Family Satisfaction With Long Term Care Facilities -
Psychometric Properties of the Family Evaluation Survey
Anuradha Marisetti
A thesis submitted in conformity with the requirements
for the degree of Master of Science
Department of Health Policy, Management & Evaluation
University of Toronto
O Copyright by Anuradha Marisetti (200 1 )
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Narne: Anuradha Marisetti
Degree and year of Convocation: Master of Science, 2001
Department of Heaith Policy, Management and Evaluation
University of Toronto, Toronto, Canada
Thesis Title: Family Satisfaction With Long Term Care Facilities - Psychometric Properties of
the FamiIy Evaluation Survey
Abstract The purpose of this study was to test the psychometric properties of the Long Term Care Farnily
Evaluation Survey. The Farnily Evaluation Survey, with 3 1 items in 5 domains was examined for
reliability, content validity, and constmct validity. Reliability was assessed using Cronbach's
alpha, and validity was assessed using Principal Axis Factoring with orthogonal and oblique
rotation techniques. The Survey demonstrated moderate to high reliability; alphas between 0.63
and 0.95 and mean inter-item correlations between 0.32 to 0.73. The factor analysis, however,
revealed four underl ying factors and these demonstrated consistently high interna1 reliabili ty
(alphas over 0.90). The results suggest that the Family Evaluation Survey, as developed by the
research team, is a psychometrically valid and reliable instrument and that it should provide a
useful way to capture faniily members' views of quality of services provided by long term care
organizations.
TABLE OF CONTENTS
Chapter
1
2
3
4
Chapter
5
Description
Introduction
Literature Review
Role of Families in Long Term Lare Facilities
Dimensions of Patient and Family Satisfaction
Development and Psychometric Testing of Instruments
Surnmary
History and Development of Famüy Evaluation Survey Instrument
History
Development of Instrument
Confidentiality
Data Collection
Response Rate
Analysis, Presentation, and Use of Data
Surnmary
Research Questions and Methods
Researc h Questions
Data Set
Effect of Missing Data on Sample Size
Summary
Description
Results and Summary of Major Findings
Page
1
6
7
1 I
15
21
22
22
25
26
27
28
28
29
3 1
3 1
35
38
38
Page
39
Demographic Information
Research Question 1 - Reliability Analysis
Domain 1 - Living Environment
Domain 2 - Communication With Staff
Domain 3 - Quality and Services
Domain 4 - Resident Care
Domain 5 - Global Questions
Research Question 2 - Validity Analysis
Further Face Validity Tests
Factor Analysis Derived New Scales
6 Discussion and Conclusion
Limitations
Conclusion
Bibliography
List Of Tables
Table Description Page
1 Missing Data By Domain 37
2 Relationship To Resident 39
3 Summary of Reliability Analysis of ScaIes 40
4 Pearson's Inter-Scale Correlations 41
5 Reliability Analysis: Domain 1 - Living Environment 42
6 Reliability Anaiysis: Domain 2 - Communication With Staff 44
7 Reliability Analysis: Domain 3 - Quality and Services 46
8 Reliability Analysis: Domain 4 - Resident Care 48
9 Reliability Analysis: Domain 5 - Global Questions 51
10 Factor Analysis Rotated Factor Mauix 53
11 Analysis of Responses Regaràing The Questionnaire 56
12 Cornparison of Original Scaies With New Scales 57
13 Correlations Among Original And New Scales 57
List of Appendices
Appendix Description Page
1 List of Organizations in Dataset 72
2 Details of Data Set 74
3 Number of Records with Missing Data 75
4 Frequency Tables For Al1 Items on Questionnaire 76
5 Factor Analysis - Orthogonal Rotation Using Varimax Method Section II and Oblique Rotation Using Direct Oblimin Method
6 Copy of Family Evaluation Survey Instrument Section III >
List of Appendices
Appendix Description Page
1 List of Organizations in Dataset 72
2 Details of Data Set 74
3 Nurnber of Records with Missing Data 75
4 Frequency Tables For Al1 Items on Questionnaire 76
5 Factor Analysis - Orthogonal Rotation Using Varimax Method and Oblique Rotation Using Direct Oblimin Method
6 Copy of Family Evaluation Survey Instrument
vii
Chapter 1
INTRODUCTION
Patient, or more generally, client satisfaction plays an important role in the assessment
and improvement of the quality of health care services provided by an organization (Cleary and
McNeill, 1988). The concept of "satisfaction" is relevant to a number of sectors such as acute
care, ambulatory care, pnmary care, pediatric care, and psychiatrie care within the health care
sector as well as within the consumer world. A consumer of health services can be someone who
directly receives health care (a patient of a physician or a hospital), those who act as proxies for
patients (parents of children or children of eiderly relatives), the wider community, or potential
users of health services (Callery and Luker, 1996). With this increasing recognition that patients
and their farnilies are central to the assessment of quality of health care, measurement of their
views about the services provided is also increasingly becoming a research focus of health care
researchers, practitioners, and administrators.
There are many pressures on health care organizations today, the main ones being
increasing financial constraints and rising consumer expectations. One third of the points for the
Malcolm Baldndge National Quality Award, which recognizes and awards quality achievement
in US cornpanies, is based on customer satisfaction (Ford et al., 1997). The National Cornmittee
for Quality Assurance (NCQA), Washington, DC, as part of its accreditation review process, now
requires managed care organizations and health insurance plans to s w e y , analyse, and report on
members' evaluations and views of the quality of services (Shaul et al., 2001). The Ontario
2
Hospital Association's Hospital Report project uses reports on patient satisfaction as one of the
main indicators of quality (Baker et al, 2000). As a result, hospitals in USA and Canada are
paying more attention to performance measurement as part of their overall quality improvement
programs such as total quality management, continuous quality improvement, and balanced score
card initiatives. In addition, since the last decade, health care organizations in Canada and USA
are also facing a cntical challenge of finding appropriate methods of collecting and rneasuring
patient or client satisfaction and integrating this with their other performance measurement
systems.
This information on patient satisfaction can be very helpful for health care organizations
in alerting them about potential problems, needs and concerns of patients. Administrators can
also use this information in their prograrn planning, program evaluation, and continuous quality
improvement initiatives. Although patient satisfaction is not the only measure of quality of care,
it is still an important marker and it provides useful information about technical and interpersonal
aspects of care (Cleary and McNeill, 1988). One of the strengths of contextualizing patient
satisfaction within quality improvement, is that patient opinions are considered as a means to an
end in the cycle of continuous quality improvement and not as an end in itself as in psychological
theories (van Campen et al, 1995).
In the past, health care organizations have tended to approach quality assurance and
improvement processes kom the perspective of health care providers, not necessady clients (van
Campen et al., 1995; Cleary and McNeill, 1988). However, when a patientklient's perspective is
not taken into account, the evaluation of the services provided by an organization is incomplete
and biased towards the provider (Larsen et al., 1979). It is now recognized that to accurately
3
reflect upon the quality of health services, one must include five varied perspectives - that of
patients/consumers, of professionals, of health care institutions, of insurers, and of the
govemment (van Campen et al., 1995). There is also an increasing recognition that data collected
fiom patients about their satisfaction should be used by the organization to make changes in
policies or procedures to respond to the feedback (Cleary and McNeill, 1988).
Within the long term care sector, both residents and their families are regarded as
consumers of services and hence it is relevant to look at the issue of their satisfaction with
services to evaluate and improve quality of semices in these facilities. Long tenn care has been
defuied as the provision of health, personal care, and social services for individuals who have lost
their capaci.ty for self-care because of a chronic illness or condition (Kane & Kane, 1983). Here,
family members play a dual role, as proxies for elderly parents where they are looked upon to
participate in the care giving and decision making for residents, as well as separate customers
who have distinct needs that have to be met by the organization. In their role as distinct
customers, families play an important role in contributing to an organization's quality
improvement initiative by providing their comments and feedback regarding the quality of care
and services. Family members' satisfaction with a long tenn care facility influences not only
whether they will continue to keep the resident in the facility, but also whether they recommend it
to others. Family mernbers can influence choices in this regard just like consumers in other
markets. Therefore long term organizations need to take into account family members'
perspectives and what they consider important. Even more important, however, is the role
satisfaction data play in quality or process improvement within a facility; these data may point the
way to important and necessary changes to processes to better meet the needs of both residents
4
and families.
A research tearn from Sumybrook Health Sciences Centre (sHSC)' , the University of
Toronto (UT), and Smaller World Communications (SWC), with the assistance of a consortium
of long term care facilities in Ontario, developed instruments to capture satisfaction of residents
and their families in long terni care facilities in Ontario. The main goals of this project, developed
and piloted at SHSC, were to support quality improvement efforts, measure global performance,
and to monitor change in the organization (Norton et al, 1996). Consequently, three articles were
published, the first reviewed the construction and administration of the patient satisfaction survey
(Norton et al, 1996); the second, summarized lessons leamed f?om conducting the surveys (van
Maris et al, 1996); and the third discussed dissemination of results (Soberrnan et al, 1997).
The main focus of the above three papers was residents' satisfaction with care. The first
paper (Norton et al, 1996) discussed the reliability of the resident satisfaction instrument only.
The first version of the famiiy s w e y that was used in the pilot study was subsequently discarded
and a completely new instrument developed. This family survey, however was not tested for its
psychometric properties. However, the two instruments have been used to collect data 60m
residents and families in 2 1 long term care organizations in Ontario and BC. The data are held at
a central databank at SWC Inc. and are available for further research in this area.
The goal of the current research is to examine the psychometric qualities of an instrument
designed to assess the satisfaction with care and services of fmilies of residents of long t em
care facilities. The present study is a secondary data analysis done to test the psychometric
properties of the Family Evaluation Survey. The goal of this project is to use data collected in
' Now Sunnybrook and Women's College Health Sciences Centre
5
long term care facilities in Ontario and BC to explore the concept of family satisfaction with long
texm care facilities through validation of a family satisfaction instrument. Two parallel thernes or
questions that guide the project are: (1) as farnily members are unique customers of long term
care facilities, what are the distinct factors that affect farnily members satisfaction with services,
and (2) what are the psychometric properties of an instrument used to collect information about
family satisfaction with long tenn care settings.
In the next section a review of the literature will be presented that focusses on factors that
are important to family members as they rate long term care facilities for its quality. Other
features covered in the literature review are how the issue of measurement of patient satisfaction
has been dealt with by other researchers, and issues regarding the development and validity of
patient satisfaction instruments. Psychometric validation methods are then used to find out
whether the family swvey instrument developed by the researchers adequately measured family
satisfaction with long term care facilities. in other words, were the questions asked the right ones
in the measurement of family satisfaction, and was the instrument reliable in its measurernent?
Chapter 2
LITERATURE REVIEW
This section covers a review of literature as it relates to the following two broad themes:
(1) role of families in long term care facilities, their needs and concerns distinct fiom those of
residents, and factors that influence their satisfaction with the faci li ty, and (2) met hodological
issues with development and testing of instruments for measurement of satisfaction.
in the long term care setting, families play a significant role in supporting care to
residents. This is especially so for residents who cannot speak for themselves. The role of
families will be examined to understand the context that fiames how family members respond to
having their loved ones in long term care facilities, the emotional and psychological implications
of having to move their family members from a home or community setting to a long terni care
facility, and the impact this has on their perceptions of care and services. Long tem care implies
care given over a sustained period of time, at a slower pace, and is different fiom acute care in
that the goals of long term care Vary fiom patient to patient depending upon their physical and
mental status (Kane and Kane, 1988). As a result, the expenences of patients and family
members can also be very different from that experienced in acute care settings. Also, families
continue to have a role in providing care for their member long after admission to a long term
care facility (Keefe & Fancey, 2000). in view of these considerations, it is relevant to consider the
role of families as we try to understand what factors influence their satisfaction with the facility.
This will be followed by a discussion on patient satisfaction, elements of patient
satisfaction in different health care settings - acute care, primary care, mental health, long term
7
care - from the point of view of patients or residents and families. Family memben have
generally been used as proxies for patients or residents, however, this research is about
understanding the role of families as customers of long term care facilities and what aspects of
semice affect their satisfaction. Even though the goals and expectations of family memben of
residents of long tenn care and patients of acute care are different, we can still draw parallels
fiom these sectors to increase our understanding of family satisfaction with long term care
facilities.
in addition to this, the literature review will also cover a discussion on the issues and
challenges associated with measurement of patient satisfaction and the availability of
psychometrically valid instruments to mesure patient and family satisfaction. It is interesting to
note that the majority of studies of families' involvement in and satisfaction with long term care
facilities were qualitative and exploratory in nature (Teno, 1999; Duncan & Morgan, 1994;
Gladstone & Wexler, 2 0 0 ) . However, the subject of patient satisfaction has been covered
extensively in the literature and there are a number of studies that address patient satisfaction
from different perspectives. Lessons will be drawn fiom patient satisfaction validation studies to
increase our understanding of satisfaction instruments and methods.
Role of Families in Long Term Care:
The care giving role of the family for their aging relative is recognized as a cntical issue
in gerontology and is at the heart of our current health care system. The demographic profile of
family caregivers has implications both from a policy perspective as well as fiom the perspective
of satisfaction of families as customers of the long term care system. Very often, it is the female
relative who ends up providing long term care for a relative in the home or the community pnor
8
to moving to a long term care facility. A number of reasons are cited for this, socializing women
to be care givers, and demographics that suggest that the current aging population has grown up
within farnily structures where women stayed home and took care of the rest of the family
(Robinson, 1997; and Laitinen, 1992).
Most of the research available on family care-giving to elderly people deals primarily with
those residing in the community with a few studies documenting the role of families of residents
in institutions ( Duncan & Morgan, 1994). In general, the decision to place a close relative in a
long term care facility is a difficult one and families go through a myriad of emotions when
making such a decision. Some of these emotions include depression, loss, guilt, and anxiety
(Johnson et al., 1992). The relocation of a relative to a nursing home affects the Iife of a resident
as well as his or her close relztives who were providing care at home up to that point. In a
descriptive study done in 1992, Johnson and her research partners found that uncertainty and
conflict were the two major themes that affected how the family felt while making a decision to
place a relative in a nursing home (Johnson, 1992). Families felt uncertain regarding the
diagnosis, future prospects for improvement of health status of the relative, safety of
environment, and about their role in the care of the relative in the facility. This uncertainty
sometimes results in feeling of loss and guilt, feeling like outsiders, conflict in family continuity,
and conflict between resident's needs and those of the family. The authon suggest that knowing
the feelings surrounding a family member's move to a long term facility would allow staff to
make the transition to the nwsing home smoother for family members (Johnson et al., 1992).
Once a resident is in the facility, however, families contribute to customizing service to
the resident and providing a link to the resident's persona1 history and community (Robinson,
9
1994). Families also contribute to direct care provision for their relatives in long term care
facilities. Keefe and Fancey (2000) found that family members' responsibilities can be broadly
categorized into direct and indirect responsibilities. Indirect responsibilities include being an
advocate for the resident, an overseer of action, being available to help out whenever staff feel it
is necessary, and fhally being responsible for establishing and maintaining a good relationship
with staff. The direct responsibilities identified in their study include providing emotional and
physical support, providing personal comforts, and maintaining a link with the community (Keefe
and Fancey, 2000). In some cases, families of cognitively impaired relatives also assist in feeding
the residents and other similar persona1 tasks. However, it is suggested that the level of
involvement of farnilies might change over the length of stay in the long term care facility and if
the health status of the resident deteriorates (Keefe & Fancey, 2000). They also suggest ways to
keep farnilies in the loop of caring for residents while not becoming solely responsible for
providing care for their relatives. These recommendations include considering fmilies as part of
the multi-disciplinary team that cares for the resident, providing information to the family about
the changing health needs of the resident, and making the recreational activities flexible and
adaptable to encourage family participation in such activities (Kee fe and Fancey, 2000).
The two most comrnon factors that influence the relationship between families and staff
are mistrust and communication difiiculties. In a qualitative study done by Hertzberg and Ekman
(2000), it was found that many examples indicating uncertainty and distrust were narrated by
family memben from their point of view. Families were generally unhappy with the level of
information they were given about the resident's progress and some felt that they had to drop in
unannounceci to check on the type of service their relatives were getting. However, the most
10
significant result of this study was that neither staff nor families checked with each other about
what they believed about each other, which leà, in most circumstances, to breakdown in relations
between them. It was also found that it was families who took the initiative in most cases to
establish a relationship with staff. This was probably because families have a bigger vested
interest in maintaining a positive relationship with staff as it would increase their level of
influence on the care provided to their relatives (Hertzberg and Ekman, 2000).
Gladstone and Wexler (2000) suggest that what farnilies value in relationships with staff
are care and attention given to the residents, attention given to the family member, information
provided about the status of the resident, and opportunities to engage in joint problem solving. In
an effort to build and maintain relationship with staff, farnilies recognize staff in non-material
ways, show empathy for staff about their workloads and pressures they are facing, and try to deal
with conflict in a conciliatory manner.
