroneous conclusion.

Despite the low percentage of "dissatisfied" residents in response to the global satisfaction question, method 2 revealed that 45% of residents would like to walk more - a preference that assesses a different aspect of "satisfaction" and might imply dissatisfaction with current levels of walking assistance. Furthermore, when residents were asked how many times each day they would like to walk, 74% stated a preference for once a day or more. In contrast, however, direct observations showed that only 27% of the residents actually received walking assistance on a daily basis.

Based on these data, we created an "objective satisfaction" index representing the discrepancy between each resident's stated preference and his/her corresponding objective frequency of received walking assistance. Results indicated that 79% of the resident sample reported a preference for more frequent walking assistance per day than was provided by staff. For example, many residents reported wanting assistance two to three times per day, but staff provided walking assistance to these residents zero to one time per day.

Finally, open-ended comments spontaneously provided by the residents revealed aspects of care that they considered to be important. For example, one resident stated, "I would like to have somewhere important to go [when walking], as opposed to just walking down the hall." This resident's satisfaction with walking assistance might increase if such assistance were rendered on her way to the dining room for meals or to a social activity, as opposed to a structured walk down the hall rendered according to the convenience of staff.

Residents often made excuses for staff such as, "I would like to walk more, but I feel it's an imposition on the staff; they are very busy." Such comments suggest that many residents might have reduced expectations of care; thus, they might be conditioned to be "satisfied" with low levels of care.

What do we conclude from these results? Clearly, the three methods reveal different proportions of "satisfied" residents; however, more research is needed before we can recommend the method that most accurately reflects residents' satisfaction with daily care activities. For now, we advocate that all three methods be used in combination. The results will differ according to the method used and will thus be more useful for developing interventions to improve care.

What else can you do to evaluate resident satisfaction more effectively? Make sure your sample includes residents who show a wide range of cognitive and physical impairment. In many facilities, cognitively impaired residents are automatically excluded from satisfaction surveys, based on the belief that these residents cannot accurately answer questions about daily care practices. Not only is this a false assumption, it is also unfortunate and ironic, since these residents are the most vulnerable to, and the most likely to receive, substandard care. We advise against using cognitive screening criteria to exclude residents from participating in satisfaction surveys.

In our survey, we did not exclude any residents due to cognitive impairment. Indeed, of the total sample, 29% were diagnosed with dementia and 24% with depression; yet, the majority of the sample - 89% - was responsive to the satisfaction interview questions.

Other recommendations are related to the way in which satisfaction interviews are conducted in the nursing home setting. We recommend that satisfaction interviews be conducted in person - a key to allowing a range of cognitively and physically impaired residents to participate. Also, in-person interviews provide an opportunity to clarify questions, which leads to more accurate data collection.

Another important point is that involved staffers should follow good interviewing techniques. For example, interviews should be conducted in a quiet environment. The interviewer's mouth should be clearly visible to the resident, and the interviewer should help the resident focus his or her attention on the questions by using the resident's name and/or using touch. Many residents might have hearing impairments that require the use of a hearing aid during the interview. If a resident in our study did not own a hearing aid, we offered them the use of amplifying earphones. This inexpensive instrument (available for approximately $40 from most electronics stores) provided effective results.

Satisfaction questions should be direct, short and simple. Response categories should be, too. Avoid asking residents to make fine discriminations on a Likert scale (e.g., a scale of 1 to 5); many residents are simply unable to use such complex point scales. As an alternative, we posed questions in stages, starting with a yes or no question and following up with a related question, in an attempt to achieve a finer discrimination of satisfaction. For example, we asked residents, "Overall, are you satisfied with how often someone helps you to walk?" Those who responded affirmatively were then asked, "How satisfied are you? Very satisfied or a little satisfied?" Those who responded negatively were asked if they were "very dissatisfied" or "a little dissatisfied."

Because of the wide differences in residents' functional skills and care needs, the satisfaction interview should be individualized to address the needs of each resident. For example, data on satisfaction with incontinence care is, obviously, appropriate and necessary to collect only for the 50% of nursing home residents who are incontinent. Moreover, even within the incontinence area, there are important differences among residents that require different types of care and, thus, different satisfaction questions. For example, a resident who is capable of toileting should be queried about satisfaction with toileting assistance and/or asked about the consistency with which such assistance is provided. Some residents are incapable of toileting successfully, even with assistance, and should be asked only about the frequency of and their satisfaction with pad changes. Similar subtle differences can be identified within, and separate questions developed for, most other daily care areas.

In summary, satisfaction is not easy to measure among nursing home residents, who are the primary customers of long-term care. Collecting satisfaction information that is useful for designing improvement programs can be more difficult to do in the long-term care setting than in most other areas of health care. Nevertheless, we must be careful to avoid the trap of investing in measurement approaches that produce positive data but do not contribute to improvements in care delivery.

Sandra F. Simmons, MA, is research associate; John F. Schnelle, PhD, is director; and Anna N. Rahman, MSW, is research associate, the Anna & Harry Borun Center for Gerontological Research, the UCLA School of Medicine Multicampus Program in Geriatric Medicine and Gerontology, Los Angeles. For further information, (818)774-3347.
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Title Annotation:patient satisfaction surveys of nursing homes
Author:Rahman, Anna N.
Publication:Nursing Homes
Date:Jun 1, 1998
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