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Correspondence: Address correspondence to Sandra F. Simmons, PhD, Jewish Home for the Aging/UCLA Borun Center for Gerontological Research, 7150 Tampa Avenue, Reseda, CA 91335. E-mail: ssimmons{at}ucla.edu
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Key Words: Satisfaction • Preferences • Assessment • Quality of care • Long-term care
Consumer satisfaction with care is commonly used in the long-term-care industry as an indicator of care quality (Patry, Gifford, & Mottshaw, 2003), although few studies have used objective, independent measures to directly evaluate the relationship between care quality and long-term-care consumer subjective satisfaction reports. Limited studies have shown that long-term-care residents report high rates of satisfaction despite objective measures that are indicative of poor care quality (Pearson, Hocking, Mott, & Riggs, 1993; Simmons & Schnelle, 1999). One recent study showed that residents reported high rates of satisfaction with daily incontinence and mobility care frequencies, although direct observations revealed that residents received, on average, less than one episode of toileting and walking assistance per day (Simmons & Schnelle).
High reported rates of satisfaction in the context of poor care quality reflect ceiling effects in many satisfaction measures and may be, at least partially, explained by acquiescent response biases and reduced expectations for care, both of which are common among long-term-care residents (Bond & Thomas, 1992; Grau, Chandler, & Saunders, 1995; Simmons & Schnelle, 1999). However, recent research shows that certain types of questions yield higher rates of satisfaction and, thus, appear to be more prone to ceiling effects and acquiescent response bias among residents. Specifically, direct satisfaction questions (i.e., questions that explicitly use a variant of the term satisfaction, such as, "overall, are you satisfied with how often someone helps you to walk?") produced the highest reported rates of satisfaction, or met need, among residents compared with alternative question types. A discrepancy index wherein two corollary questions were asked about a resident's perceived and preferred care levels produced the lowest rate of "met need" among residents (Simmons & Schnelle; Levy-Storms, Simmons, & Schnelle, 2002).
Our purpose in this study was to evaluate if the satisfaction levels of long-term-care residents and their family members regarding incontinence and mobility care were sensitive to an intervention designed to improve care. The incontinence and mobility intervention was implemented in a randomized controlled trial in four long-term-care facilities. Resident and family satisfaction data were collected in two of the four facilities. The results of the intervention trial in all four facilities showed a significant effect on daily incontinence and mobility care frequency and multiple continence and physical functioning outcome measures (Schnelle et al., 2002). In the current study, we provide important data about the sensitivity of resident and family member satisfaction reports as a quality-of-life outcome measure of the intervention. We addressed the following research questions:
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Two facilities participated in this study, one of which was proprietary. The two facilities ranged in size from 177 to 194 occupied beds. The resident-to-nurse aide staff ratio for the day shift (7 a.m. to 3 p.m.) averaged eight residents to one nurse aide across the two facilities, which is typical of industry standards.
Nursing home staff identified a total of 278 residents as incontinent across the two facilities. Of the 278 incontinent residents, 206 (74%) met study-inclusion criteria. We obtained informed consent, or the assent of the resident and the consent of a responsible party designated in the medical record, from 145 (70%) of the 206 eligible residents. During baseline data collection, 13 consenting residents were lost from the study as a result of death (4), transfer out of the facility (5), consent withdrawal (2), or a decline in cognitive functioning to the point of unresponsiveness (2).
Resident Interviews
The remaining 132 residents were approached for interview by trained research staff, and 127 (96%) completed at least one baseline interview (interview time, M = 22 ± 10 min). Interviews were conducted in the absence of long-term-care staff according to a standardized protocol (Levy-Storms et al., 2002; Simmons & Schnelle, 1999). All 127 residents who completed the first baseline interview were approached within 1 week for a second interview, and 105 (83%) completed a second interview. Our purpose in having two baseline interviews conducted was to evaluate the stability of residents' interview responses under conditions in which there was no change in usual care. Reasons for incomplete data for Baseline Interviews 1 (n = 6) and 2 (n = 22) include resident refusal or inability to complete the interview. Seventeen participants were lost from the study during the 8-week intervention period as a result of death (8), transfer out of the facility (5), or consent withdrawal (4). We attempted to have postintervention interviews conducted with the remaining 115 participants who completed at least one baseline interview and 8 weeks of intervention. Of these 115 participants, 97 (84%) completed a postintervention interview. These 97 participants comprised the resident sample for baseline to post-8-week comparisons between intervention (n = 45) and control (n = 52) groups. Postinterviews were conducted during the 8th week of the intervention while the intervention was in place for the intervention group and the control group continued to receive usual care.