In summary, it can be said that if care for a resident can be categonzed into technical and
non-technical care, staff in long term care facilities provide the technical types of care while
farnilies play a role in providing non-technical types of care. Also, since family members have
more personalized information about their relatives, they are uniquely positioned to enhance the
level and degree of care provided by staff (Duncan and Morgan, 1994). Families bring their own
set of expertise and knowledge of the resident's history, personality and habits pnor to
institutionalization while the staff bring a different set of skills and expertise required to care for
the resident (Gladstone and Wexler, 2000). Farnilies and staff play complementary and important
roles in the care of residents and therefore a well functioning relationship between these two
groups would contribute to better service for residents.
Dimensions of Patient And Famiiy Satisfaction
There is general agreement in the literature reviewed that patient satisfaction plays a very
key role in providing input into quality improvernent programs within health care organizations.
This has led to an increase in use of patient satisfaction ratings to evaluate the quality of care
provided by health care organizations and empincal data fkom patient surveys are being
increasingly used to target quality improvement initiatives. However, the recognition of
residents' or farnily members' satisfaction with nursing homes as a valid outcome measure of
quality, is a recent phenomenon ( h i c h , 2000). It has been suggested that satisfaction data can
be used by organizations for two important purposes: (1) as a marketing tool where satisfaction
data is used to emphasize how well an organization is doing with a view to retain existing clients
and to attract new clients and (2) as a quality improvement tool to address needs and concerns
expressed by dissatisfied clients (Ingram & Chung, 1997).
There are now a number of empirical studies of patient satisfaction and this has grown
into a substantive body of literature (Hays & Arnold, 1986, van Campen et al, 1995, Ware et al.,
1986). However, it has been pointed out that the literature on patient satisfaction is often diffise
and not focussed (Aharony & Strasser, 1993). There is also a considerable variance in how
patient satisfaction has been conceptualized.
The Linder-Pelz mode1 characterizes patient satisfaction as a positive attitude. Linder-
Pelz (1982) explains patient satisfaction using the attitude theory fiamework of Fishbein & Ajzen
in which there is a fundamental distinction between attitude and peceptions. Taking this
approach, Linder-Pelz defines patient satisfaction "as the individual's positive evaluation of
12
distinct dimensions of health care". Her model is an expectancy-value model that focuses on
socio psychological determinants of patient satisfaction. The attributes in Linder-Pelz model are
distinct dimensions of health care such as access, efficacy, cost, and convenience. However, the
model and the six hypotheses she put forward were not supported by empincal research (Linder-
Pelz, 1982 (b))
Pascoe (1983), reviewed and summarized a number of empincal studies and different
models of conceptualizing patient satisfaction and has developed a model for understanding
patient satisfaction in primary health care settings. Drawing tiom previous research, Pascoe
(1983) approaches patient satisfaction as an evaluation of services received where the evaluation
is seen as a cornparison of salient characteristics of the individual's health experience to a
subjective standard. He M e r States that this comparative process is assumed to include two
inter-related psychological activities: (a) acognitive based evaluation of the structure, process and
outcome of service, and @) an affectively based response or emotional reaction to the structure,
process, or outcome of services (Pascoe, 1993; p. 189). Some of the assumptions of this model
are that patients generally discnminate between and are able to judge the quality of multiple
aspects of their health care experience. This theory however, has not been tested empirically
(Aharony & S trasser, 1 993).
Aharony & Strasser (1 993) also reviewed the work done by two independent researchers
that suggests a framework that links service quality, customer satisfaction, and behavional
intentions. Both these models were based on the theoretical work done by Parasuraman and his
colleagues (1 986).
Kruzich (2000) in his paper summarizes what is known about organizational and
13
individual coirelates of nursing home satisfaction of residents and families. His review identifies
that the more dominant paradigm for assessing quality is the mode1 proposed by Donabedien of
structure, process and outcome as three indicators of quality. The conceptual linkages between
the three categones is that good structure increases the likelihood of good process which in tum
increases the likelihood of good outcomes. The most eequently used structural measures include
nursing hours per patient, expenditures per resident, ratings of physical environment and
occupancy rates. He suggests that structural components are more objective, reliable and easil y
measurable as cornpared with process and outcome indicators. However, an exclusive focus on
stnictural components of quality have some obvious shortcomings, the main one being that there
is little empincal support for a relationship between stnictural variables such as nurse-resident
ratios and resident outcomes (Knizich, 2000).
Process variables relate to the manner in which care is delivered and inlcudes factors such as
rating of care plans, meal plans, and ngidity of resident management practices (Kxuzich, 2000).
In one major study done by the National Citizens' Coalition for Nursing Home Reform, it was
found that residents felt that receiving care in a dignified and courteous manner was most
important for them. In addition, they felt it was important for them to be able to maintain control
over their daily lives (Knizich, 2000).
Though the studies and articles reviewed do not specifically cover family members
satisfaction, it can be assumed that farnily satisfaction is govemed by the same theoretical
pnnciples of patient satisfaction. There has been little research on families as distinct customers;
families have traditionally been surveyed as proxies for residents in giving feedback regarding
satisfaction. However, studies have s h o w that farnily members' views may differ corn that of
14
residents and that family members can be considered distinct customers of the long term care
system (Norton et al, 1996; and Greene et al, 1997-98). In the study by van Maris et al, (1 997),
they found that overall, more farnilies than residents rated the care provided as excellent.
McCusker (1984), also f o n d similar results when he evaluated patient and family satisfaction
with chronic and terminal care. Sometimes family member's rating of quality depends upon their
knowledge and level of experience, on their relatives' cognitive and physical functioning, and on
what the family can afford (Greene et al, 1997-98). Other researchers also confirmed that patients
and their family members assessed the quality of care differently; however, they found that
patients rated the quality higher than the relatives did ( Latinen (1992), and McCusker (1 984)).
The literature on patient satisfaction suggests that there is no consensus regarding whether
patient satisfaction is a Mdimensional or multidimensional construct (Kristjanson, 1993).
However, Pascoe (1983), suggests that there are a limited nwnber of dimensions of patient
satisfaction. Ware et a1 (1978) after a meta-analysis of 11 1 studies, came up with "eight
distinguishable dimensions which constitute the major sources of satisfaction and dissatisfaction
with care: art of care, technical quality of care, accessibility/convenience, finances, physical
environment, availability, continuity, and e~cacy/outcomes of care" (p.3). Later, Ware (198 l),
reduced the number of dimensions to five - quality of care, accessibility/convenience, finances,
physical environment, and availability. According to the meta analysis done by Hall & Doman
(1988) of 2 11 studies, the dimensions of patient satisfaction that are most fkequently identified
include: humaneness, infonnativeness, overall quality, cornpetence, overall satisfaction,
bureaucracy, access, cost, facilities, outcome, continuity, and attention to psychosocial problems.
While many factors have been identified as being related to patient satisfaction such as patient
15
socio-demographic characteristics, physical and psychological statu, and attitudes and
expectations of rnedical care, there is no consensus in the literature of which of these factors is
most strongly correlated with patient satisfaction (Aharony & Strasser, 1993).
With regard to satisfaction with services provided by long term care organizations, the
dimensions of quality important for residents: living environment, laundry, food, activities, staff,
autonomy, and dignity (Norton et al., 1996). For family members of residents of long term care
facilities, the dimensions of quality were: facility staffing, services, environmental features, and
facility operational policies and procedures (Greene et al, 1997-98). In addition, family memben
also reported that communication with staff, trust, involvement in care planning for residents, and
joint problem solving are important in maintainhg a good relationship with staff (Gladstone and
Wexler (2000); Hertzberg and Ekman (2000).
Wasser et al., (2001) suggest that for family members with critically il1 patients, the
dimensions of quality that are important include: assurance, information, proximity, cornfort, and
help to family members. Literature relating to parents of children in hospital settings suggest that
similar factors influence satisfaction of family members of patients in acute care settings, the
most common of which is communication between staff and family members (Astedt-Kurki, et
al., 1997). Family members who reported having had good expenences with visiting the hospital
felt so mainly because they felt welcome by staff or because they felr they were helping their
relative on the ward (Astedt-Kurki, et al., 1997).
Development and Psychometric Testing of Patient Satisfaction Instruments:
From the literature reviewed, it appears that while there is general agreement that
satisfaction is an important factor to be considered as part of quality improvement initiatives, it is
16
difficult to measure (Wilkinson, 1986, Larsen et al, 1979). The challenge faced by most health
care organizations is using appropriate tools and statistical methods for measuring patient
satisfaction so that it is usefùl in their quality improvement prograrns (Ingram & Chung, 1997).
Several methods, both qualitative and quantitative, are available for collecting data on patient
satisfaction, the most common ones being self administered questionnaires, telephone interviews,
or face to face interviews (Hays & Arnold, 1986, Ford et al., 1978). Every organization has to
balance the advantages, disadvantages, and biases associated with each method while selecting
the most appropriate one that would work for them. Some biases to watch out for are non-
response bias, administration of instrument biases, timing of surveys, response format, and use of
proxies (Ford et al., 1997). Self adrninistered questionnaires have a number of advantages
including removing any response bias that may affat other methods, and these are also less
expensive to adrninister. However, one of the biggest weakness of this method is that the
response rate tends to be low (Hays and Arnold, 1986).
Researchers have also pointed out that measurement of patient satisfaction through the
development of s w e y s and questionnaires has preceded theory development (Cleary and
McNeill, 1988; van Carnpen et al, 1995, Ryden et al., 2000; Aharony & Strasser, 1993). In a
study of patient satisfaction instruments, van Campen and his colleagues (1995) found that out of
the 100 measuring instruments developed to measure patient satisfaction, 41 were reported as
being tested for reliability and validity and only 8 had gone through testing more than twice. They
reviewed instruments which operationalized standards set in the literature about patient
satisfaction and these were: a) was the instrument based on clear and sound theory, b) was it
structured around sub scales that measured different aspects of patient satisfaction, c) was the
17
instrument psychometrically valid, d) was it feasible in surveys arnong large populations, and e)
could it be applied to quality assurance in home care settings? Based on these cnteria, the
research focussed on the following 5 instruments: Patient Satisfaction Questionnaire (PSQ),
Client Satisfaction Questionnaire (CSQ), Satisfaction with Physician and Primary Care Scale
(SPPCS), Patient Judgements of Hospital Quality instrument (PJHQ), and Service Quality
Instrument (SERVQUAL).
One of the major theoretical implications of this review was that there seemed to be lack
of comection between patient satisfaction theory development and instrument development and
this was confinned in their findings that none of the instruments were based explicitly on
theoreticaI foundation with the exception of SERVQUAL. However, when the fact that surveys
are used in the context of quality improvement for intemal use within organizations is
considered, it is easy to undentand why there are so many self developed questionnaires to
measure patient satisfaction that are not necessarily rooted in the patient satisfaction theory.
In addition to challenges of developing satisfaction surveys without theoretical
underpimings, there are also several methodological challenges with measuring patient
satisfaction. There are some specific measurement issues with the survey methodology such as
the bbhalo" effect with uni formly high levels of satisfaction; lac k of meaningful comparisons, lack
of standardized instruments that have proven reliability and validity, and difficulty in avoiding
sampling biases (Avis, 1997; Larsen et al., 1979, Ryden et al., 2000). Other measurement issues
identified in the literature are direct versus indirect approaches to measuring patient satisfaction
(direct methods being more appropriate for micro level information on patients' perceptions and
indirect methods providing more comprehensive or macro level analyses of the system), multiple
18
item versus single item tools (multiple items allowing for more variability among respondents),
and multi versus unidimensionality of patient satisfaction (multidimensionality requinng longer
scales with more specific questions as opposed to undimensionality) (Knstjanson, 1983, Larsen
et al, 1979; and Ryden et al.,2000).
Other weaknesses of the survey methodology is that sometimes patients are asked to
comment on technical quality of services provided but feel that they might not feel qualified to
assess. It is also felt that satisfaction surveys also tend to focus on peripheral aspects of care such
as manner of physicians and not on the technical quality of treatment and as such may not be the
best way of finding out the customer's perspectives in order to improve quality of service
(Callery and Luker, 1996). in addition to these, with regard to resident satisfaction in long term
care facilities, the validity of results fiom such questionnaires might be influenced by factors such
as lower expectations or lack of knowledge of residents of long terni care facilities (Teno, 1999).
It is suggested that qualitative methods such as conversational interviews with patients or family
members are more usefui than questionnaires in providing valuable information about services
provided within the context of their whole experience at the hospital (Callery and Luker, 1996;
Avis, 1997).
Despite the issues and weaknesses identified in the literature, van Carnpen and his
colleagues (1 999, found that with over 100 instruments developed, self developed surveys was
still the most pre-dominant method of measuring patient satisfaction (van Campen et al., 1995).
A nurnber of studies have identified ways io overcome the weaknesses of satisfaction sweys
(Larsen et al, 1979; Hays & Arnold, 1986; and Kristjanson, 1983). One common method to
strengthen psychometrics of an instrument is to start with a qualitative approach to generate a
19
pool of items to be included in the survey (van Campen et al., 1 995; Ware et al., 1 983; Norton,
P.G., et al, 1996, Background document, SWC). The most common steps in developing an
instrument identified in the references above, includes literature reviews to develop an outline of
satisfaction constructs, focus group discussions with patients, clients, family members, and care
providers to generate a pool of items which is categorized into content areas by experts in the
field who are independent judges. Following this, is usually a content analysis and grouping of
items according to content areas which results in a taxonomy of quality attributes. Exploratory
factor analysis can then be conducted to test for underlying constructs covered in the instrument
(Hay and Arnold, 1986; Wilkinson, 1986).
Some studies reviewed include methods like convergent and divergent validity techniques
to test the construct validity of the instrument. In most cases, researchers administered at least
one other instment to test their hypotheses regarding patient satisfaction in addition to the
questionnaire which they were testing (Knstjanson, 1993, Oermann et al., 2000, Drain, Ryden et
al., 2000). In this situation, researchers examine construct validity using analyses of convergent
relationships between patient satisfaction levels and other theoretically related constructs, e.g.,
disease severity (Oermann et al, 2000), perceptions of chronic and terminal care (Knstjanson,
1993); morale (Ryden et al., 2000) .
Larsen et al, (1979), suggest that in order to make the results of patient satisfaction
surveys more relevant and meaningful, the organization should analyse results more closely to
identiQ sub groups of dissatisfied clients or ask for qualitative cornments to probe more and
understand what clients are really saying. This would counter the "halo" effect of uniformly high
satisfaction scores generally obtained through satisfaction surveys. Other suggestions include
20
monitoring client satisfaction over time using tirne senes, quasi-experimental methods, and
triangulating patient satisfaction measurement with other behavioural indices (Larsen et al, 1979).
Hays & Arnold (1986) suggest that one should try a combination of methods like following up
self-adrninistered questionnaires with telephone interviews to increase response rate. They also
recommend using multiple item scales to ensure greater variability between respondents, to
control for acquiescent response bias, and to distinguish between different dimensions of
satisfaction.
Other researchers have used methods like discriminant analysis to address the "halo"
effect of surveys and also to help distinguish between different levels of satisfaction.
Discriminant analysis is a statistical technique that permits the sîudy of differences between two
or more groups with respect to several variables studied simultaneously. The idea of doing
discriminant analysis is to identiw dimensions of care that differentiates between levels of
responses, e.g., "excellent" and "gooâ" (Dansky, 1 996). This technique would also help
organizations target their efforts in continuous quality improvement initiatives (where the target
is to maximize "excellent" responses or to reduce the number of "poor" responses).
With regard to assessing the reliability of a multi item instrument, the most widely used
method is the intemal consistency method, generally expressed as "Cronbach's Alpha (a)".
Cronbach's alpha is a measure of the correlation among items in a scale and while an alpha
estimate (a) of 0.70 is generally considered minimally acceptable for recently developed
instruments, for established instruments, a has to be around 0.80 ( N u ~ a l l y , 1967). Most studies
also used test-retest methods to test for stability of results over time.
21
Summary:
In surnmary, a review of the literature showed that patient satisfaction is not a new subject. There
are a nurnber of studies and articles that comprehensively deal with the subject and explore both
conceptual and methodofogical issues associated with patient satisfaction. One common theme
that emerges h m the literature is that there is no commonly accepted theory of patient
satisfaction and that measurement of patient satisfaction has preceded theory development.
Though this might be a weakness for academic researchers, this might not be very relevant for
patient satisfaction measwement and feedback which is tied closely to the quality improvement
movement.
The literature review also revealed that while there were a number of studies on the role
of families in long term care facilities, most of them were exploratory in nature and covered
qualitative analysis of correlates of satisfaction and used methods such as open ended interviews.
