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BRIEF REPORT |
1 University of California, Los Angeles, School of Medicine.
2 Department of Community Health Sciences, University of California, Los Angeles, School of Public Health.
3 Sepulveda, VA, Northridge, California.
4 Department of Social Welfare, University of California, Los Angeles, School of Public Affairs.
5 Los Angeles Jewish Home for the Aging/Borun Center for Gerontological Research, Reseda, California.
Address correspondence to Lené Levy-Storms, PhD, MPH, Departments of Social Welfare and Medicine, University of California, Los Angeles, School of Public Affairs, Box 651656, 5226 Public Policy Building, Los Angeles, CA 90095-1656. E-mail: llstorms{at}ucla.edu
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Abstract |
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Methods. NH residents (N = 69) were interviewed with both closed-ended (i.e., forced-choice) and open-ended (i.e., residents' own words) questions about their perceptions of care across eight care domains. Unmet needs included comments indicating that residents desired a change in staff- and non-staff-related care. Staff-related unmet needs were further coded into unmet emotional support (i.e., emotional support or manner of care delivery) and instrumental (i.e., instrumental support or frequency of care) needs.
Results. Of 66 residents who commented, 66% expressed at least one unmet need across eight care domains. Among these 44 residents, 52% and 84% had unmet emotional support and instrumental support needs, respectively (
=.68 and.92). An additional 18% expressed both unmet emotional support and instrumental support needs.
Discussion. The refined method offers a systematic way to code residents' comments about their care into unmet needs related to the manner and frequency of care delivery. The findings have direct implications for the identification of care areas in need of improvement from the resident's perspective and the evaluation of improvement efforts.
Measures of nursing home (NH) residents' perceptions of care and quality of life through interviews are often limited by "ceiling effects." Response acquiescence may, in part, explain these results. Response acquiescence is the tendency of residents to provide mostly satisfied responses regardless of content and even when poor quality of care is known to exist (Simmons & Schnelle, 1999
; Smith, 2000). However, this problem has only been noted in reference to closed-ended interview questions, wherein response options are limited (Cleary & Edgman-Levitan, 1997). One recent study indicated that ceiling effects were not as evident if residents' comments to open-ended questions were analyzed (e.g., What would you change about how staff help you during mealtime?) (Levy-Storms, Simmons, & Schnelle, 2002). This article described a reliable method to code residents' comments to such open-ended questions into a frequency count of unmet needs. The overall frequency of unmet needs identified by this coding system provided a higher estimate of unmet needs when compared with more traditional satisfaction questions (e.g., Are you satisfied with mealtime assistance?). This article did not, however, define the type of unmet needs that the residents described.
The purpose of the current study was to expand on the basic protocol for coding NH residents' comments about their perceptions of eight daily care domains into types of unmet needs. Residents' comments were elicited through the use of both structured open-ended questions (e.g., If you could change something about the way staff provides mealtime assistance, what would it be?) and documentation of residents' spontaneous comments to closed-ended questions during interviews. The results from the closed-ended questions were described previously in another article (Levy-Storms et al., 2002). The primary research question addressed in this study was the following: Can the basic protocol be expanded so that residents' comments indicative of a desire for change/unmet needs can be reliably coded into specific types of unmet needs? Two types of unmet needs were based on residents' perceptions of social support: unmet emotional support needs and unmet instrumental support needs (House, Landis, & Umberson, 1988). Operationally these concepts referred to unmet needs related to the "manner of care delivery" and the "frequency of care delivery," respectively.
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METHODS |
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). Of the 111 residents, 18 (16%) failed the responsiveness screen. The remaining 93 NH residents were cognitively intact (CPS = 0) or had mild (CPS = 1 or 2) to moderate (CPS = 3 or 4) cognitve impairment and were eligible for an interview. Each resident was interviewed with standardized protocols relevant to assistance within the following eight daily care domains: social activities, walking, mealtime, dressing, showering, getting in/out of bed, toileting, and pad changes. Each care domain had a separate set of questions and required an average of 10 minutes to complete each set. Of the 93 eligible residents, 69 (74%) responded to questions relevant to at least one of eight care domains. Most residents participated in four to seven sets of questions about care domains for which they required assistance from staff, and each resident provided an average of four comments across all care domains. The remaining 24 residents refused, died, or were not able to be located for an interview. Of the 69 respondents, 66 provided comments to open-ended questions and/or spontaneous comments to closed-ended questions within at least one care domain. The comments of these 66 residents comprised the final sample for the current study.