Family Member Interviews
Using a standardized protocol, an attempt was made by trained research staff to contact the person designated in each participant's medical record as the responsible party, typically a family member (97%), for interview over the telephone. Of the 132 respective responsible-party members, 115 (87%) were contacted and willing to complete a baseline interview (interview time, M = 23 ± 9 min). Eighty-two family members who completed a baseline interview and whose relative completed 8 weeks of intervention also completed a postintervention interview. These 82 family members comprised the family respondent sample for baseline to post-8-week comparisons between intervention and control groups (n = 41 per group). We notified family members by mail of the results of study randomization procedures (resident assignment to intervention vs. control groups) following randomization at baseline.
Measures
Characterization of Residents
We obtained descriptive information from each participant's medical record, including age, gender, ethnicity, length of residency within the facility, and diagnoses. We evaluated participant cognitive status with the Mini-Mental State Exam (MMSE; Folstein, Folstein, & McHugh, 1975; Molloy, Alemayehu, & Roberts, 1991). In addition, we calculated the MDS-derived Cognitive Performance Scale (CPS) score, which ranges from 0 (cognitively intact) to 6 (severely cognitively impaired, comatose), for each participant. The CPS has been validated against the MMSE (Hartmaier et al., 1995). Previous research has shown that 90% of long-term-care residents with a CPS total score of 2 or less (0–2) can provide reliable interview information about their received care, and approximately one half of those with a CPS score of 3 can provide reliable interview data (Simmons et al., 1997).
Direct Observations of Usual Care Provided by Staff
Research staff conducted direct, time-sampled behavioral observations for at least 2 min every 15 min for 8 hr across 3 days to document routine incontinence and mobility care rendered by indigenous long-term-care staff for all participants at baseline and for control group participants at post-8 weeks. Research staff conducted their observations either between the hours of 7 a.m. and 3 p.m. or 8 a.m. and 4 p.m. to increase the likelihood that morning incontinence care, which typically occurs as residents are assisted out of bed, would be captured in the observational data. We computed the average numbers of toileting and walk assists provided by long-term-care staff across the 3 observation days for each participant. We assessed the stability of these objective incontinence and mobility care levels as documented by the direct observation protocol across days (i.e., Days 1, 2, and 3). In addition, we had research staff conduct a more intensive observational schedule (i.e., every 2 min) for a small subset of residents (n = 15) to substantiate that a 15-min observational schedule was sufficient to document all routine incontinence and mobility care activities. Because there were no observed differences in care frequencies between the 15- and 2-min interval schedules for the subset of residents, we report the results of the 15-min schedule in this study.
The observational protocol used to document long-term-care staff incontinence and mobility care behavior has been used in multiple studies involving more than 20 facilities located in multiple states. These studies indicate that the frequency of incontinence care (i.e., toileting assistance) is remarkably similar between facilities and stable across multiple days within facilities (Schnelle, MacRae, Ouslander, Simmons, & Nitta, 1995; Schnelle, Newman, Fogarty, Wallston, & Ory, 1991; Schnelle, Sowell, Hu, & Traughber, 1988). Specifically, the frequency of toileting assistance has been observed to range from zero to two per resident per day. Similarly, incontinent residents residing in six different facilities who were capable of walking but required staff assistance received walking assistance zero to two times per day (MacRae, Schnelle, Simmons, & Ouslander, 1996; Schnelle et al., 1995). In the current study, we again established interrater reliability for the direct observational protocol on the basis of 178 intervals (44.8 hr) of direct-care observations. There was significant interrater agreement on all incontinence and mobility care activity occurrences and the extent of staff assistance provided to the resident (kappa coefficients ranged 
= 0.73–1.0, p <.001 across care activities).