While the literature covered, quite exhaustively, topics of patient satisfaction in a number of
different settings, there were not many quantitative studies done on farnilies and their satisfaction
with health care organizations. Also, not many empirical studies were done to test the role of
family members as customers of health care organizations as opposed to proxies for patients or
residents.One important observation is that the literature review did not yield any
psychometrically valid instruments that could be used to measure patient or family satisfaction in
more than one sector. Several instruments were available for specific settings, e.g., primary care,
acute care, cancer care, mental health, and terminally ill. However, these instruments are limited
in scope because of their constricted language, and they measure context specific information that
cannot be transferred easily to other settings.
Chapter 3
HISTORY AND DEVELOPMENT OF INSTRUMENT
This section will re-trace the steps of the research team, comprising researchers from
University of Toronto and Sunnybrook Health Sciences Centre and supported by the consortium
of long term care organizations, as they studied resident satisfaction with long term care facilities
and subsequently developed the Family Evaluation Survey. in addition, it will cover the methods
used by the research tearn to collect data from 21 long term care organizations in Ontario and BC
which has been used in the current research for psychometric validation of the instrument. There
will be a brief description of how the data collected was analysed and reported back to the
organizations participating in the study so that they could incorporate this into their quality
improvement initiatives.
History :
As part of the first study done by the team of researchers at U of T and SHSC, in which
they studied resident satisfaction with long terni care facilities, the research team also wanted to
compare the responses from residents with that of their farnily members. The LTC Resident
Evaluation Survey, which was developed to capture resident's responses to quality of services,
was used to serve dual purposes: to measure resident satisfaction, and to understand residents'
perceptions and needs through the eyes of their family members. in that study, the researchers
used the same instrument in one-to-one interviews with residents as well as in a mail format for
families. Their hypothesis that families could be used as surrogates for residents was not ptoven
as it becarne clear from the data gathered, that family members have a somewhat different
23
perspective than residents on the services and quality of care provided in different areas and that
residents and families are two distinct customers of the health care system (Norton et al, 1 996).
The Long Term Care Family Evaluation Survey was then developed in response to this
finding, by SWC, in conjunction with Sunnybrook Health Science Centre and the Hospital
Management Research Unit at the University of Toronto in the spring of 1996, with a view to
capture f m i l y members' perspective and their specific needs and concerns. There are now two
different instruments that are being used to collect resident and family data, the results of which
can be used in conjunction with one another. Presently, SWC has the exclusive rights to
implement the Long T e m Care Resident and Family Evaluation S w e y for al1 faciiities in North
America.
The main purpose of the Family Evaluation Survey was to develop a systematic way of
collecting feedback from families of residents to be used in the quality improvement process of
organizations. Their purpose was not to study resident or farnily satisfaction in pursuit of a theory
of family satisfaction, but to use the data collected through the research to make improvements in
the organization. The researcbers felt that since family members were distinct customers of the
health care system, they could shed some light on the quality of care and what needs to be
improved. They hypothesized that family rnembers provided the organization with feedback fiom
another perspective with respect to the quality of services since residents and farnily members
view care from different perspectives. It is like looking into a room through two different
windows; an organization would get a more complete picture of the quality of their services when
seen h m two different standpoints. If an organization depended upon feedback fiom residents
alone to inform their quality improvement processes, they might miss out on some major areas of
24
improvement, e.g., the smell in facility may not bother residents because they are used to it but
farnily memben may notice this more. This is important from a quality improvement point of
view because i t might motivate action on the part of the organization even though it was not seen
as a problem fiom the residents point of view. In addition, the farnily survey was developed with
a purpose to fil1 gaps or weaknesses in the Resident survey by collecting information from
farnilies whose residents may not have been able to participate.
In summary, the research team saw the following advantages in developing the Family
Evaluation Survey: (1) it is a useful tool that could complement the Resident Evaluation Survey
to give a comprehensive picture to the organizations about what influenced patient's and their
families perceptions of quality. The two surveys could be used to provide valuable feedback to
the participating organizations that could in tum be used in their quality improvement initiatives.
(2) The family survey would provide the organizations with specific cornments on how the
facility met the farnily member's needs, distinct from those of the residents. (3) Family members
rnight identiQ aspects of care that might not be identified by residents as needing improvement.
The dimensions of satisfaction included in the family survey were different fiom those
included in the resident survey. Through this survey, the researchers wanted to understand the
explicit dimensions of quality such as living environment, communication with staff, resident
care, and quality and services. The questions included in the survey reflected these dimensions.
The research tearn made a conscious decision to keep the length of the questionnaire short and
not to repeat any questions as they wanted to maximize the response rate for the survey. The
pnmary purpose of the survey was to collect information that could be used for quality
improvement processes.
25
Development of Instrument:
Several sources of qualitative information were used to define the LTC Family Evaluation
Survey. Data fiom focus groups conducted at long tem care facilities in Ontario and Manitoba as
well as resident and family data from Alberta were pnmariiy considered while developing the
Farnily Evaluation Survey. These data indicated that 65 items ranging ffom communication with
staff to providing care in a dignified manner were consistently important for families. From these
65 items, items that met the following two cntena were included in the survey:
1) questions that reflected family's needs and not residents' needs and
2) intemal organizational processes could be changed based on the responses.
The questionnaire was pilot tested among 20 families fiom three long term care facilities
in Ontario in 1997 which led to the development of the current questionnaire. The final family
evaluation survey has 36 questions and is divided into five general domains:
Living Environment - 4 questions about the physical layout and comfort of the resident's room
Communication with Staff - 7 questions about family-staff communication and relationships
Quality and Services - 10 questions about certain aspects of the quality of care and services
Resident Care - 3 questions about how the family member is cared for
Global Questions - 7 questions to provide an overall picture of satisfaction with the facility
Each domain has between 4 and 10 questions that ask the family member to rate staff or
the facility on certain charactenstics or behaviours on a traditionally accepted Likert type scale.
Because not al1 of the questions lend themselves to a rating scale, some questions ask whether a
certain characteristic or behaviour is present. For those questions seeking to identiQ whether a
certain characteristic or behaviour is present, the family member is asked to respond with either
"yes", "somewhat", "sometimes" or "no"
et5 "Does your family member's room meet W h e r specific needs?
"Yes", "Somewhat" or "No"
The majority of questions which ask the family mernber to rate staff or the facility use the
response scale "Excellent", "Very Good", "Good", "Fair", or "Poor"
eg- "How would you rate your reiationship with the staff?
"Excellent", "Very Good", "Goo~", "Fair", or "Poor"
Throughout the questionnaire, space is provided for comments. In addition, two questions
relating to the relationship between the family rnember and resident and their rating of the
resident's health in cornparison to other residents were also included. Finally, every s w e y had
three questions to elicit feedback on the questionnaire itself and suggestions for fùture
improvements of the questionnaire. A copy of the Family Evaluation Survey is at Appendix 6.
The process of developing the family survey by Smaller World Communication and the
research team, included a pilot testing phase when the family survey was tested with
approximately 20 families f?om three hospitals in Ontario (Sunnybrook Health Science Centre,
Perley & Rideau Veterans' Health Centre, and the Queen Elizabeth Hospital). After the pilot test,
the questionnaire was revised to reflect the comments made by families.
Confidentiality :
SWC obtained pnor approval from SHSC's review cornmittee before piloting the family
survey instrument in 1996. Subsequently, hospitals and other long term care facilities used their
own standard review procedures before letting SWC conduct surveys of families. In some cases,
this meant that protocols passed hospital review cornmittees, while in others, the senior executive
okayed the proj ect .
Every survey had a "Statement of Confidentiality" that assured respondents that al1
information provided by the family member would be held confidentially; that no narnes would
be recordeci on the questionnaire; and that the ID number would be used only to link the
responses of family members to those of the residents and their nursing unit. The questionnaire
also stated that participation was completely voluntary and that the main purpose of the
evaluation survey is to find out how families felt about the facility so that irnprovements could be
made. Finally, respondents could cal1 SWC if they had any questions about the survey.
Data Collection:
Data collection took place as individual data collection projects in each organization
between 1997 and 2000. A family member was defined by the research team as a close relative of
the resident or any person who visited the resident very offen and was considered a significant
visitor. For each resident selected, whether or not the resident could complete the interview, only
one family member or significant visitor was contacted by phone and was sent the questionnaire
by mail for completion. in a few cases, residents requested that more than one family member or
fnend to be included in the survey and these were included. SWC provided al1 necessary
materials to the organization and the facility in turn identified tamily members or significant
visitors to whom the survey may be sent. The mailed out package included a self addressed,
stamped envelope with SWC as the retum address. This guaranteed the retwn of al1 completed
questionnaires to SWC. These are cumentiy being stored in their office. Since data collection was
the responsibility of each individual organization, each organization followed up with the family
members differently, e.g., in some facilities, volunteers did the follow-up calls to encourage the
28
significant visitors to complete the questionnaire, and in others, reminder letters were sent.
Response Rate:
Twenty one organizations participated in this process of collecting family feedback; one
organization had seven facilities and therefore, in all, data from 27 facilities was used in this
study (a list of organizations in the dataset is at Appendix 1). Of the 27 facilities, seven facilities
completed more than one wave of data collection and the others completed only one wave. The
complete data set had responses received fiom 3783 surveys covering data collected over a period
of 3 years, fiom 1997 to 2000. The average response rate was approximately 56%. However,
there were significant differences in the number of responses from each organization (ranging
h m 29 to 301). The response rate also differed frorn one organization to the other (ranging corn
35% to 83%).
Analysis, Presentation and Use of Data:
Once SWC receives data fiom participating long term care organizations they analyse
these data and present relevant information to the management of these organizations. The
purpose of this is to provide the organization a way to incorporate family members feedback into
their quality improvernent processes. SWC provides every facility with their scores on each of the
domain in the survey along with the average score for the domain in the database as welI as with
the highest scores achieved by an organization for the same domain. This is to allow
organizations to see how they are doing as compared to the average as well as the highest
performer and also to motivate the organization to irnprove their scores in areas where their
scores are low compared with their peer organizations.
If the goal of an organization is to provide top quality services to its clients, it would
29
stnve for 100% "excellent" scores and a "good" rating wouid not good enough. While it is
unrealistic to expect al1 families to rate the services as excellent, having excellence as a goal
creates an ideal atmosphere for continuous quality improvement. For the questions that ask
whether a charactenstic or behaviour is present, top quality would mean 100% positive scores.
Ideally, a top facility wants its customers (residents and farnily members) to Say "yes" that a
positive behaviour or characteristic is present al1 the time. Responses indicating that only
"sometimes" a behaviour or charactenstic is present may be acceptable in some circumstances
but is not the "ideal". For the rating questions in the survey, special attention should be paid to
those items on which a high percentage of respondents rated as 'bpoorl' or "fair". Results of this
nature indicate that there maybe a much larger problem requinng imrnediate attention.
Once the resuits are presented to an organization, there are several ways for the
organization to improve the quality of their services and improve satisfaction. The organization
could work with staff to find out which areas they expected to receive better scores and what they
feel are realistic scores. It could also first improve the areas with the lowest scores or irnprove the
areas that are easy to improve. On the other hand, organizations could determine which areas are
important rather than easy to improve and tackle these areas first based on the feedback received
fiom their customers (residents and farni 1 y members).
Summary
The development team used both prirnary and secondq data to inform their creation of
the Family Evaluation S w e y . Their analysis methods for the data collected focussed on five
scales built into the instrument. Although it has been widely used for data collection and
reporting to organizations, there has not be a psychometric analysis of the instrument beyond a
30
small, initiai analysis which included a pilot test confirming face validity of the instrument.
Chapter 4
RESEARCH GOALS AND METHODS
The main purpose of the present study is to establish the psychometric properties of the
fmi ly survey instrument developed by Smaller World Communication (S WC) to rneasure family
satisfaction with long term care facilities. However, as mentioned earlier, two themes or
questions run simultaneously through the study. One is to gain an understanding of the
components of fmily members' satisfaction with long term care facilities and the second, to test
the Family Evaluation Survey instrument for psychometric validation. The two thernes are
interlinked throughout the study since the former relates to the content of family satisfaction and
the latter, to methods for testing the instrument for reliability and validity.
Researcb Questions:
While the content area of patient and family satisfaction and factors afEecting family
satisfaction has been covered in the literature review section, the focus of the study is to
empirically test the psychornetric properties of the Farnily Evaluation Survey. Psychometics
refers to those statistical methods that empirically investigate whether a test measures what is
intended (validity) and yields consistent findings over time (reliability). These methods produce
quantitative indices that represent both the amount and type of reliability and validity associated
with a test or rneasure. The following are the three research questions that were examined in the
study and the statistical analysis strategies used to answer these questions.
32
a) Did the Family Evaluation Suwey demonstrate internal consistency reliability?
Reliability refers to the consistency of measurement or the degree to which an instrument
measures the same way each time it is used under the same condition with the sarne subjects. in
short, reliability is the repeatability of an instrument. Nunnally (1 967) defined reliability as "the
extent to which (measurements) are repeatable and that any random influence which tends to
make measurements different from occasion to occasion is a source of measurement error"
e.206). The two common forms of estimating reliability are: testhetest and internal consistency.
Testhetest is the more conservative method of estimating reliability. This involves implementing
the sarne instrument at two separate times for each subject. Intemal consistency reliability
estimates reliability by grouping questions in a questionnaire that measure the sarne concept and
running a correlatin between these groups of questions to determine if the instrument is reliably
measuring that concept. One common way of computing correlation values among questions on
an instrument is by using Cronbach's alpha. The pnmary difference between testhetest and
intemal consistency estimates is that testhetest involves two adminstrations of the measurement
instrument, whereas the internal consistency method involves only one administration of that
instrument. In the current study, since data available was fiom a single administration of the
instrument, it was appropriate to measure internal consistency reliability using Cronbach's alpha.
The farnily survey was tested for internal consistency reliability using Cronbach's Alpha
to measure how each item on a scale related with each other. Cronbach's alpha was calculated for
the four domains and the global questions on the questionnaire; average inter item correlations
were also examined to see how the items related to each other on the questionnaire.
33
b) Did tbe Family Evaluation Survey demonstrate content and construct validity? Did the
empirical analysis support the original intent of the researchers who developed the Family
Evaluation Su wey?
Validity is the measure that demonstrates whether an instniment measures what it is set
out to measure. The validity of an instrument identifies whether it correctly measures the
concepts or constructs under study and is concerned with systemic errors that might have crept
into the measurement instrument. Content validity addresses the adequacy of item sampling to
reflect content sub scales. Content validity also refers to the degree to which the instrument has
adequately sarnpled the total possible meanings of the consûuct under study. The construct in the
current study is that families are distinct customers of long term care facilities and there are
several factors that influence their satisfaction with services, distinct fiom what affect residents'
satisfaction with a facility. Validity is generatly assessed by comparing a new tool or measure to
an accepted "gold standard". As there is no validated "gold standard" measure of families with
resident care in long term care facilities, indirect methods such as factor analysis were used to
detennine the validity of the family survey.
The main goal of the researchers in developing this instrument was to determine the level
of family members' satisfaction with the care provided in long term care facilities. The focus was
on family needs and concems specifically, distinct fiom those of residents. In this questionnaire,
the researchers hypothesized that satisfaction could be captured within five sub scales: living
environment, communication with staff, quaiity of service, resident care, and a set of global
questions to capture overall satisfaction. The current study examined whether the data supported
this hypothesis that family members have multiple needs and concems that have to taken into
34
consideration by the organizations. The questions sought to be answered through the curent
study were: what are the distinct factors of satisfaction addressed by the questionnaire? Do the
five domains identified by the researchers correspond with the factors that underlie satisfaction?
Are the number of questions in each scale sufficient to address the factor identified?
Factor analysis, which is an empirical method used to identiQ or discover the
multidimensional structure of a consû-uct such as farnily satisfaction, was conducted to address
these questions. Principal Axis Factoring method with both orthogonal and oblique rotations was
the technique used. The reason for choosing Principal Axis Factoring was to determine how
many underlying factors are present in the survey and what they represent. These two rotations
were used in recognition of the fact that since the survey measured only one construct, farnily
satisfaction, the factors might be correlated with each other. Factors with eigenvalues more than 1
were extracted (selected) for rotation. Use of eigenvalues is the most commonly used index for
determining how many factors to use in a factor analysis; scree plots are also used.
The Izst three questions on the survey that refer to improving the questionnaire itself were
not included in the factor analysis or scaling analysis as they did not relate directly to the
reliability or validity of the instrument. They are exarnined, however, to test for face validity of
the questionnaire. Face validity addresses whether a measure appears relevant to the construct
being studied. Anastasi (1988) States that face validity "pertains to whether the test 'looks valid'
to the examinees who take it, the administrative personnel who decide on its use, and other
technically untrained observers". Analysis of these three questions would reveal whether the
respondents had any difficulty in answenng any of the questions and whether the questionnaire
left out anything that was important to them.