There was no difference between the proportion of NH residents with CPS scores of 0–2 (N = 43) and 3–4 (N = 50) in completing at least one set of questions about a care domain (
= 2.88; p =.09), in the number of care domains completed out of the total eight possible (CPS: 0–2, mean = 3.93 ± 2.29; CPS: 3–4, mean = 3.41 ± 2.83; t = 0.98; p =.33) or in the number of "don't know," "missing/no response," or "nonsense" responses. These results support previous research that has shown that most NH residents with CPS scores of 0–2 and a substantial proportion of those with CPS scores of 3–4 can provide reliable information about their perceptions of received care (Simmons et al., 1997).
The University of California, Los Angeles, Human Subjects Review Board provided a waiver of informed consent, as the data were collected as part of quality assurance.
Coding Protocol for Residents' Comments
Within each care domain, research staff asked residents what they would change about the way staff provides care (e.g., mealtime interview protocol: "If you could change something about the way staff help you with your food, what would it be?" See Appendix for complete listing). Although "staff" could refer to either licensed or nonlicensed staff, certified nursing aides (CNAs) provide 90% of direct care (Ripich, Wykle, & Niles, 1995), so most of residents' comments pertained to CNAs. Residents' comments to open-ended questions as well as their spontaneous comments to closed-ended questions (direct satisfaction and discrepancy questions) were recoded into quantitative measures of unmet and met needs. Most comments were one sentence or a phrase and thus were easily recorded verbatim during the interview. Two raters independently coded residents' comments from transcripts. The numerical codes were then exported to SAS. Cohen's kappa coefficients provided a test for interrater reliability for each step of the refined coding protocol.
The refined coding protocol included three steps. First, each response was coded for whether it indicated a desire for something other than the status quo as done in the previous study (Levy-Storms et al., 2002). For example, a comment indicating a desire for a change might state: "I would like to walk more often [than I currently get to walk]." If the comment did not indicate a desire for change, then it was indicative of "met" need, and no further coding was done. This step yielded an average kappa value of.80.
Second, all comments coded as unmet needs were then coded as to whether or not they required interaction with staff to be remedied ( =.87). For example, a comment indicating a staff-related issue is: "I would like more encouragement," and a comment indicating a non-staff- related issue is: "I do not like my roommate." If the comment indicated a non-staff-related issue, then no further coding was done.
Third, all comments indicating a staff-related issue were further coded as to whether they reflected a need for emotional support if it referenced the interpersonal manner of care delivery (e.g., "When they dress you or help you, they are rough, not kind"; =.68). It was coded as a need for instrumental support if it referenced the occurrence and/or frequency of care delivery (e.g., "I would like a shower every day"; =.92). The emotional support and instrumental support categories were not mutually exclusive in that a response could contain references to both simultaneously (e.g., "I would like a shower four to five times a week" and "Give you one person each time they shower you, not a different person each time").
Residents' comments provided in the context of an interview about a particular care domain may or may not have pertained to that care domain. Comments that were ambiguous (e.g., "I don't know") were coded as such and excluded from further analyses. In only two care domains were some responses ambiguous: walking (4%) and social activity (10%) of total comments in each domain.
Test–retest reliability was collected on a subset of 58 residents that were interviewed twice approximately 1 to 2 months apart. Of these 58 residents, 20 residents provided 20 comments at two time points. The comments included either responses to open-ended questions or spontaneous comments to closed-ended questions. At both time points, these comments were recoded into unmet and met needs and compared. The test–retest reliability was =.50, which is acceptable (Grove, Andreasen, McDonald-Smith, Keller, & Shapiro, 1981). The remaining analyses describe the response patterns of residents across and within the eight care domains.
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RESULTS |
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Response Patterns Across Care Domains
Of 66 residents who completed at least one set of questions about a care domain and provided at least one comment, 37% provided comments to open-ended questions only and 63% provided comments to closed- and open-ended questions. The average number of comments indicative of unmet needs per resident across one or more care domains was 1.96 (SD = 2.16; range = 0–8). The average number of comments indicative of met needs per resident across one or more care domains was 2.35 (SD = 2.10; range = 0–8). Overall, 66% (N = 44) of residents expressed unmet needs, and 34% (N = 22) expressed met needs across one or more care domains.
Types of Unmet Needs and Met Needs Within Care Domains
Among 66 residents who provided at least one comment, the percentage of unmet and met needs, respectively, by domain was as follows (in decreasing order): in/out of bed (N = 18: 89% unmet/11% met), toileting (N = 17: 53%/47%), dressing (N = 27: 52%/48%), shower (N = 25: 48%/52%), pad changes (N = 25: 48%/52%), social activity (N = 51: 40%/60%), walking (N = 35: 38%/62%), and mealtime (N = 30: 30%/70%) domains. Thus, relative to other care domains, the highest level of unmet need occurred in the getting in and out of bed care domain, and the lowest level occurred in the mealtime domain. These patterns in the percentages of unmet and met need by care domain changed when they were examined by subtypes of unmet and met needs.
