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Nursing homes: In the eye of the beholder

December 14, 2010
by V. Tellis-Nayak, PhD
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Residents, families, and surveyors weigh in

Note: This feature is a digest of an article that won this past September's “2010 GE Award For Best Research Paper” from the National Investment Center for the Seniors Housing & Care Industry. Bradley N. Shiverick, CPHQ; and Mauro Hernandez, PhD, contributed to the article as well.

Old age brings losses, and soon, a new realization. You become aware that the world now treats you with benign neglect. It no longer tries to connect with the person whose company others once sought, who now lies caged within a failing body. Even in friendly company, people unduly focus on your dependency. Social encounters have become mortifying reminders of how as you lost your independence you became a non-person, how it devalued you. You would rather make a strategic retreat and avoid these silent, daily indignities.

Situations such as these illuminate the themes of a new study that looks at three parties in the life of a nursing home: namely, residents, their families, and state surveyors. Each group views the same nursing home through its social filter and then slants its interpretation and passes a judgment that, curiously, both matches and contrasts with the conclusions drawn by the other groups.

The authors drew a sample of 2,430 resident responses and 3,779 family responses from the archives of satisfaction surveys conducted in 2006 and 2007 by My InnerView in 89 nursing homes located in 30 states. To this data, they added the results of the most recent standard state survey conducted in each of the 89 nursing homes. These samples fairly well mirror the demographic characteristics of the nation's approximately 17,000 nursing homes.

Voices of residents, families

The voices of residents and families speak of their satisfaction, hopes, wishes, desires, and expectations. The authors searched through this thicket of responses and their discoveries can be summarized as follows:

  • A remarkable number of residents (44%) and families (40%) registered their overall satisfaction with nursing home life as Excellent (1% and 2% respectively described it as Poor). Even more residents (47%) and families (42%) said they would recommend their nursing home to others as an Excellent place to receive care (about 2% of residents and 4% of families would recommend it as Poor). Each of the 22 areas of nursing home life drew an Excellent rating from an average of 41% of residents and 37% of families.

  • Residents and families said three experiences in the nursing home bring the highest satisfaction: Staff Show Respect for the resident, staff ensure Resident Safety, and the Quality of RN/LPN Care. Adequacy of Nursing Staff pleases them the least, although even here, a third of residents and a fourth of families said nursing homes do an Excellent job.

Satisfaction is not engagement

Customer satisfaction does not tell you much about customer engagement. Families are very pleased that their nursing home meets residents’ Religious and Spiritual Needs; they are hardly pleased with its Laundry Services. However, in these two cases a nursing home neither benefits from increased family loyalty nor suffers by its erosion. This is so for a simple reason: The way families see it, these two areas are marginal to real quality. However, the issue of Staff Competence kindles a fire. A stellar performance in this area will turn families into loyal advocates of the nursing home, and a mediocre job will make critics out of them.

The resident-family bond brings them to a consensus and leads them to speak in unison (e.g., both groups place high value on Staff Care and Concern for resident). However, while both sides may hold nursing homes in high regard, families are less generous when evaluating their nursing home. That is, more residents than families express high satisfaction in all aspects of nursing home life, and more of them are prepared to recommend their nursing home to others as Excellent (see Tables 1 and 2).

The judgment of state surveyors

The overall satisfaction residents and families express about their nursing home correlates with the number of deficiencies cited by state surveyors (see Table 3). In other words, nursing homes where more residents and families rate their satisfaction as Excellent receive fewer deficiencies, and conversely, those with fewer residents and families rating satisfaction as Excellent end up with more deficiencies cited. Similarly, the greater the number of residents and families that would recommend their nursing home to others as a good place to receive care, the more likely that their nursing home would receive fewer deficiencies.

These findings merit attention not so much for their content as for their implications for quality, policy, and practice. Consider the following few.

Nursing home life

To begin with, the high level of satisfaction in nursing homes we refer to here validates similar findings in other studies. However, note two provocative details in our findings. First, a sizable number of residents and families are not only pleased with their nursing home, they also stand ready to canvass for it in the community.

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