35
Data Set:
M e r receiving approval fkom the Research Ethics Board, University of Toronto, the data
were stripped of al1 identi fiers such as hospital narne, unit name, etc. before being transferred
fiom SWC in SPSS 10.0 for Windows format. Before starting the analysis on the data received,
the data set was scrutinized for completeness and correctness.
The complete data set had responses received fiom 3783 surveys covering data collected
over a penod of three years, fiom 1997 to 2000. Dunng this period, data collection had occwred
at different times within the 27 different organizations and some organizations had collected data
more than once though not fiom the sarne respondents. Some of the organizations that collected
data more than once during this penod were large. It was felt that this would result in an over
abundance of cases fiom any one organization which might bias the results towards those
organizations. Hence it was decided that data collected in the most recent wave within an
organization would be considered. in other words, if an organization collected data at two or
three different time periods, only the most recent data were considered to ensure that each
organization was represented only once in the data set. The first step, therefore, was to select
cases collected in the most recent wave. This reduced the total number of records in the data set
fiom 3783 to 2649 records. The average response rate for the most recent wave of data collection
was 56%. From a mail-out of 4656 surveys, responses were received from 2649 respondents.
The next step was to shidy the data set for missing data so as to ensure that the data set
WJS complete and didn't have t w many records with missing data. It is important to examine the
number of missing responses and to consider the impact of non-response bias on the results of a
survey, when evaluating an instrument for research purposes (Irvine et al., 2000). The topic of
36
missing data has been studied extensively in educational and psychological research and "missing
data" is refemed to as blank responses that occur either because the respondent skips an item by
mistake or reads an item and consciously decides not to answer it (Ludlow and O'Leary, 1999).
In the case of patient satisfaction research, however, it is suggested that missing data might be
related to "amount of respondent burden associated with the instrument's administration" (Irvine
et al., 2 0 ) .
In the present study, each record in the data set referred to each respondent of the survey.
The intent was to screen the data set to try to get the most number of records for analysis
purposes. Since there were a number of surveys that were not answered completely, a decision
had to be made with respect to dealing with records with missing data. Since the survey had 3 1
questions that measured family satisfaction, it was decided that any survey that had more than 15
questions unanswered would not be considered in the analysis. The rationale for inclusion in the
data set was that for an individual survey to be considered valid for use, at least half the questions
would have to be answered. This was an arbitrary decision and it is recognized that the cut off
point could be at any level. As can be seen fiom the Table at Appendix 3 which shows the
nmber of missing records for each item in the survey, 33% of respondents answered al1 the
questions. Further, about 99.1 % of respondents had answered at l e s t 15 questions on the survey.
By deleting the records that had more than 15 questions rnissing, the dataset was reduced by only
18 records. The final data set that was considered for analysis in this study had 263 1 records.
Appendix 2 shows the details of the data set and the final number of records considered for
analysis in this study.
The data set was then also scrutinized to see if there were any questions on the survey that
37
had significant missing data. This procedure helped clean up the data set so as to avoid skewing
of reliability and scaling analysis of each domain. This analysis would also infonn the discussion
on the face validity of the questionnaire as it would reveal whether there was any pattern based
on the questions not answered. Frequency tables were created for all questions and the analysis of
showed that there is a small percentage of missing data in most scales with the exception of the
quality and service domain. The following table shows the breakdown of missing data by
domain.
Table 1 : Missing Data by Dornain
Domain # Items Missing % Items with Missing Data
Living Environment 4 1.6 to 2.3
Communication with 7 1.4 to 15.1 staff
Quali ty and Services 10 2.3 to 46.7
Resident Care 3 2.5 to 10.3
Global Questions 7 1.5 to 13.1
Insignificant amount of missing data
"rate staff at appreciating your help (1 6.4% missing) "rate staff at caring about you (1 5.9% missing)
"does the resident get help eating" (24.7%) "enough time taken to feed resident" (48.2%)
"are specific needs methesident encouraged to be independent" (1 0.3%)
"how are staff at taking care of your needs" (13.1%)
The two items under Quality and Services with approx. 25% and 48% missing data were
eliminated fiom the data set when calculating reliability estimates for the Quality and Service
domain and when conducting factor analyses on the s w e y items.
In addition to these two questions that were deleted from reliability and validity exercises,
the questions relating to relationship to resident and the family member's assessrnent of the
38
resident's health as compared to other residents were not analysed. It was felt that since the
current analysis focussed on components of family satisfaction these questions were not relevant
for the analysis.
Eff'ect of Missing Data on Sample Size:
The statistical program used for analysis purposes was SPSS 10.0 for Windows. SPSS has
different methods for handling missing records - list wise and pair wise deletions. List wise
deletions is where cases that have missing values for any of the variables selected are omitted
tiom the analysis. Pair-wise deletion is where al1 cases that have valid data for the pair of
variables tested are only considered in the analysis. In the current study, where the option was
available, pair wise deletion was selected, e.g., for the factor analysis procedures, pair wise
deletions were considered. However, for reliability analysis, SPSS uses list wise deletions. This
results in different sample sizes for different scales which range from 2007 in the
Communication with Staff domain to 2450 in the Living Environment domain (see Table 3).
Summary:
The data analysis strategies include calculating Cronbach's Alpha to test for reliability
and factor analysis to determine construct and content validity of the instrument. Records with
more than 15 questions unanswered were deleted from the analysis so as to increase
generalizability of results. In addition, two questions in the "Quality and Service" domain were
deleted from psychometric analysis since they had significant number of missing responses. The
main questions sought to be answered by the current research were whether the family evaluation
survey was reliable and valid.
Chapter 5
RESULTS AND MAJOR FINDINGS
Demogra~hic Information:
The research team defined a farnily member as a close relative of the resident or any
person who visited the relative very fiequently. Almost half of the respondents either had a
motherlfather (in-law) (43%); and one third, had a spouse (29%) in thc facility. The rest of the
respondents were brotherlsister (8%), chi ldren (8%), or other fami l y members (7%). On1 y one
percent of respondents had grandparents in faci li ties.
Table 2: RELATIONSHIP TO RESIOENT
kelationship to Family Member Percent
4USBANDMIIFE 28.3
3ROTHERlSISTER (IN-LAW) 8.1
WOTHEWFATHER (IN-LAW) 42.8
SRANDPARENT 1 .O
%ILD 8 .O
OTHER FAMILY MEMBER 6.7
3THER 5.2
Total 1 O0 .O
Research Ouestion 1 : Does the Familv Evaluation Survev dernonstrate interna1 consistencv
reliabilitv?
Cronbach's alpha was calculated for the five scales of the survey (the 7 global questions
40
were also treated as a scale, in addition to the four domains identified in the swey). A scale will
be considered reliable based on the following criteria: Cronbach's alpha > 0.70; item-item
correlations r = .30 to -70; item total correlations >.40. Four of the five scales demonstrated
reliability coefficients of .80 and above, greater than the generally recornmended value (0.70).
The estirnates ranged from 0.63 (Living Environrnent) to 0.95 (Communication With Staff). A
summary of the reliability estimates for the 5 domains is given below and details of reliability
statistics for each domain follows. It must be pointed out that the sample sizes fluctuated for each
domain since SPSS 10.0 program uses Listwise deletion methods only in reliability analysis.
Table 3: Sumrnary of Reliability Analysis of Scales
1 Mean Mean Inter-Item Domain Items N Score SD Alpha Correlation
1 Living Environment 4 2450 5.46 1.48 0.63 0.32
Communication with 7 2007 26.89 6.36 0.95 O. 73
Quality and Service 8 2080 27.14 5.89 0.89 0.47
1 Global Questions 7 2013 23.84 5.5 0.90 0.57
To obtain the inter scale correlations, mean scores of the items in each domain were
converted into scales and Pearson's correlation was then calculated to measure correlation among
scales. The following table shows the correlations between the five domains. It can be seen that
the four scales relaiing to communication with staff, rating quality and services for residents, and
the overall global questions are correlated highly with each other (ranging from 0.65 to 0.83). The
only exception is the living environment scale which has low to moderate correlation with al1 the
other scales.
41
Table 4: Pearson's Correlations Between Scales
LIVING COMM QUALITY RESIDENT GLOBAL
LIVING 1 .O0
COMM .4 1 1 .O0
QUALITY .44 .82 1 .O0
RESIDENT -40 -76 .83 1 .O0
1 GLOBAL .36 .65 .7 1 -7 1 1.00 1
Domain 1 : Living Environment: This domain had 4 items and was intended to capture
respondents' satisfaction with the living facilities of the organization. Respondents had 3
response choices under this domain - "Yes", "Somewhat" and "No". The item statistics shows
that the results in this domain are al1 skewed towards the positive suggesting that overall family
members found the living environment met their needs. However, with regard to the
psychometric properties of the scale. the reliability coefficient alpha was a moderate 0.63. While
the correlation matrix showed that al1 the items in the scale were weakly to moderately correlated
with each other (mean inter-item correlation was 0.32), item 3 was the most weakly correlated
with other items. If this item was deleted from the scale, the alpha would remain at 0.64 whereas
if any of the other items were deleted, the alpha would drop to 0.53. A detailed view of the
reliability analysis is given below:
Table 5: Reliability Analysis: Domain 1 - Living Eovironment
Item Statistics:
Mean
Std. Deviation
Variance
S kewness
Std. Error of Skew ness
Minimum
Maximum
Valid 2595
Missing 36
2.78
0.46
0.22
2.03
Correlation Matrix:
N of Cases = 2450.0
Inter-item Correlations:
Mean Minimum Maximum Range M a m i n Variance
0.3298 0.2354 0.4782 0.2428 2.03 12 0.0075
Item-total Statistics:
Sub Scale Scale Mean If Scale Corrected Squared multiple Alpha if Item Deleted Variance if item-total correlation item
Item Deleted correlation deleted
Reliability Coefficients 4 items
Alpha = 0.63
Domain 2: Communication With Staff: This scale had a total of 7 items and asked family
members to rate family-staff communication and relationships. This Likert type scale had 5
choices ranging from "Excellent" to "Poor". The item statistics demonstrates that the results are
positively skewed with most respondents rating their communication with staff as "Good" to
"Excellent". The scale also demonstrated high intemal consistency with the reliability coefficient
alpha of 0.95. Al1 the items were strongly correlated with each other with a mean inter-item
correlation of 0.73. An examination of the "alpha if item deleted" shows that if any item is
deleted, alpha would continue to be as high &ove 0.90. A detailed view of the reliability analysis
is given below:
Table 6: Reliability Analysis: Domain 2 - Communication With Staff
Item Statistics:
COMMS COMM6 COMM 7 COMM8 COMM9 COMM 10 COMM 11
Valid N
Missing
Mean
Std. Deviation
Variance
S kew ness
Range
Minimum
Maximum
Correlation Matrix
l l COMMS COMM6 COMM7 COMM8 COMM9 COMMlO COMM11
COMMS 1
COMM6 0.83 1
COMM7 0.63 0.62 1
COMMS 0.69 0.69 0.82 1
COMM9 0.63 0.66 0.73 0.75 1
COMMIO 0.68 0.7 1 0.74 0.77 0.83 1
COMMll 0.69 0.68 0.76 0.77 0.77 0.84 1
N of Cases = 2007
45
Inter-item Correlations:
Mean Minimum Maximum Range MadMin Variance
O. 729 0.6191 0.8372 0.2181 1.3523 0.0045
Item-total Statistics
Scale Mean if Scale Conected Squared Alpha if Item Item Deleted Variance if Item Total Multiple Deleted
Item Deleted Correlation Correlation
COMMS 23.23 29.64 0.78 0.72 0.94
COMM6 23.35 29.60 0.79 0.72 0.94
COMM7 22.70 3 1 .O1 0.8 1 0.72 0.94
COMMS 22.90 29.78 0.85 0.76 0.94
COMM9 23 .O3 30.3 1 0.83 0.73 0.94
COMMlO 23.15 29.37 0.87 0.80 0.94
COMM11 23.00 30.27 0.86 0.77 0.94
Reliability Coefficients 7 items
Alpha = 0.95
Domain 3: Oualitv and Service: This scale had a total of 10 items and asked respondents about
certain aspects of the quality of care and services provided. Of the 10 questions on the scale, two
were deleted as they had significant missing data (approx. 23 and 48%) fkom further analysis. Six
items on the scale have score choices ranging from "Excellent" to "Poor" while for the other two
questions family members were asked to respond with "Yes", "Somewhat" or "No". The
responses for the item "do you know who to taik to in order to get information about your family
membef* was re-coded for analysis purposes to be consistent with other questions in the scale,
46
with a higher number (3) being a positive response (Yes) and 1 being the negative response (No).
The item statistics for this scale shows that once again, a majority of respondents rated the
quality of services positively. For the 8 items on the scale, the intemal consistency coefficient was
high at 0.89. -4s can be seen from the correlation matnx below, items 12 to 17 were moderately to
higtily correlated with each other (ranging fiom 0.5 1 to 0.82) but the items 20 and 2 1 were
weakly correlated with the other items. The mean inter-item correlation for the scale was 0.48.
Further, the item total statistics shows that if item 20 and 2 1 are dropped C'do you know who to
t a k to in order to get information about your family member?" and "do you fear that staff might
punish your family member because of something you Say or do?"), the reliability coefficient of
the scale increases to 0.90. This suggests that these two items are only weakly related to the
underlying concept behind this scale.
Table 7: Reliability Analysis: Domain 3 quality and Sewice
Item Statistics:
QOFC QOFC QOFC QOFC QOFC QOFC QOFC QOFC 12 13 14 15 16 17 20 2 1
Valid 2517 2591 2422 2579 2492 2533 2556 2439 N
Missing 114.00 40.00 209.00 52-00 139.00 98.00 75.00 192.00
Mean 3.17 3.69 3.48 3.76 3.6 1 3.62 2.73 2.74
Std. Deviation 1.13 1 .O5 1.13 1.1 1 1 .O8 1 .O5 .58 0.6
Variance 1.28 1.10 1.27 1.22 1.16 1.1 1 .34 .36
Skewness -.22 -.52 -.42 -.65 -.5 1 -.47 -2.08 -2.17
Range 4.00 4.00 4.00 4.00 4.00 4.00 2.00 2.00
Minimum 1 .O0 1 .O0 1 .O0 1 .O0 1 .O0 1 .O0 1 .OO 1 .O0
Maximum 5.00 5.00 5 -00 5.00 5 .O0 5 .O0 3.00 3 .O0
Correlation Matrix
QOFCl2 QOFC13 QOFC14 QOFClS QOFC16 QOFC17 QOFC20 QOFC21
QOFCl2 1.00
QOFC13 0.52 1 .O0
QOFCl4 0.55 0.60 1 .O0
QOFClS 0.50 0.64 0.70 1 .O0
QOFC16 0.52 0.66 0.7 1 0.8 1 1 .O0
QOFC17 0.51 0.62 0.69 0.78 0.82 1 .O0
1 QOFC21 0.21 0.27 0.33 0.4 1 0.4 1 0.36 0.16 1-00
N of Cases = 2080
Inter-item Correlations:
Minimum Maximum Range Variance
1 0.4768 0.1618 0.8 158 0.6539 5 .O407 0.04 1 1 Item-total Statistics :
l
Scale Mean if Scale Variance Corrected Item Squared Alpha if Item Item Deleted if Item Deleted Total Multiple Deleted
Correlation Correlat ion
QOFC 12
QOFC 13
QoFC14
QoFC 15
QoFC 16
QOFC 17
QOFC20
QOFC2 1
Reliability Coefficients 8 items Alpha = 0.89
Domain 4: Resident Care: This domain had three items which measured respondents'
satisfaction with how their family member was cared for during their stay in the facility. Here
respondents were asked to rate the facility using a Likert type scale with scores ranging from
"Excellent" to "Poor". Like in the other scales, the scores obtained were skewed positively, with a
majonty of family members rating the tacility fiom "good" to "excellent". As regards
psychometric properties, the intemal consistency of this scale was high at 0.89. The three items
are highiy correlated with each other and the mean inter-item correlation was 0.73.