Table 1 shows the proportion of respondents who reported unmet needs by type for each care domain. The percentages do not add to 100 because residents may have provided comments to an open-ended question and to a closed-ended question within one care domain. There were four types of unmet needs within each care domain: emotional support, instrumental support, both emotional support and instrumental support, and non-staff-related unmet needs. Unmet emotional support needs ranged from lows of 19% and 20% in the bed and walking domains, respectively, to a high of 64% in the dressing domain. Unmet instrumental support needs ranged from a low of 33% in the mealtime domain to a high of 87% in the walking domain. Reports of both unmet emotional and instrumental support needs in the same comment ranged from lows of 6%, 7%, and 7% in the bed, walking, and dressing domains, respectively, to a high of 17% in the shower and pad change domains. Non-staff-related unmet needs ranged from a low of 0% in four of the eight care domains (shower, dressing, walking, and pad change) to a high of 33% in the mealtime domain.
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DISCUSSION |
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).
Recoding residents' comments into indicators of unmet and met needs supplements information from closed-ended questions in two ways. First, over 30% of residents provided comments to only open-ended questions (i.e., they did not offer spontaneous comments to closed-ended questions), so their comments would have been otherwise missed if only closed-ended questions had been used in the interviews. Second, by recording residents own words, subtle but often specific aspects of both technical and interpersonal aspects of care delivery were assessed. This approach expands on previously evaluated strategies for assessing residents' satisfaction with care via their unmet and met needs that relied exclusively on responses to closed-ended questions and/or focused only on the frequency of technical care (Levy-Storms et al., 2002). That is, how staff interact with residents and residents' unmet emotional support needs have received minimal attention relative to the frequency of care delivery and residents' instrumental support needs. The results of the current study suggest that residents' comments should be used in combination with closed-ended questions to more fully address manner of care delivery and quality-of-life issues from the resident's perspective (Kane, 2001; Kane et al., 2003; Walker, Porter, Gruman, & Michalski, 1999).
The current study has several limitations. First, the study sample is limited to one home and therefore limits the generalizability of the findings. However, the focus in this brief report was on the internal validity of the coding protocol. Second, unanswered feasibility issues remain about how useful the proposed coding protocol will be in practice. Recording and coding residents' comments required more time and interviewer training than recording only forced-choice responses to closed-ended questions would have taken; however, the coding criteria were operationally defined such that college-educated research assistants could reliably code residents' responses with less than an hour of training. Although it might be feasible for nursing home staff to use this method to assess residents' needs, it is unlikely that residents would express negative sentiments to the staff that directly provide their care. This feasibility issue can be explored in future research, but the level of detailed information gained in the short term makes this method valuable.
Most certainly, this method could be reliably used in the research context to assess perceived social support and/or evaluate quality-of-life improvements. For example, open-ended questions and the coding protocols could be used concurrently with other measures of social support from family and friends, which would enable exploration of how formal and informal support affects residents' needs. This method of questioning would also be useful as an outcome to an intervention, if its effects may be broader than would be revealed by tightly defined outcome measures. For example, in other data, family responses to open-ended questions revealed that they noticed significant improvements in the emotional support received by their relatives during an incontinence intervention. They did not notice improvements in the instrumental support received, even though the intervention was verified with objective incontinence frequency measures. Thus, the important effects of this intervention would have been missed altogether if the methodology described in this article were not utilized.
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Appendix |
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Toileting
If you could change something about the toileting schedule and/or the way staff help you to use the toilet, bedpan, or urinal, what would it be?
Walking
If you could change something about the walking schedule and/or the way staff help you walk, what would it be?
Pad Changes
If you could change something about the pad changing schedule and/or the way staff changes your pad, what would it be?
Dressing
If you could change something about the way staff help you to get ready and/or the things they do for you, what would it be?
Bathing and Showering
If you could change something about your shower or bath schedule and/or the way staff help you to take a shower or bath, what would it be?
Mealtime and Feeding Assistance
If you could change something about the way staff help you with your food, what would it be?
In and Out of Bed
If you could change something about your bedtime schedule and/or the way staff help you in and out of bed, what would it be?
Social Interaction
If you could change something about the care or staff here, what would it be?
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Acknowledgments |
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Footnotes |
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Received for publication October 23, 2004. Accepted for publication March 22, 2005.
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This article has been cited by other articles:
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  L. Levy-Storms, J. F. Schnelle, and S. F. Simmons What Do Family Members Notice Following an Intervention to Improve Mobility and Incontinence Care for Nursing Home Residents? An Analysis of Open-Ended Comments Gerontologist, February 1, 2007; 47(1): 14 - 20. [Abstract] [Full Text] [PDF]
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