Interview Questions
On the basis of previous research (Simmons & Schnelle, 1999), we had three types of interview questions posed to both residents and family members about toileting and walking assistance care frequencies: (a) direct satisfaction (e.g., "Are you satisfied with how often someone on the staff helps you or your relative to walk?"), (b) perceived care (e.g., "How many times during the day does someone on the staff help you or your relative to walk?"); and, (c) preferred care (e.g., "How many times during the day would you like for someone on the staff to help you or your relative to walk?"). Interview questions were focused on care frequency because an increase in toileting and walking assistance care frequencies was the primary component of the intervention (Schnelle et al., 2002). Numeric response options indicative of care frequency included the following: 0, 1, 2, 3, or 4 or more (times per day); or "other," wherein a resident or family member could report a specific number indicative of care frequency (e.g., 5 times per day).
We used the two corollary questions about perceived and preferred care (items b and c in the aforementioned list) to calculate a discrepancy index such that the difference in perceived and preferred care frequencies (perceived minus preferred care) reflected the level of "unmet need." For example, if a resident replied that staff helped her or him to walk once per day in response to the second type of question but reported a preference to receive two walk assists per day in response to the third type of question, then she or he had a walking assistance discrepancy index of –1 (perceived minus preferred care: 1 – 2 = –1). The question order was perceived care frequency, direct satisfaction, and preferred care frequency.
Intervention Protocol
Following the completion of baseline incontinence and mobility assessments, we randomized residents into intervention and control groups. We then maintained the intervention group in the intervention for 8 weeks. We completed postintervention assessments at 8 weeks while the intervention was in place for the intervention group and the control group continued to receive usual care. We determined incontinence and mobility care provision provided by indigenous long-term-care staff to control participants on the basis of direct observations made after the 8 weeks (see the aforementioned Direct Observations subsection). The intervention was implemented by research staff every 2 hr, 5 days a week, between the hours of 8 a.m. and 4:30 p.m., for a possible total of four care episodes per day. During each care episode, residents were prompted to toilet and were changed, if needed. Either before or after incontinence care, research staff provided assistance to residents either to walk or, if nonambulatory, to wheel their chairs, and to repeat sit-to-stands using the minimum level of human assistance possible for all care provision. We assessed walking ability for both intervention and control participants by using a standardized, performance-based, graduated-assistance protocol at baseline (Schnelle et al., 1995, 2002). The number of times a resident accepted toileting or walking assistance from research staff (out of four possible opportunities per day) was documented daily during the intervention immediately following care provision by use of a standardized form. In addition, process reliability, which involved direct observation of intervention implementation, was conducted weekly by a supervisory-level research staff member. The intervention protocol and the significant positive effects of the intervention on multiple physical functioning (e.g., endurance, strength) and continence status clinical outcome measures have been reported elsewhere (Schnelle et al., 2002). All study protocols were approved by the University of California, Los Angeles Internal Review Board.
Data Analyses
We conducted all analyses by using SPSS for Windows statistical package, version 11.5. We compared demographic characteristics by using t tests for independent samples for continuous variables (age, length of residency, and MMSE and CPS total scores) and chi-square analyses for categorical variables (gender, ethnicity, and dementia and depression diagnoses). We conducted demographic characteristic comparisons between residents who remained in the study for 8 weeks (n = 115) and those who dropped out (n = 30). We also conducted these comparisons between those who completed an interview at both time points (baseline and post-8 weeks, n = 97) versus those who did not (n = 18), and intervention (n = 45) versus control (n = 52) groups.
We used multivariate analyses of variance (MANOVAs) and the McNemar test of change among correlated measures to compare resident and family satisfaction and preference outcome measures between the intervention and control groups over time (baseline to post-8 weeks). Specifically, we conducted MANOVAs by group over time for all continuous measures (objective, perceived, and preferred care frequencies, including the discrepancy indices), whereas we conducted McNemar analyses for correlated proportions for the categorical measure (direct satisfaction questions yielding a yes–no response). We also compared satisfaction and preference measures between groups (intervention vs. control) at each time point (baseline and post-8 weeks) by using t tests for independent means (continuous measures) or independent proportions (categorical measures).
We conducted additional MANOVA and McNemar subanalyses for resident participants with a CPS total score of 0 to 2 (cognitively intact to mildly impaired, n = 29) and 0 to 4 (cognitively intact to moderately impaired, n = 79) and family participants who reported a visitation frequency of once or more per week (n = 58) and during week days (n = 48). We also completed subanalyses for both residents and family members within each of the two participating facilities. Results were comparable for these subgroups; thus, we report data for the entire resident (n = 97) and family (n = 82) respondent groups who completed an interview at both time points.