Table 8: Reliability Analysis: Domain 4 - Resident Care
Item Statistics:
Valid N
Missing
Mean
Std. Deviation
Variance
Skew ness
Range
Minimum
Maximum
Correlation Matrix
N of Cases = 2265
Inter-item Correlations:
Mean Minimum Maximum Range Max/M in Variance
O. 7309 O. 706 0.7657 0.0597 1.0845 0.0008
Item-total Statistics
Scale Mean if Scale Variance Corrected Item Squared Alpha if Item Item Deleted if Item Deleted Total Multiple Deleted
Correlation Correlation
Reliability Coefficients 3 items Alpha = 0.89
Global Questions: This scale had seven items in al1 with Likert type choices ranging fiom
"excellent" to "poor" and "definitely recommend" to "definitely not recommend" and was
intended to get an overall picture of how satisfied farnily members were with the facility. The
scale included three global questions that asked overall, how the farnily member would rate the
50
quality of care and services, if the family rnember would recommend the facility to others, and
whether the family member had told other people that care at the facility is excellent. The item
statistics demonstrates that the results were positively skewed and a majority of family members
were generally satisfied with the facility, they would recornmend the facility to their families or
fnends, and had told people that care was excellent.
Intemal consistency for this scale was high at 0.90. The correlation matrix shows that the
first four items (G24,26, 27 & 28) correlated highly with each other (coefficients between 0.81 to
0.91) but correlated low to moderately with the last three items (G29,30 & 3 1) with coefficients
ranging fiom 0.33 to 0.69. The average inter-item comelation for the scale was 0.57. The item
total statistics demonstrates that if the last three questions are dropped ("overall, how would you
rate the quality of care and services provided?", "if this type of care were required for another
family member or fnend, would you recornmend this facility" and "have you told people that care
here is excellent?"), the reliability coefficient increases above 0.90. This also supports the other
statistics that these questions do not hang well together in the scale. However, it is common
practice to include such types of global questions on most patient satisfaction questionnaires. A
detailed view of the reliability analysis for this scale is given below:
Table 9: Reliability Analysis: Dornain 5 - Global Questions
Item Statistics:
Valid N
Missing
Mean
Std. Deviation
Variance
Skewness
Range
Minimum
Maximum
Correlation Matrix:
N of Cases = 2013
In ter-item Correlations:
Mean Minimum Maximum Range MaxIMin Variance
0.576 0.325 0.9087 0.5838 2.7962 0.041 1
Item Total Statistics:
Scate Mean if Scale Variance Corrected Item Squared Alpha if Item Item Deleted if Item Deleted Total Multiple Deleted
Correlation Correlation
G25 20.18 20.17 0.87 0.85 0.87
Reliability Coefficients 7 items Alpba = 0.90 Research Ouestion 2: Content and Construct validitv of Familv Evaluation Suwev:
The 29 item Family Evaluation Survey (n=263 1) was factor analysed using Principal Acis
factoring and factors with eigenvalues more than 1 were extracted. Scree plots were also created
to confirm visually, the number of factors extracted. Two different rotation techniques were used:
orthogonal rotation using Varimax procedure and oblique or correiated rotation using Oblimin
procedure. Results of the factor analysis show that there is one major factor that expiains about
half the variance and three smaller factors that accounts for approx. 13% of the variance. The
total variance explained by the factor analysis is approx. 66%. The results of the factor analysis
demonstrate that there were four factors in al1 - one factor with 12 items, one with 9 items and 2
factors with 4 items each. Incidentally, the number of factors and the number o f items in each
factor are the sarne for both rotation techniques; the difference being the factor loadings of each
item on the factor. The scree plot supports this interpretation and a summary o f the rotated factor
analysis is as follows: The detailed factor analysis with both rotations is in Appendix 5.
Table 10 - Rotated Factor Matrix(a)
Questions Factor
1 2 3 4
G29 Overall- rate quality of care and services provided .75 .37 -31 .20
QOFC 16 Rate staff at putting residents' needs first -73 .42 .23 .15
QOFClS 1s member well taken care of when you are not there? .73 .39 .23 .18
ROLL24 Rate staff on looking afier persona1 problerns and needs .73 .32 .25 -16
ROLL23 Specific needs met/encouraged to be independent .70 -34 .24 .19
QOFC 17 Rate staff at knowing what members care requirements are -68 .45 .22 .15
ROLL22 Does hosp treat member with patience and respect? A7 -36 .24 .16
QOFC13 -Rate hygiene and cleanliness of the way things are done .6 1 .28 .20 .18
G30 Would you recomrnend this facility to others .6 1 .21 .18 .28
G3 1 Have you told people that the care here is excellent? -56 .25 .15 .26
QOFC 12 -Rate hospital at keeping track of members personal belongings .42 .32 .19 -18
QOFC2 1 Do you fear staff retaliation on member for what you dokay? .36 .20 . l l .16
COMM10 How are staff at caring about you? .38 .79 .19 .14
COMMI 1 How would you rate your relationship with staff? -39 -74 .18 .14
COMM9 How are staff at appreciating your help? -3 8 .73 -17 .14
COMM8 -Rate staff at responding patiently to questions & concems .48 .68 -20 .13
COMM6 -Rate staff at involving you in planning members care .39 .67 -19 .23
COMMS -Rate staff at keeping you informed .4 1 -66 .15 -20
COMM7 -Rate staffs politeness and courtesy towards you .49 .61 .20 .13
QOFC20 Know who to talk to for info. . l l -33 .O7 .16
QOFC14 Rate hospital at dealing with concerns and complaints 0.5 1 0.55 0.21 0.24
Questions Factor
1 2 3 4 I 1 G26 Rate hospital at maintaining rnembers' dignity . -29 -12 -89 .11 ( 1 G25 Rate hospital in taking =are of rnernbers needs .30 -13 .87 .13 1 1 G27 Rate staff at providing tender love and care .3 1 .21 .83 0.1 1
G28 Rate hospital at taking care of your needs 0.18 0.39 0.78 0.14
LIVl Room meet needs -0.15 -0.1 O -0.6
1 LW2 Facility layout meet needs -. 18 -.O8 --O9 --." I ( LW4 Comfortable place to visit -.12 -.19 -.O6 -.48 1
1 LW3 Bring personal items in -.16 -.23 -.O9 -.35 1
The rotated factor matnx primarily showed that al1 the items on the questionnaire loaded
on one of four factors. The first factor which is now named "Resident Related" was the major
factor with 12 items mainly drawn corn the domains "Quality and Services" and "Global
Questions". Ail items that loaded on this factor related to the fmily members' rating of staff and
the facility in providing quality services to the resident including the two over arching questions
at the end of the questionnaire that asked respondents whether they would recommend this
facility to others and whether they told people that care was excelient. The strongest factor
extracted, this explained 48.9% of variance in the original factor extraction.
The second factor, which is now named "Farnily Member Related" drew all the items
from the second domain on the questionnaire, b%ornmunication with staff 'and two items from the
Quality and Services domain. Al1 items in this scale related to the family member as the focus of
the question - communication with staff, relationship with staff, the facility's procedures
regarding responding to cornplaints and concerns, etc. With nine items loaded on this factor, this
was the second factor and explained 6.5 % of variance in the original factor extraction.
55
The third factor had four items and al1 related to rating the facility for taking care of the
residents' and family members' needs, maintaining residents' dignity, providing loving and
tender care. Al1 these questions were drawn fiom the Global questions on the questionnaire.
Three of the four items in this factor asked the respondents to directly rate the facility and only
one asked them to rate staff. This factor, now named "Facility Related", accounted for 3.5. % of
variance in the original factor extraction.
The last factor corresponded hlly with the "Living Environment"domain on the
questionnaire. A11 four items 6om the living environment domain loaded on this factor. This
factor still named, "Living Environment", accounted for 2.9 % of variance in the original factor
extraction.
The structure matrix and the pattern matrix derived fiom the factor analysis using direct
Oblimin rotation technique yielded the same results as above. In this method, the structure matrix
showed the first factor as "resident related", the second factor as "facility related", third factor,
"living environment" and the fourth factor as "family member related.
Further Face Validity Tests:
As was mentioned earlier, when the instrument was developed, the research team
conducted some preliminary face validity tests through focus groups discussion while developing
the questionnaire and then pilot testing the survey in three facilities. To further confirm face
validity, in the present analysis, the last three questions on the questionnaire were analyzed where
respondents were asked to Say "Yes" or "No"to the following questions:
Q34: Did you have difficulty answenng any questions? Ifso, which question numbers:
435: Did you have difficulty understanding any questions? If so which question nurnbers:
56
436: 1s there anythmg missing that is important to you that the questionnaire did not ask
about? If so, please explain:
These three questions were examined to see what feedback respondents could provide to
improve the questionnaire. From the summary of frequency table below, it can be seen that
approx. 17% of the respondents did not have difficulty answenng the questions; only 4% of
respondents had difficulty understanding the questions; and approx. 16% of respondents felt that
the questionnaire missed items that were important to them.
Table1 1 : Analysis of Responses Regarding The Questionnaire
Factor Analysis Derived New Scales:
The factor analysis showed that the questionnaire had four main factors instead of the five
domains instead of five domains identified by the developers. These four factors did not
correspond exactly with the domains used in the questionnaire, hence four new scales based on
the factor analysis were created. The factors are now named: Resident Related, Family Member
Related, Facility Related, and Living Environment. Reliability coefficients and average inter item
correlations of the four new scales are given below:
Valid
Missing
1YES
2 NO
Total
System
Total
Q- 34
Frequency
410
2064
2474
157
263 1
Q - 35
Valid %
16.6
83.4
1 O0
Frequency
1 07
2358
2465
166
263 1
4-36
Val id %
4.3
95.7
100
Frequency
43 1
1838
2269
362
263 1
Valid %
16.4
69.9
100
Table 12: Reliability Statistics for the New Scales
Factors Alpha Mean Inter-Item Correlation
Resident Related 0.94 0.57
Family Member Related 0.9 1 0.62
Facility Related 0.95 0.84
Living Environment 0.63 0.32 .
Reliability analysis was conducted on the new scales and a cornparison of the reliability
tests between the original domains and the new factors are given below.
Table 13: Pearson's Correlations Among Original and Factor Analysis (F.A.) Derived
Scales
Original Domains
Living Comm Quality Res. Care Global
Living 1 .O
Comm 0.4 1 1 .O0
Quality 0.44 0.82 1 .O0
Res Care 0.40 0.76 0.83 1 .O0
Global 0.36 0.65 0.7 1 0.7 1 1 .O0
Resident 0.45 0.82 0.96 0.93 0.76
Family 0.44 0.99 0.85 0.76 0.66
Faciliîy 0.29 0.53 0.57 0.57 0.96
Living 1 .O0 0.4 1 0.44 0.40 0.36
a Listwise N=2564
--
F.A. Derived Scales - - - - - -- - - - - -
Resident Family Facility Living
It is important to note that since al1 the items in the living environment domain
58
loaded on the fourth factor, "living environment" there is no difference in the Cronbach's alpha or
mean inter-item correlation statistics between the original domains and the new factor denved
scales. Cronbach's alpha for the other three scales is between 0.92 and 0.95, indicating that these
scales have a very high degree of intemal consistency. The inter-item correlations for the new
scales are also high, ranging fiom 0.57 to 0.84.
A cornparison of the intemal consistency reliability of the new scales with the old scales
demonstrates that when the items are regrouped in accordance with the factor structure the items
hang well together as evidenced by uniformly high mean inter-item correlations. When the new
scales are compared with the original domains, it can be seen that the Resident Related factor is
highly correlated with "Quality and Service" and Resident Care" domains ( r = 0.96 and 0.93
respectively). Likewise, the Family Member Related factor is highly correlated ( r = 0.99) with
the "Communication With Staff' domain and with "Quality and Service" domain ( r = 0.85). The
Facility Related factor correlates highly with the b'Global" domain ( r = 0.96) and the Living
Environrnent factor correlates perfectly ( r = 1) with the "Living Environrnent" domain on the
original questionnaire.
Chapter 6
DISCUSSION AND CONCLUSION
The purpose of the study, which was a secondary data analysis project, was to test
psychometric properties of the Family Evaluation Survey, developed to collect family satisfaction
data fiom 27 long term care facilities in Ontario and BC. The Family Evaluation Survey had 3 1
items categorized in five domains (Living Environment, Communication with Staff, Quality and
Services, Resident Care, and Global Questions). Two items were removed fiom the dataset
because of a significant arnount of missing data (Table 1). Reliability was assessed using
Cronbach's alpha, and validity was assessed using Principal Axis Factoring with Orthogonal and
Oblique rotation techniques.
Three main findings emerge fiom this study. First, the psychometric findings provide
support for the Family Evaluation Survey with 29 items as developed by the research team.
However, the factor analysis extracted four factors instead of five domains, which have been
named, Resident Related, Family Member Related, Facility Related and Living Environment.
While the new factors correlate strongly with the domains, they do not correspond cornpletely
with the domains identified in the original instrument. Second, the results are generally
supportive of the researchers' original intentions when they created the survey which were to
capture the views of family members fiom a different perspective from that of residents and to
provide a way to link this with their quality improvement processes. Finally, the results show that
the items included in the survey are reflective of dimensions of service that family members
consider while rating their satisfaction as identified in the literature.
The original Family Evaluation Survey demonstrated moderate to high intemal
consistency reliability. The reliability of the five domains was moderate to high, with Cronbach's
Alpha ranging from 0.63 to 0.95 and average inter-item correlations ranging fiom 0.32 to 0.73.
(See Table 3). As regards the Living Environment scale which had the lowest reliability
coefficient of 0.63 and average inter item correlation of 0.32, in future versions of the survey, the
researchers should consider asking a few more questions to more fully explore how fmily
memben rate the living environment of the facility. The lack of reliability of this scale may also
be because it only uses three-point scales (Yes, Somewhat and No). The research tearn might
need to re-consider the use of only 3 point scales, as well as consider more items. This will
strengthen the scale and increase its reliability. Since there are only 4 items in this scale at
present, a couple of questions could be added to this scale without increasing the burden of the
questionnaire. Taking the same approach, the insirument developers might need to consider
whether the Communication with Staff domain requires seven items as it has a high reliability
coefficient ( a 4.95) and mean inter item correlation of 0.73.
Though the results demonstrated that the Survey was reliable, the factor analysis showed
that the items were arranged into four underlying factors which were different fiom the way the
items were categorized into five domains on the original questionnaire. When the items are re-
grouped according to the factor analysis into four factors, the reliability estimates for the four new
scales range fiom 0.63 to 0.95 (Table 15). This suggests that the items in the new factors hang
well together. This also suggests that while the original Family Evaluation Survey provides a
reliable way of assessing family satisfaction, if the items are presented as four factors, the
61
reliability and validity of the survey increases.
Two items ("does the resident get help eating" and "enough time taken to feed resident")
were not included in the factor analysis, and therefore the scales, because of a large amount of
missing data (24.7% and 48.2% respectively) (See Table 1). It could be speculated that probably
for a number of respondents, this question was not relevant as their family member did not
require help eating. In fiiture versions of the survey, it is suggested that a question could be added
to the survey that asks respondents whether their family member requires help eating and if not,
they could be given an option of skipping these questions. The research team should consider
whether the items themselves are sufficiently important to organizations and the questionnaire
that they continue to be included even if they are not scaled with other items, and to conduct
fürther analysis to find out why people did not answer these questions.
The factor analysis results supported a multi-dimensional scale structure. Several
researchers have indicated that patient satisfaction is a multi-dimensional constmct and that
di fferent features of service affect satisfaction (Cleary & McNeil, 1 988; Ware et al., 1983). The
factor analysis results of this study suggest that four distinct factors make up family members
satisfaction with a long term care facility. While rating their satisfaction with a facility, family
members think, first and foremost, about the quality of services their member receives in the
facility. Family members also consider their relationship to staff, how staff cornmunicate with
them, whether they know who to talk to for information, etc. In addition to these two factors,
farnily members also take into account the facility itself; whether the facili ty treats residents with
dignity and respect, whether the facility takes care of family members needs, etc. Finally, farnily
members consider the physical facilities of the organization including whether it is comfortable
62
place to visit, whether the facility layout meets their needs, etc.
The correlation matrix (Table 13) also shows that the "resident related" factor was highly
correlated with " family member reiated" factor and was correlated moderately with the other two
factors. This is not surprising since al1 the questionnaire was aimed at collecting responses
regarding family's satisfaction with services provided to their members in the facility.
From a content point of view, these results are also consistent with the literature on the
subject which suggests that the major quality dimensions that family members take into account
while rating an organization are communication and relationship with staff, facility staffing,
services, environmental features, and facility operational policies and procedures (Greene et al,
1997-98, Norton et al, 1996, Gladstone and Wexler, 2000 and Hertzberg and Ekman,20ûû). The
findings of this study also support earlier studies on general indicators of overall patient
satisfaction in general which are humaneness, informativeness, overall quality, cornpetence,
overall satisfaction, bureaucracy, access, cost, facilities, outcorne, continuity, and attention to
psycho social problems (Hall and Doman, 1988; and Ware et al, 1983).
The purpose of the Family Evaluation Survey instrument was to help organizations
identiQ what was important to family members and to provide feedback on how family members
rated different aspects of the organization. When the researchers developed the pool of items to
be included in the survey through focus group discussions with family members, they wanted to
focus only on items that were related to the family member and not the resident since their intent
was to study family members as unique customers of long term care facilities. During the focus
groups they found that family members consistently brought up issues relating to care provided to
residents as being important for them, which were then included in the survey.
63
The results fiom this study supports this point made by family members; the strongest
factor in the questionnaire with 12 items loaded on it, related to how the resident was treated,
cared for, whether staff put residents needs first, overali, quality of care and services, and whether
the resident is taken care of when rnember is not there. With regard to the researcher's intent to
capture what was important for family members as unique customers of long term care facilities,
again, this study shows that the family evaluation survey does the job. The second factor that was
extracted in the factor analysis related to family members' experiences with the facility. Nine
items loaded on this factor, with items like "how are staff at caring about you?", "how would you
rate your relationship to staff ', and "rate staff at involving you in planning member's care"
arnong others.
When the instrument was developed, the researchers had also identified a set of global
questions which were intended to provide the facility with an overall picture of how satisfied
respondents were with the facility. However, the results of the factor analysis did not identify a
separate factor that captured the items in this domain. Instead, the results suggest that most of the
questions under this domain loaded heaviIy on the first factor, "Resident Related" and were
integral to the survey in understanding what is important for family members. Also, the factor
analysis suggests that the third domain the questionnaire, "Resident Care" did not stand out as a
separate factor, al1 items in this domain loaded on the first factor that related to the resident.
The results of this study suggest that the Family Evaluation S w e y is psychometncally
valid instrument, and supports its use in quality improvement initiatives within facilities on an
ongoing basis. The factors underlying family satisfaction accurately reflect family members'
specific needs and concems and any information collected using the instrument could be
64
considered by management as they initiate quality improvement efforts. Table 5 shows that the
mean scores on al1 the domains are high and this is consistent with previous studies in patient
satisfaction (Wilkinson, 1986, Ryden, MB et al., 2000). The survey has the same drawbacks as
other patient satisfaction instruments, in that, there is a "halo" effect with most results being
skewed towards the positive end of the scale (Wilkinson, 1986). However, the message to
organizations is that they should not focus solely on the high scores. They should consider the
whole range of farnily members expenences and pay more attention to those scores which
indicate "fair" or "poor" ratings. They should then channel their limited resources to eliminate
these negative experiences instead of just improving the positive experiences (Drain, 2001).
Limitations:
This study has some limitations in terms of generalizability of results. The first limitation
of the study had to do with data collection. First, organizations were not randomly selected into
the study; organizations were self selected.. However, there was substantial variability in types
and sizes of organizations in the study, and the lack of random selection should not affect the
psychometric anaiysis. Second, since data collection was the responsibility of individual
organizations and each one followed their own method for follow up, there is wide disparity in
response rates in organizations (ranging from 35% to 83%). Finally, since the data set did not
have data fiom the sarne respondents for more than one time penod, the instrument could not be
tested for stability over time using test-retest methods. Although the survey has high intemal
consistency reliability and content validity, it will be essential to perfonn iùrther validation
studies to establish test-retest reliability of the survey.
As regards generalizing the content validity of the survey, one of the limitations of the
65
study is its inability to compare this instrument with an universally accepted gold standard for
"family satisfaction7'. in the absence of this, content validity was tested using indirect methods
such as factor analysis. Also, since we were not able to link resident and farnily data in this study,
we are unable to test one of the hypothesis of the researchers that fami ly satisfaction data serves
the purpose of complementing data gathered fkom residents for quality improvement purposes.
Conclusion:
The study provides support for a psychometrically valid Family Evaluation Survey as
developed by the research team. However, the reliability and validity of the instrument increases
when the items on the survey are re-grouped according to the factors denved through the factor
analysis. A number of suggestions have been identified in the previous sections to increase the
strength of the survey such as adding a few more questions to flesh out how farnilies rate the
living environment of the facility, and reducing the number of questions that ask families to rate
communication with staff. Another suggestion made was to ask respondents whether their family
member required help eating and if not, to skip the two questions on the survey that rate the
facility on the amount of time taken to feed residents.
Further research is required on the missing data and characteristics of family members
who did not answer al1 the questions. in particular, the questions relating to communication with
staff that have significant missing data need to be further studied. Of the six questions on the
survey that had significant missing data, three related directly to family members' experiences
and satisfaction. The three questions were: "rate staff at appreciating help" (16.4% missing) "rate
staff at caring about you" (1 5.9% missing), and "how are staff at taking care of your needs"
(1 3.1 %).. People might not have answered these questions either because the questions were
66
difficult to understand, or because they do not see a role for staff in caring about them as unique
customers. It is important to explore these reasons through future research. Further research is
also required to examine the missing data for the three items to see if there is any systematically
similarity arnong those who did not answer the questions or whether it is random error.
Another area of fùrther research is analysis of verbatim comments made by respondents
on the questionnaire. At the end of each domain and at the end of the survey space was provided
for respondents to write their comments. As pointed out in the literature, it is important to
consider qualitative comments made by patients as part of measwing patient satisfaction since
these comments provide useful information to the organization. Aharony & Strasser (1993) also
emphasize the need for more qualitative research since qualitative comments may be more
representative of a patients' experience thus enriching the feedback received from patients. Other
compelling reasons for increasing use of qualitative comments is that the analysis of comments
would help researchers to better understand patients cognitive and affective processes (Aharony
& Strasser, 1993).
To sum up, scales developed using the items o f the Farnily Satisfaction Survey have
strong psychometnc properties when used to capture family members' satisfaction with long tenn
care facilities. The data support a multi-dimensional constnict of family satisfaction with four
underlying factors. As it is one of the first instruments in this area to be psychometrically
validated, the Family Satisfaction Survey represents an advance in measuring family members'
satisfaction with long terni care facilities. Its simple format and easy to read questions and scoring
will support its wide use in the long term care system. Secondly, psychometric data fiom this
study indicate strong intemal consistency and validity of the instrument. Because the study
encompassed a large number of long term care facilities (rather than just one), it offers an
oppomuiity for broader generalization o f results and thus a usefül tool in quality improvement
policy. Finally, it also provides us a head start in fùrther exploring the construct of farnily
members as distinct customers of the long tenn care system.
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Hall, J.A. and Doman, M.C. "What Patients Like About Their Medical Care and How OAen They Are Asked: A Meta-Analysis of the Satisfaction Literature". Social Science Medicine 27(9) (1 988): 935-939.
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Kane, RA., and Kane, R.L. "Long Tenn Care: Variations on a Quality Assurance Theme". Inquiry 25 (Spnng 1988): 132-146.
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Smaller World Communications. Appendix B: Background Information.
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Appendix 1: List of Organizations in Data Set
Organization * Frequency Percent
Mississauga Long Term Care FacUity
Queen ElizribetMRehabilitation Institute of Toronto
Providence Centre, Scarborough
Sunnybrook and Women's College Health Sciences Centre
The Perley & Rideau Veterans Health Centre
Peace Arch
Baycrest Centre for Geriatric Care
Wüliam Oder Health Centre - Peel Mernorial Campus
The Riverdale Hospital
West Park Healthcare Centre
St. Joseph's Hedtb Centre
Marian Hill Inc.
Parkwood Mernonite Park Inc.
Hamilton Health Science Corp.
Grey Bruce Health Services
Central Okanagan
Providence Continuing Care Centre - Kingston
Lodge at Broadmead
Capital Health Region - PHC - Arbutus
Capital Health Region - PHC - Holy Family
Capital Health Region - PHC - YouvWe
Capital HeaIth Region - PHC- Brock Fahrni
*. These are the current names of the organizations. Some of the organizations might have had different names at the time of data collection).
Organizrrtion Frequency Percent
Capital Health Region - PHC- Langara 90 3.4
Capital Health Region - PRC- Aeather 24 0.9
Capital Health Region - PHC- Mount St. Joseph 39 1.5
The Creàit Valley Hospital 29 1 . 1
Unionville Home Society 93 3.5
Total 263 1 100
Appendix 2: Details of Data Set
Description Number of Records
Transferred fiom Smaller World Communications 3783
Records selected based on most recent wave of data collection 2649
(Less) Records deleted for having more than 15 blank item 18
responses
Data set used for al1 analysis
Appendix 3: # Records With Missing Data
# Questions Frequency Percent Cumulative Valid Percent Percent
.O0
1 .O0
2.00
3.00
4.00
5.00
6.00
7.00
8-00
9.00
10.00
1 1 .O0
12.00
13.00
14.00
15.00
Total
Appendix 4: Frequency Tables
Descriptive Statistics
Ln/ 1 Room meet needs
LIV2 Facility layout meet needs
LW3 Bring personal items in
LW4 Cornfortable place to visit
COMMS -Rate staff at keeping you informed
COMM6 -Rate staff at involving you in planning members care
COMM7 --Rate staffs politeness and courtesy towards you
COMM8 -Rate staff at responding patiently to questions & concems
COMM9 How are staff at appreciating your help?
COMM 10 How are staff at caring about you?
COMM1 1 How would you rate your relationship with staff!
QOFC 12 -Rate hospital at keeping track of members personal belongings
QOFC 13 -Rate hygiene and cleanliness of the way things are done
QOFC 14 Rate hospital at dealing with concerns and cornplaints
QOFC 15 1s member well taken care of when you are not there?
QOFC 16 Rate staff at putting residents' needs first
QOFC 17 Rate staff at knowing what members care requirements are
QOFC20 Know who to talk to for info.
QOFC21 Do you fear staff retaliation on member for what you dokay?
ROLL22 Does hosp treat member with patience and respect?
ROLL23 Specific needs metlencouraged to be independent
ROLL24 Rate staff on looking after personal problems and needs
Question Mean SD N
G25 Rate hospital in taking care of members needs 3.56 1.12 2599
G26 Rate hospital at maintainhg members' dignity 3.57 1.16 2577
G27 Rate staff at providing tender love and care 3.48 1.21 2530
G28 Rate hospital at taking care of your needs 3.37 1.15 2287
G29 Overall - rate quality of care and services provided 3.85 -97 2592
G30 Would you recomrnend this facility to others 3.6 1 .63 2473
G3 1 Have you told people that the care here is excellent? 1.79 .41 2464
Frequency Tables
LIV1 Room meet needs
Valid Cumulative Frequency Percent Percent Percent
Valid 1 NO 59 2.2 2.3 2.3
2 SOMEWHAT 445 16.9 17.1 97.7
3 YES 2091 79.5 80.6 100
Total 2595 98.6 100.0
Missing System 36 1 -4
Total 263 I 100.0
UV2 Facility layout meet needs
Valid Cumulative Frequency Percent Percent Percent
Valid
Missing
Total
1 NO
2 SOMEWHAT
3 YES
Total
9 WN'T KNOW OR N/A
System
Total
LW3 Bring personal items in
Frequency Percent VaIid Cumulative Percent Percent
Valid
Missing
Total
1 NO
2 SOMEWHAT
3 YES
Total
9 N N ' T KNOW OR N/A
System
Total
LW4 Cornfortable place to visit
Valid Cumulative Frequency Percent Percent Percent
Valid 1 NO
2 SOMEWaAT
3 YES
Total
Missing 9 DONT KNOW OR NIA
S ystem
Total
Total
COMM5 -RATE STAFF AT KEEPING YOU INFORMED
Valid Cumulative Frequency Percent Percent Percent
Valid 1 POOR
2 FAIR
3 GOOD
4 VERY GOOD
5 EXCELLENT
Total
Missing 9 DON'T KNOW OR NIA
System
Total
Total
COMM6 -RATE STAFF AT INVOLVING YOU IN PLANNING MEMBERS CARE?
Frequency Percent Valid Percent Cumulative Percent
3 GOOD 644 24.5 25.9 48.0
4 VERY GOOD
S EXCELLENT
Total
Missiag 9 DON'T KNOW OR N/A
System
Total
Total
COMM7 -RATE STAFF'S POLITENESS AND COURTESY TOWARDS YOU?
Frequency Percent Valid Percent Cumulative Percent
Valid 1 POOR
2 FAIR
3 GOOD
4 VERY GOOD
5 EXCELLENT
Total
Missing System
Total
COMM8 - RATE STAFF AT RESPONDlNG PATIENTLY TO QUESTIONS &
CONCERNS
Frequency Percent Valid Percent Cumulative Percent
Valid
Missing
Total
1 POOR
2 FAIR
3 GOOD
4 VERY GOOD
5 EXCELLENT
Total
9 DON'T KNOW OR NIA
System
Total
COMM9 HOW ARE STAFF AT APPRECIATING YOUR HELP?
Frequency Percent Valid Percent Cumulative
Percent
Valid 1 POOR
2 FAiR
3 GOOD
4 VERY GOOD
5 EXCELLENT
Total
Missing 9 DON'T KNOW OR NIA
System
Total
Total
COMM10 HOW ARE STAFF AT CARING ABOUT YOU?
Frequency Percent Valid Percent
Cumulative Percent
Valid 1 POOR
2 FAIR
3 COOD
4 VERY GOOD
5 EXCELLENT
Total
Missing 9 DON'T KNOW OR N/A
System
Total
Total
COMM1 1 HOW WOULD YOU RATE YOUR RELATlONSHlP WITH THE STAFF?
Frequency Percent Vaiid Percent
Cumulative Percent
Vaiid 1 POOR
2 FAIR
3 GOOD
4 VERY GOOD
5 EXCELLENT
Total
Missing 9 DON'T KNOW OR N/A
System
Total
Total
QOFC12 - RATE HOSPITAL AT KEEPING TRACK OF MEMBERS PERS.
BELONGINGS
Frequency Percent Valid Percent Cumulative Percent
Valid 1 POOR
2 F m
3 GOOD
4 VERY GOOD
5 EXCELLENT
Total
Missing 9 DON'T KNOW OR NIA
System
Total
Total
QOFC13 -RATE HYGIENE AND CLEANLINESS OF THE WAY THINGS ARE DONE
Valid Frequency Percent Percernt Cumulative Percent
Valid 1 POOR
2 FMR
3 GOOD
4 VERY GOOD
5 EXCELLENT
Total
Missing 9 DONT KNOW OR NIA
System
Total
Total
QOFC14 RATE HOSP. AT DEALING WlTH CONCERNS OR COMPLAINTS
Valid Cumulative Frequency Percent Percent Percent
Valid 1 POOR
2 FAïR
3 GOOD
4 VERY GOOD
5 EXCELLENT
Total
Missing 9 DON'T KNOW OR NIA
System
Total
Total
QOFC15 IS MEMBER WELL TAKEN CAR€ OF WHEN YOU ARE NOT THERE
Valid Frequency Percent Cumulative Percent
VaMd 1 POOR
2 FAIR
3 GOOD
4 VERY GOOD
5 EXCELLENT
Total
Missing System
Total
QOFC16 RATE STAFF AT PUTTlNG RESIDENTS NEEDS FlRST
Valid Cumulative Frequency Percent Percent
Vaiid 1 POOR
2 FAIR
3 GOOD
4 VERY GOOD
5 EXCELLENT
Total
Missing 9 DON'T KNOW OR N/A
System
Total
Total
QOFCl7 RATE STAFF AT KNOWING WHAT MEMBERS CARE REQUIREMENTS
ARE
Frequency Percent Vaüd Cumulative Percent Percent
Valid 1 POOR
2 FAïR
3 GOOD
4 VERY GOOD
5 EXCELLENT
Total
Missing 9 DON'T KNOW OR NIA
System
Total
Total
QOFC18 Resident gets help eating
Frequency Percent Valid Percent
Cumulative Percent
Valid 1 YES
2 SOMEWHAT
3 NO
Total
Missing 9 DON'T KNOW OR NIA
System
Total
Total
QOFCl9 Enough time taken to feed resident
Frequency Percent Valid Percent
Cumulative Percent a
Valid 1 YES
2 SOMEWHAT
3 NO
Total
Missing 9 DON'T KNOM OR NIA
System
Total
Total
QOFCZO KNOW WHO TO TALK TO FOR INFO
Valid Frequency Percent Cumulative Percent
Valid 1 No
2 SOMEWHAT
3 Yes
Total
Missing 9 DON'T KNOW OR N/A
System
Total
Total
QOFCZI DO YOU FEAR STAFF RETALlATlON ON MEMBER FOR WHAT YOU
DOISAY
Valid Frequency Percent Cumulative Percent
Valid 1 YES
2 SOMEWHAT
1 l Total
Missing 9 DON'T KNOW OR N/A
System
Total
Total
ROLL22 DOES HOSP. TREAT MEMBER WlTH PATIENCE AND RESPECT?