Residents (n = 97) and family members (n = 82) who completed an interview at both time points still may have provided "don't know" responses or otherwise failed to answer some question types. Acceptable responses included "yes" or "no" for the direct satisfaction questions and numerical responses (e.g., three times a day) for questions about perceived and preferred care frequencies. A response of "don't know" was initially included in all analyses; the proportion of such responses did not differ by intervention and control groups at either time point for residents or family members. We conducted final baseline to post-8 week comparisons by respondent group (residents and family members, intervention vs. control) and question type (direct satisfaction, perceived and preferred care frequencies) such that a respondent who provided a "don't know" or "no response" answer to a question type at either time point was excluded from the baseline to post-8 week comparisons for that question type only.
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Toileting and Walking Assistance Care Frequencies
Table 2 shows the effects of the intervention (baseline usual care to postintervention) on both toileting and walking assistance care frequencies for the intervention and control groups. Direct observations of usual care at baseline showed that each group received an average of less than one episode per person per day for both toileting and walking assistance (range 0–2 for both care activities), with no differences between groups. Specifically, 61% received no toileting assistance and 94% of those capable of walking received no walking assistance during an 8-hr daytime observation period. Walking assistance care frequencies are reported only for those participants within each group who were capable of walking with some level of staff assistance according to the baseline mobility assessment (n = 77).
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Resident Satisfaction and Sensitivity to Intervention Effects
Residents' reported daily care frequency preferences were stable across two baseline interviews (n = 105) for both toileting (preference for episodes/day, M = 2.2 ± 1.8 vs. 2.3 ± 1.8 for Interviews 1 and 2, respectively) and walking assistance (preference for episodes/day, M = 2.2 ± 1.9 vs. 2.2 ± 1.9 for Interviews 1 and 2, respectively). Pearson correlation coefficients for the group of participants (n = 105) were.29 (p <.05) for toileting assistance and.47 (p <.01) for walking assistance preferences. Correlation coefficients were higher for resident participants with a CPS total score of 2 or less (toileting =.53, p <.05; walking =.69, p <.01).
Table 3 shows baseline to postintervention results for resident participants by group (intervention vs. control) and care activity (toileting and walking assistance). There were no baseline differences between groups (intervention vs. control) on any measure. The difference between the total resident sample (n = 97) and the sample sizes listed in Table 3 by question type reflects the number of residents who responded "don't know" or otherwise failed to answer the question at either or both time points (see the Data Analyses subsection). There were more residents who had missing data (md) as a result of answering "don't know" or refusing to answer for the direct satisfaction questions (toileting md = 18, or 19%; walking md = 19, or 25%) compared with questions about perceived (toileting md = 4, or 4%; walking md = 2, or 3%) and preferred (toileting md = 5; walking md = 2) care frequencies, which we used to calculate the discrepancy indices (toileting md = 8; walking md = 4).
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Family Satisfaction and Sensitivity to Intervention Effects
Table 4 shows baseline to postintervention results for family participants by group and care activity. There were no baseline differences between groups on any measure. The difference between the total family sample (n = 82) and the sample sizes listed in Table 4 by question type reflects the number of family members who responded "don't know" (see the Data Analyses subsection). More family members had missing data (md) from "don't know" responses for questions about toileting assistance frequency, regardless of question type, compared with questions about walking assistance frequency.
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= 6, df = 1, p <.001). No significant change occurred in either group in response to the direct satisfaction question about walking assistance. When asked about perceived care frequencies, 70% (57/82) reported "don't know" for toileting whereas 22% (14/63) reported "don't know" for walking assistance. Family members' reported perceptions of care frequency did not change over time for toileting assistance in either group; however, perceived care frequencies did change over time for walking assistance, which showed a significant Group x Time interaction (F = 19.96, p <.001). Follow-up t tests for paired samples showed a significant increase for perceived walking assistance only in the intervention group (t = 4.56, p <.001).
When asked about preferred care frequencies, 62% (51/82) reported "don't know" for toileting whereas 33% (21/63) reported "don't know" for walking assistance. For the remaining family members who provided a numerical response, a significant time effect occurred for toileting assistance care frequency preferences (F = 5.37, p <.05) only. Follow-up t tests for paired samples showed a significant decrease in preferred toileting assistance only in the control group (t = 2.23, p <.05). This decrease in toileting assistance preferences among family members in the control group was, at least partially, due to nine family members' reports postintervention that they no longer preferred for their relative to receive any toileting assistance as a result of their relative's inability to use the toilet, even with staff assistance, for various reasons (bed bound, unable to initiate a void).
The toileting assistance discrepancy index could not be calculated for most family members (68/82, or 83%) because of one or more "don't know" responses to the four questions (perceived–preferred care at two time points) necessary to calculate the index; no significant changes occurred over time in this measure (Table 4, Toileting Assistance Discrepancy Index). There were less missing data for the walking assistance discrepancy index (24/63; 38%), and a significant time effect occurred based on the index (F = 12.64, p <.01). Follow-up t tests for paired samples showed a significant decline in this measure, which suggests an improvement in met need, for both intervention (t = –2.09, p <.05) and control (t = –3.65, p <.05) groups.
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In contrast, residents' reports were sensitive to care improvements based on the discrepancy indices, which reflect the difference between perceived and preferred care, for both toileting and walking assistance. From the results of this study, it is clear that residents are capable of responding to these types of specific questions. These results are consistent with those of other studies, which have shown that the discrepancy index measure is less influenced by ceiling effects and acquiescent response bias among residents compared with direct satisfaction questions (Simmons & Schnelle, 1999). Other studies also have shown that family members are not good proxies for the satisfaction of residents with daily care and life quality, even when visiting frequently (Cohn & Sugar, 1991; Gasquet et al., 2003; Lavizzo-Mourey et al., 1992; van Maris et al., 1996).
There are several notable limitations of this study. First, resident and family satisfaction reports were collected in only two of the four intervention sites that were part of the larger trial, which limited the sample sizes available for analyses and also may pose limits to the generalizability of study results. Specifically, because of small sample sizes, we were unable to examine individual resident and family satisfaction responses in relation to the degree of benefit that the same individual derived from the intervention; however, most intervention participants showed significant improvement in either or both continence and mobility outcome measures (Schnelle et al., 2002). The demographic characteristics of the sample (predominately female and White) also limit the generalizability of study results.
Second, the interview questions posed in this study to both residents and family members were limited to specific questions about incontinence and mobility care frequencies as an increase in daily care frequency defined the major component of the intervention. However, the intervention also included improvements in the manner of care delivery as defined by social stimulation, offering residents fluids, and the timeliness and predictability of assistance (Schnelle et al., 1995). Research suggests that residents' responses to structured open-ended interview questions (e.g., "If you could change something about the way staff help you to walk or your walking schedule, what would it be?") may have been sensitive to such manner of care improvements (Levy-Storms et al., 2002), but these types of questions were not posed to residents in this study. Third, interview questions were presented in the same order to all study participants. Thus, we could not evaluate if there was an order effect for the questions. It is possible that posing the interview questions in an order different from that used in this study could yield different results. Finally, the large number of "don't know" responses limited our statistical power to detect a significant effect of the intervention based on family member reports.
In summary, the results of this study suggest that efforts to improve daily incontinence and mobility care quality should include interviews with the residents who are direct recipients of care. Although the majority of residents were able to complete an interview in this study, MDS-derived cognitive functioning information also may be used to select residents for interview (Simmons et al., 1997; Simmons & Schnelle, 2001). Direct satisfaction questions are not useful for evaluating long-term-care quality or improvement efforts. Instead, a discrepancy-based measure of met need that reflects the difference between perceived and preferred care, such as that described in this and previous work (Simmons & Schnelle, 1999), provides a measure that is sensitive to improvements in care quality in these daily care areas.
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1 Department of Geriatrics and Borun Center for Gerontological Research, University of California, Los Angeles.
2 Jewish Home for the Aging of Greater Los Angeles, Reseda, CA.
3 Department of Medicine, Wesley Woods Center, Division of Geriatric Medicine and Gerontology, Emory University, Atlanta, GA.
4 Birmingham/Atlanta Veterans Administration GRECC, Atlanta, GA.
Decision Editor: Linda S. Noelker, PhD
Received for publication April 7, 2004. Accepted for publication August 30, 2004.
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