Frequency Percent Valid Percent
Cumulative Percent
Valid 1 POOR
2 FUR
3 GOOD
4 W R Y GOOD
5 EXCELLENT
Total
Missing 9 DONT KNOW OR N/A
System
Total
Total
ROLL23 SPEClFlC NEEDS METIENCOURAGED TO BE INDEPENDENT
Frequency Percent Valid Percent
Cumulative Percent
Valid 1 POOR
2 FAIR
3 GOOD
4 VERY GOOD
5 EXCELLENT
Total
Missing 9 DON'T KNOW OR N/A
System
Total
Total
ROLL24 RATE STAFF ON LOOKING AFTER PERSONAL PROBLEMS AND NEEDS
Frequency Percent Valid Percent
- -
Cumulative Percent
Valid 1 POOR
2 FAIR
3-D
4 VERY GOOD
5 EXCELLENT
Total
Missing 9 DON'T KNOW OR N/A
System
Total
Total
G25 RATE HOSPITAL IN TAKING CAR€ OF MEMBERS NEEDS
Frequency Percent Valid Percent
Cumulative Percent
Valid 1 POOR
2 FAIR
3 GOOD
4 VERY GOOD
5 EXCELLENT
Total
Missing System
Total
G26 RATE HOSPITAL AT MAlNTAlNlNG MEMBERS DlGNlTY
Valid Frequeocy Percent Cumulative Percent
Valid 1 POOR
2 FAIR
3 GOOD
4 VERY GOOD
5 EXCELLENT
Total
Missing 9 DONT KNOW OR N/A
System
Total
Total
627 RATE STAFF AT PROVlDlNG TENDER LOVE AND CARE
Frequency Percent Valid Percent
Cumulative Percent
Valid 1 POOR
2 FAIR
3COOD
4 VERY GOOD
5 EXCELLENT
Total
Missing 9 DON'T KNOW OR NIA
System
Total
Total
628 RATE HOSPITAL AT TAKING CAR€ OF YOUR NEEDS
Valid Cumulative Frequency Percent Percent
Valid 1 POOR
2 FAIR
3 GOOD
4 VERY GOOD
5 EXCELLENT
Total
Missing 9 DON'T KNOW OR N/A
System
Total
Total
G29 OVERAlL- RATE QUALlTY OF CARE AND SERVICES PROVlDED
Valid Cumulative Frequency Percent Percent
VaIid 1 POOR
2 FAIR
3 GOOD
4 VERY COQD
5 EXCELLENT
Total
Missing System
Total
G30 WOULD YOU RECOMMEND THIS FAClLlTY TO OTHERS?
Valid Cumulative Frequency Percent Percent Percent
Valid 1 DEFINITELY NOT RECOMMEND 34 1.3 1.4 1.4
2 PROBABLY NOT RECOMMEND
3 PROBABLY RECOMMEND
4 DEFIhlTELY RECOMMEND
I Total 2473 94.0 100.0
1 Missing 9 W N v T KNOW 1 .O
I System 157 6.0
Total 158 6.0
1 Total 263 1 100.0
631 HAVE YOU TOLO PEOPLE THAT THE CAR€ HERE IS EXCELLENT
Frequency Percent Valid Cumulative Percent Percent
Valid 1 NO
2 YES
Total
Missing 9 DON'T KNOW
System
Total
Total 263 1 100.0
434 DID YOU HAVE DIFFICULTY ANSINERING ANY QUESTIONS
Frequency Percent Valid Cumulative Percent Percent
Valid 1 YES
2 NO
Total
Missing System
1 Total - -
435 DID YOU HAVE OlFFlCULTY UNDERSTANDING ANY OF THE QUESTIONS
Frequency Percent Valid Cumulative Percent Percent
Valid 1 YES 107 4.1 4.3 4.3 ( 2 NO
Total
Missing System
Total 263 1 100.0 1
436 ANYTHING IMPORTANT TO YOU THIS QUESTIONNAIRE DID NOT ASK
Frequency Percent Valid Percent
Cumulative Percent
Valid 1 YES
2 NO
Total
~Missing System
Total
Appendix 5: Factor Analysis
Communalities
Factors Initial Extraction
LW 1 Room meet needs
LW2 Facility layout meet needs
LIV3 Bring personal items in
LIV4 Cornfortable place to visit
COMM5 -Rate staff at keeping you infonned
COMM6 -Rate staff at involving you in planning members care
COMM7 -Rate staffs politeness and courtesy towards you
COMM8 -Rate staff at responding patiently to questions & concems
COMM9 How are staff at appreciating your help?
COMM 10 How are staff at caring about you?
COMM 1 1 How would you rate your relationship with staff?
QOFC 1 2 -Rate hospi ta1 at keeping trac k of members personal belongings
QOFC13 -Rate hygiene and cleanliness of the way things are done
QOFC14 Rate hospital at dealing with concems and cornplaints
QOFC 15 1s member well taken care of when you are not there?
QOFC16 Rate staff at putting residents' needs first
QOFC 17 Rate staff at knowing what members care requirements are
QOFC20 Know who to talk to for info.
QOFC2 1 Do you fear staff retaliation on member for what you do/say?
ROLL22 Does hosp treat member with patience and respect?
ROLL23 S pec i fic needs metkncouraged to be independent
ROLL24 Rate staff on looking afier personal problems and needs
G25 Rate hospital in taking care of members needs
G26 Rate hospital at maintaining rnembers' dignity
G27 Rate staff at providing tender love and care
G28 Rate hospital at taking care of your needs
1 Factors Initial Earaction 1 G29 Overall - rate quality of care and services provided -8 1 .83
G30 Would you recommend this facility to others .57 .52
G3 1 Have you told people that the care here is excellent? -47 0.52
Scree Plot Scree Plot
'= 6
1 3 5 7 0 11 13 13 17 19 21 23 25 27 :
Component Number
Total Variance Explained
r Initial Eigenvalues
- -- --
Extraction Sums of Squared Loadings
- - -
Rotation Sums of Squared Loadings 1
I ./O of Cumulative Factor Total ./O of Cumulative ./O of V" Total ~arianrc ./. variance Cumu'ativ e Y* I
Section II: APPENDlX 5
Factor Analysis - Orthogonal Rotation (Varimax Procedure)
Page 1
Conelation Matrix
Conelation -RATE STAFF AT KEEPING YOU INFORME0
-RATE STAFF AT INVOLVING YOU IN PLANNING MEMBERS CARE?
-RATE STAFF'S POLITENESS AND COURTESY TOWARDS YOU?
-RATE STAFF AT RESPONDING PATIENTLY TO QUESTIONS 8 CONCERNS
HOW ARE STAFF AT APPRECIATING YOUR HELP? HOW ARE STAFF AT CARING ABOUT YOU? HOW WOUtD YOU RATE YOUR RELATIONSHIP WlTH THE STAFF?
-RATE HOSPITAL AT KEEPING TRACK OF MEMBERS PERS. BELONGINGS
-RATE HYGtENE AND CLEANLINESS OF THE WAY THINGS ARE DONE
RATE HOSP. AT DEALING WlTH CONCERNS OR COMPLAINTS
IS MEMBER WELL TAKENCAREOFWHEN YOU ARE NOT THERE RATE STAFF AT
KEEPING YOU
INFORMED MEMBERS
CARE? m
PUlTlNG RESIDENTS' NEEOS FIRST. RATESTAFFAT KNOWING WHAT MEMBERS CARE REQUIREMENTS ARE
Know who to talk to for info.
AND COURTESY TOWARDS
YOU? I
Page 2
-RATE STAFF AT
I m
-68
.68
.81
O
3
i
1
1
-.32
-RATE STAFF AT
INVOLVING YOU IN
PLANNING
I I
-RATE STAFF'S
POLITENESS
-RATE STAFF AT
RESPONDING PATIENTLY
TO QUESTIONS
8 CONCERNS
Correlation Matrix
-RATE STAFF AT
INVOLVING YOU IN
PLANNING MEMBERS
CARE?
.2s
.57
-6 1
-59
.40
.38
.43
.50
-RATE STAFF'S
POLITENESS AND
COURTESY TOWARDS
YOU? iI
-RATE STAFF AT
RESPONDIN( PATIENTLY
TO
-RATE STAFF AT KEEPING
YOU INFORMED
QUESTIONS 8 CONCERN!
RETALlATlON ON MEMBER FOR WHAT YOU DOISAY?
OOES HOSP. TREAT MEMBER WlTH PATIENCE AND RESPECT?
SPECIFIC NEWS MET/ENCOURAGED TO BE INDEPENDENT RATE STAFF ON LOOKING AFTER PERSONAL PROBLEMS AND NEEDS
RATE HOSPITAL IN TAKING CARE OF MEMBERS NEEDS. 1 RATE HOSPITAL AT MAlNTAlNlNG MEMBERS DIGNITY.
RATE STAFF AT PROVlDlNG TENDER LOVE AND CARE.
RATE HOSPITAL AT TAKING CARE OF YOUR NEEDS. OVERALL- RATE QUALIN OF CAR€ AND SERVICES PROVIOED 1
1 WOULD YOU 1 RECOMMEND THIS FACILIN TO OTHERS? HAVE YOU TOLD PEOPLE THAT THE CAR€ HERE IS EXCELLENT1
A-LIV 1 LIV 2 LIV 3
Page 3
Correlation -RATE STAFF AT KEEPING YOU INFORME0
-RATE STAFF AT INVOLVING YOU IN PLANNING MEMBERS CARE?
--RATE STAFF'S POLITENESS AND COURTESY TOWAROS YOU?
-RATE STAFF AT RESPONDING PATIENTLY TO QUESTIONS 8 CONCERNS
HOW ARE STAFF AT APPRECIATING YOUR HELP? HOW ARE STAFF AT CARING ABOUT YOU? HOW WOULD YOU RATE YOUR RELATIONSHIP WlTH THE STAFF?
-RATE HOSPITAL AT KEEPING TRACK OF MEMBERS PERS. BELONGINGS
-RATE HYGIENE AND CLEANLINESS OF THE
RATE HOSP. AT OEALING WlTH CONCERNS OR COMPLAINTS
IS MEMBER WELL
RATESTAFFAT PUITlNG RESIDENTS' NEEDS FIRST. RATESTAFFAT KNOWING WHAT MEMBERS CAR€ REQUIREMENTS ARE
Know who to talk to for info.
HELP?
MEMBERS PERS.
BELONGING
HOW ARE STAFF AT
APPRECIAT ING YOUR
Page 4
16
17
2
5
$
3
5
1
.65
I
HOW ARE STAFF AT CARING
ABOUT YOU?
HOW WOULO YOU RATE
YOUR RElATlONSHl P WlTH THE
STAFF?
-RATE HOSPITAL
AT KEEPING TRACK OF
1
I
Correlation DO YOU FEAR STAFF RETALIATION ON MEMBER FOR WHAT YOU DOISAY?
DOES HOSP. TREAT MEMBER WlTH PATIENCE AND RESPECT?
SPEClFtC NEEDS METIENCOURAGED TO BE INDEPENDENT RATE STAFF ON LOOKING AFTER PERSONAL PROBLEMS AND NEEOS
RATE HOSPITAL IN TAKING CARE OF MEMBERS NEEDS. RATE HOSPITAL AT MAINTAINING MEMBERS DIGNITY. RATE STAFF AT PROVlDlNG TENDER LOVE AND CARE. RATE HOSPITAL AT TAKING CAR€ OF YOUR NEEDS.
OVERALL- RATE QUALITY OF CARE AND SERVICES PROVIDED
WOULD YOU RECOMMENO THIS FAClLlTY TO OTHERS?
HAVE YOU TOLD PEOPLE THAT THE CAR€ HERE IS EXCELLENT/
A-LIV1 LIV 2 LIV 3 A LW4
HOW ARE STAFF AT
APPRECIAII ING YOUR
HELP?
3 4
-60
-58
.58
-38
-37
.44
.49
.64
-45
STAFF AT CARING
ABOUT YOU?
HOW ARE
I l
1
RELATIONSH P WlTH THE
STAFF?
- 1
YOU RATE YOUR
I
N r n
I
!
l
--
-RATE HOSPITAL
AT KEEPINC TRACK OF MEMBERS
PERS. BELONGINC
S
-2 '
.4t
*4€
-47
.37
.35
-36
-36
Page 5
Correlation -RATE STAFF AT KEEPING YOU INFORME0 -RATE STAFF AT INVOLVING YOU IN PLANNING MEMBERS CARE?
-RATE STAFF'S POLITENESS AND COURTESY TOWARDS YOU?
-RATE STAFF AT RESPONDlNG PATIENTLY TO QUESTIONS 8 CONCERNS
HOW ARE STAFF AT APPRECIATING YOUR HELP?
HOW ARE STAFF AT CARING ABOUT YOU? HOW WOULD YOU RATE YOUR RELATlONSHlP WlTH THE STAFF?
-RATE HOSPITAL AT KEEPING TRACK OF MEMBERS PERS. BELONGINGS
-RATE HYGIENE AND CLEANLINESS OF THE WAY THINGS ARE DONE
RATE HOSP. AT DEALING WlTH CONCERNS OR COMPLAINTS
IS MEMBER WELL TAKEN CARE OF WHEN YOU ARE NOT THERE RATESTAFFAT PUTTING RESIDENTS' NEEDS FIRST. RATESTAFFAT KNOWING WHAT MEMBERS CAR€ REQUIREMENTS ARE
Know who to talk to for info.
-RATE HYGIENE
AND CLfANLlNES
S OF THE WAY THINGS ARE DONE
RATE HOSP. AT DEALING
W ITH CONCERNS
OR COMPtAINT5
lS MEMBER WELL TAKEN
CARE OF WHEN YOU ARE NO1 THERE
RATE STAFF
NEEDS FIRST.
.6
Page 6
AT PUTTING RESIDENTS'
- 4
5
7
3
r
l
œ
D
Correlation DO YOU FEAR STAFF RETALIATION ON MEMBER FOR WHAT YOU DOISAY?
OOES HOSP. TREAT MEMBER WlTH PATIENCE AND RESPECT? SPECfFlC NEEDS METENCOURAGED TO BE INDEPENOENT RATE STAFF ON LOOKING AFTER PERSONAL PROBLEMS AND NEEDS
RATE HOSPITAL IN TAKING CAR€ OF MEMBERS NEEDS. RATE HOSPITAL AT MAI NTAINING MEMBERS DIGNITY. RATE STAFF AT PROVlDlNG TENDER LOVE AND CARE. RATE HOSPITAL AT TAKING CARE OF YOUR NEEDS. OVERALL- RATE QUALITY OF CARE AND SERVICES PROVIDED WOULD YOU RECOMMENO THIS FAClLlTY TO OTHERS? HAVE YOU TOLD PEOPLE THAT THE CAR€ HERE IS EXCELLENT1 A-LW1 LIV 2 LIV 3
AND CLEANLINES
S OF THE WAY THINGS ARE DONE
RATE HOSP. IS MEMBER AT OEALING WELL TAKEh
W ITH 1 CARE OF
COMPLAINTS THERE
.4'
-RATE HYGIENE
1
I n
1
I
RATE STAFF AT PUTTING RESIDENTS'
NEEDS FIRST.
Page 7
.25
L
CONCERNS WHEN YOU OR ARE NOT
I
- I
1
,
I
!
!
DO YOU FEAR STAFF RETALIATIOb ON MEMBER FOR WHAT
YOU DOISAY?
RATE STAFF AT KNOWINC
WHAT MEMBERS
CAR€ REQUIREME
DOES HOSP. TREAT
MEMBER W lTH
PATIENCE AND
RESPECT? Know who to
talk to for info NTS ARE Correlation -RATE STAFF AT
KEEPING YOU INFORMED -RATE STAFF AT INVOLVING YOU IN PLANNING MEMBERS CARE?
-RATE STAFF'S POLITENESS AND COURTESY TOWARDS YOU?
-RATE STAFF AT RESPONDING PATIENTLY TO QUESTIONS & CONCERNS
HOW ARE STAFF AT APPRECIATJNG YOUR HELP? HOW ARE STAFF AT CARING ABOUT YOU? HOW WOULD YOU RATE YOUR RELATIONSHIP VJITH THE STAFF?
-RATE HOSPITAL AT KEEPING TRACK OF MEMBERS PERS. BELONGINGS
-RATE HYGIENE AND CLEANLINESS OF THE WAY THINGS ARE DONE
RATE HOSP. AT DEALING WlTH CONCERNS OR COMPLAINTS
IS MEMBER WELL TAKEN CARE OF WHEN YOU ARE NOT T HERE RATE STAFF AT PUTTING RESIDENTS' NEEDS FIRST. RATE STAFF AT KNOWING WHAT MEMBERS CARE REQUIREMENTS ARE
Know who to talk to for in fo.
Page 8
Correlation DO YOU FEAR STAFF RETALlATlON ON MEMBER FOR WHAT YOU DOISAY?
DOES HOSP. TREAT MEMBER WlTH PATIENCE AND RESPECT?
SPECIF IC NEEDS METENCOURAGECI TO BE INDEPENDENT
RATE STAFF ON LOOKING AFTER PERSONAL PROBLEMS AND NEEDS
RATE HOSPtTAL IN TAKING CARE OF MEMBERS NEEDS.
RATE HOSPITAL AT MAlNTAlNlNG MEMBERS DIGNITY. RATE STAFF AT PROVlDlNG TENDER LOVE AND CARE. RATE HOSPITAL AT TAKING CARE OF YOUR NEEDS. OVERALL- RATE QUALITY OF CARE AND SERVICES PROVIDED
WOULD YOU RECOMMEND THIS FAClLlTY TO OTHERS? HAVE YOU TOLD PEOPLE THAT THE CAR€ HERE IS EXCELLENT1
A-LW 1 LIV 2 LIV 3 A LIV4
RATE STAFF AT KNOWING
WHAT MEMBERS
CARE REQUlREME
NTS ARE Know who to
talk to for info.
DO YOU FEAR STAFF RETALIATION ON MEMBER FOR WHAT
YOU DOISAY?
DOES HOSP. TREAT
MEMBER W ITH
PATIENCE AND
RESPECT?
Page 9
Correlation -RATE STAFF AT KEEPING YOU lNF ORME0 -RATE STAFF AT INVOLVING YOU IN PLANNING MEMBERS CARE?
-RATE STAFF'S POLITENESS AND COURTESY TOWAROS YOU?
-RATESTAFFAT RESPONOING PATlENTtY TO QUESTIONS & CONCERNS
HOW ARE STAFF AT APPRECIATING YOUR HELP?
HOW ARE STAFF AT CARING ABOUT YOU? HOW WOULD YOU RATE YOUR RELATIONSHIP WlTH THE STAFF?
-RATE HOSPITAL AT KEEPING TRACK OF MEMBERS PERS. BELONGINGS
-RATE HYGIENE AND CLEANLINESS OF THE WAY THINGS ARE DONE
RATE HOSP. AT DEALING WlTH CONCERNS OR COMPLAINTS
IS MEMBER WELL TAKEN CAR€ OF WHEN YOU ARE NOT THERE
RATESTAFFAT PUTTING RESIDENTS' NEEDS FIRST. RATESTAFFAT KNOWING WHAT MEMBERS CARE REQUIREMENTS ARE
Know who to talk to for info.
Correlation Matrix
i I 1
O TO BE INOEPEN
DENT -
SPECIFIC NEEDS
METIENC OURAGE
I
I-
3
I
l
AFTER PERSONAL PROBLEMS AND NEEDS
RATE HOSPITAL IN TAKlNG CAR€ OF
MEMBERS
Page 10
RATE HOSPITAL AT MAINTAINING
MEMBERS
I
RATE STAFF ON LOOKING
NEEDS. 1 DIGNITY.
4
9
t
!
-45
Correlation Matrix
Correlation DO YOU FEAR STAFF RETALIATION ON MEMBER FOR WHAT YOU DOISAY?
DOES HOSP. TREAT MEMBER WlTH PATIENCE AND RESPECT?
SPEClFlC NEEDS METiENCOURAGED TO BE INDEPENDENT RATE STAFF ON LOOKING AFTER PERSONAL PROBLEMS AND NEEOS
RATE HOSPITAL IN TAKING CAR€ OF MEMBERS NEEDS. RATE HOSPITAL AT MAINTAINING MEMBERS DIGNITY. RATE STAFF AT PROVlDlNG TENDER LOVE AND CARE. RATE HOSPITAL AT TAKING CAR€ OF YOUR NEEDS.
OVERALL- RATE QUALlTY OF CARE AND SERVICES PROVIDED WOULD YOU RECOMMEND THIS FAClLlTY TO OTHERS? HAVE YOU TOLD PEOPLE THAT THE CAR€ HERE IS EXCELLENT/
A-LIV1 LIV 2 LIV 3 A LIV4
--
SPEClF lC NEEDS
METIENC OURAGE D TO BE INDEPEN
DENT
.36
.72
1 .O0
.77
-49
.48
-51
-46
.76
.58
.55
.24
.28 -29 .29
RATE STAFF ON LOOKING
AFTER PERSONA1 PROBLEMS AND NEEDS
RATE HOSPITAL IN TAKING CARE OF MEMBERS
NEEDS.
-23
-47
-49
.50
1 .O0
.90
-85
.80
-57
-40
.37
.18
.22
.19 -18
RATE HOSPITAL A l MAINTAININC
MEMBERS DIGNITY.
Page 11
Correlation -RATE STAFF AT KEEPING YOU INFORMED -RATE STAFF AT INVOLVING YOU IN PUNNING MEMBERS CARE?
-RATE STAFF'S POLIT ENESS AND COURTESY TOWARDS YOU?
-RATE STAFF AT RESPONDING PATIENTLY TO QUESTIONS & CONCERNS
HOW ARE STAFF AT APPRECIATING YOUR HELP?
HOW ARE STAFF AT CARING ABOUT YOU? HOW WOULO YOU RATE YOUR RELATIONSHIP WITH THE STAFF?
-RATE HOSPITAL AT KEEPING TRACK OF MEMBERS PERS. BELONGINGS
-RATE HYGIENE AND CLEANLINESS OF THE WAY THINGS ARE DONE
RATE HOSP. AT DEALJNG WITH CONCERNS OR COMPLAINTS
IS MEMBER WELL TAKEN CAR€ OF WHEN YOU ARE NOT THERE RATE STAFF AT PUlTlNG RESIDENTS' NEEDS FIRST. W T E STAFF AT KNOWING WHAT MEMBERS CAR€ REQUIREMENTS ARE
Know who to talk to for info.
RATE STAFF RATE AT HOSPITAL
PROVIDING AT TAKING TENDER CAR€ OF
LOVE AND YOUR CARE. NEEDS.
OVERALL- RATE
QUALllY Of CARE AND SERVICES PROVIDED
THIS FACILITY TO
OTHERS?
Page 12
Correlation DO YOU FEAR STAFF RETALIATION ON MEMBER FOR WHAT YOU DOISAY?
OOES HOSP. TREAT MEMBER WlTH PATIENCE AND RESPECT?
SPEClFlC NEEZ!; METENCOURAGED TO BE INDEPENDENT
RATE STAFF ON LOOKING AFTER PERSONAL PROBLEMS AND NEEDS
RATE HOSPITAL IN TAKING CARE OF MEMBERS NEEDS.
RATE HOSPITAL AT MAlNTAlNlNG MEMBERS DIGNITY. RATE STAFF AT PROVlDlNG TENDER LOVE AND CARE.
RATE HOSPITAL AT TAKING CARE OF YOUR NEEDS.
OVERALL- RATE QUALlTY OF CARE AND SERVICES PROVIDED
WOULD YOU RECOMMEND THlS FAClLlTY TO OTHERS?
HAVE YOU TOLD PEOPLE THAT THE CAR€ HERE IS EXCELLENT/
A-LtV1 LIV 2 LIV 3 A LIV4
RATE STAFF AT
PROVlDlNG TENDER
LOVE AND CARE.
RATE HOSPITAL AT TAKING CAR€ OF
YOUR NEEDS.
OVERALL- 1 RATE QUALITY OF CAR€ AND SERVICES PROVIDED
WOULD YOU RECOMMEND
THlS FAClLllY TO
OTHERS?
Page 13
Correlation Matrix
Correlation -RATE STAFF AT KEEPING YOU INFORME0
-RATE STAFF AT INVOLVING YOU IN PLANNING MEMBERS CARE?
-RATE STAFF'S POLITENESS AND COURTESY TOWARDS YOU?
-RATE STAFF AT RESPONDING PATIENTLY TO QUESTIONS & CONCERNS
HOW ARE STAFF AT APPRECIATING YOUR HELP?
HOW ARE STAFF AT CARING ABOUT YOU? HOW WOULD YOU RATE YOUR RELATIONSHIP WlTH THE STAFF?
-RATE HOSPITAL AT KEEPING TRACK OF MEMBERS PERS. BELONGINGS
-RATE HYGIENE AND CLEANLINESS OF THE WAY THINGS ARE OONE
RATE HOSP. AT DEALING WlTH CONCERNS OR COMPLAINTS
IS MEMBER WELL TAKEN CAR€ OF WHEN YOU ARE NOT THERE RATE STAFF AT PUlTlNG RESIDENTS' NEEDS FIRST.
RATESTAFFAT KNOWING WHAT MEMBERS CAR€
I info. Know who to talk to for
- -
HAVE YOU TOLO
PEOPLE THAT THE
CAR€ HERE 1s
EXCELLENTr
Page 14
Correlation DO YOU FEAR STAFF RETALIATION ON MEMBER FOR WHAT YOU DOISAY?
OOES HOSP. TREAT MEMBER WlTH PATIENCE AND RESPECT?
SPEClFlC NEEOS MET/ENCOURAGED TO BE INDEPENDENT RATE STAFF ON LOOKING AFTER PERSONAL PROBLEMS AND NEEDS
RATE HOSPITAL IN TAKING CARE OF MEMGERS NEEDS. RATE HOSPITAL AT MAlNTAlNlNG MEMBERS DIGNtTY.
RATESTAFFAT PROVIDING TENDER LOVE AND CARE.
RATE HOSPITAL AT TAKING CARE OF YOUR NEEDS.
OVERALL- RATE QUALITY OF CAR€ AND SERVICES PROVIDED
WOULD YOU RECOMMEND THIS FACILITY TO OTHERS?
HAVE YOU TOLD PEOPLE THAT THE CARE HERE IS EXCELLENT/
A-LIV1 LlV 2 LIV 3 A LIV4
HAVE YOU TOLD
PEOPLE THAT THE
CAR€ HERE I S
LIV 2
.19
-26
-28
-26
.22
-2 1
-21
.21
.31
-30
-28
-49 1 .O0 .24 .37
Page 15
KEEPING YOU INFORMED -RATE STAFF AT INVOLVING YOU IN PLANNING MEMBERS CARE?
-RATE STAFF'S POLITENESS AND COURTESY TOWARDS YOU?
-RATE STAFF AT RESPONDING PATIENTLY TO QUESTIONS 8 CONCERNS
HOW ARE STAFF AT APPRECIATING YOUR HELP? HOW ARE STAFF AT CARING ABOUT YOU? HOW WOULD YOU RATE YOUR RELATIONSHIP WlTH THE STAFF?
-RATE HOSPITAL AT KEEPING TRACK OF MEMBERS PERS. BELONGINGS
-RATE HYGIENE AND CLEANLINESS OF THE WAY THINGS ARE DONE
RATE HOSP. AT DEALJNG WlTH CONCERNS OR COMPLAINTS
IS MEM8ER WELL TAKENCAREOFWHEN YOU ARE NOT THERE
RATESTAFFAT PUTTlNG RESIDENTS' NEEDS FIRST.
RATESTAFFAT KNOWING WHAT MEMBERS CAR€ REQUIREMENTS ARE
Know who to talk to for info. DO YOU FEAR STAFF RETALlATlON ON MEMBER FOR WHAT YOU DOISAY?
Initial
*74
-76
-74
-76
-74
-82
.76
.40
.54
.ô9
-75
-79
-74
-18
-25
Extraction
Extraction Method: Principal Axis Factoring.
Page 16
DOES HOSP. TREAT MEMBER WlTH PATIENCE AND RESPECT?
SPEClFlC NEEDS METfENCOURAGED TO BE INDEPENDENT M T E STAFF ON LOOKING AFTER PERSONAL PROBLEMS AND NEEDS
RATE HOSPITAL IN TAKING CARE OF MEMBERS NEEDS. RATE HOSPITAL AT MAINTAINING MEMBERS DIGNITY. MTESTAFFAT 3ROVIDING TENDER -OVE AND CARE.
U T € HOSPITAL AT rAKlNG CAR€ OF YOUR rlEEDS. NERALL- RATE 7UALITY OF CAR€ AND SERVICES PROVIDED NOULD YOU 5ECOMMEND THIS 'ACILITY TO OTHERS? 4AVE YOU TOLD EOPLE THAT THE :ARE HERE IS IXCELLENTi
Initial
.67
-70
.71
.85
.85
.82
.77
-8 1
-57
-52
-29 -33 -2 1 -25
Extraction
.67
.70
Extraction Method: Principal Axis Factoring.
Page 17
Total Variance Explrinûd
Factor 1
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Total 14.477 2.077 1.589 1.275 -942 -867 .802 .741 -643 -577 -541 ,502 .428 -381 -360 .330 .291 -278 -235 .23 1 -21 5 -189 .l78 -1 74 -168 ,155 .137 -123
3.396E-02
Initial Ehenval % of Variance
49.920 Cumulative %
49.920
-
Extrad Total 14.168 1.908 1 -045 A68
% of Variance 48.853
Cumulative % 48.853
Extraction Method: Principal Axis Factoring.
Page 18
Total Variance Explained
Factor - 1 2 3 4 5 6 7 B 3 10 II 12 i 3 14 15 i 6 7 8 9 10 1 2 3 4 5 6 7 0 3
Rotai Total
6 . W % of Variance
23-60:
Extraction Method: Principal Axis Factoring.
l Loadinas
Page 19
Scree Plot
Factor Number
Factor Matrix*
OVERALL- RATE QUALIN OF CAR€ AND SERVICES PROVIDED
RATESTAFFAT PUITlNG RESIDENTS' NEEDS FIRST. IS MEMBER iNELL TAKEN CARE OF WHEN YOU ARE NOT THERE
RATESTAFFAT KNOWING WHAT MEMBERS CAR€ REQUIREMENTS ARE
-RATE STAFF AT RESPONDING PATIENTLY TO QUESTIONS 8 CONCERNS
HOW ARE STAFF AT CARING ABOUT YOU? RATE STAFF ON LOOKING AFTER PERSONAL PROBLEMS AND NEEDS
l SPEClFlC NEEOS MEWENCOURAGED TO BE INDEPENDENT
tor 3.00
.O9
.O2
.O7
-00
-.19
-.26
.O8
.10
Extraction Method: Principal Axis Factoring.
Page 20
Factor Matrixa
RATE HOSP. AT DEALING WlTH CONCERNS OR COMPLAINTS
HOW WOULD YOU RATE YOUR RELATIONSHIP WlTH THE STAFF?
-RATE STAFF'S POLITENESS AND COURTESY TOWARDS YOU?
DOES HOSP. TREAT MEMBER WlTH PATIENCE AND RESPECT?
HOW ARE STAFF AT 4PPRECfATING YOUR IELP? -RATE STAFF AT NVOLVING YOU IN XANNING MEMBERS ;ARE?
-RATESTAFFAT (EEPING YOU NFORMED RATE HYGIENE AND XEANLINESS OF THE MAY THINGS ARE DONE
UTE STAFF AT 'ROVIDING TENDER .OVE AND CARE.
?ATE HOSPITAL AT 'AKING CARE OF YOUR IEEDS. VOULD YOU ECOMMEND THIS 'ACILITY TO OTHERS? IAVE YOU TOLD 'EOPLE THAT THE :ARE HERE IS XCELLENTI
WTE HOSPITAL AT EEPING TRACK OF IEMBERS PERS. ELONGINGS
O YOU FEAR STAFF ETALlATlON ON IEMBER FOR WHAT OU DOJSAY?
IV 3
- LIV4 now who to talk to for fo.
tor 3.00
Extraction Method: Principal Axis Factoring.
Page 21
Factor MaWx8
a. 4 factors extracted. 9 iterations required.
b
, RATE HOSPITAL AT MAINTAINING MEMBERS DIGNITY.
RATE HOSPITAL IN TAKING CAR€ OF MEMBERS NEEDS. LIV 2 A LW1
Rotated Factor MaWx8
OVERALC- RATE QUALITY OF CARE AND SERVICES PROVIDED
RATESTAFFAT PUTTING RESIDENTS' NEEDS FIRST.
IS MEMBER WELL TAKEN CARE OF WHEN YOU ARE NOT THERE RATE STAFF ON LOOKING AFTER PERSONAL PROBLEMS AND NEEDS
Extraction Method: Principal Axis Factoring.
Factor
1 SPEClFlC NEEOS METIENCOURAGED TO BE INDEPENDENT
RATESTAFFAT KNOWING WHAT MEMBERS CARE REQUIREMENTS ARE
1 .O0
-64
.65
-36 .33
DOES HOSP. TREAT MEMBER WlTH PATIENCE AND
1 RESPECT?
WOULD YOU RECOMMEND THIS FACILtTY TO OTHERS?
-RATE HYGIENE AND CLEANLJNESS OF THE WAY THlNGS ARE DONE
HAVE YOU TOLD PEOPLE THAT THE CARE HERE IS EXCELLENT1
tor 3.00
.31
-23
.23
-25
-24
.22
-24
.18
-20
.15
4.00
.O3
.O2
2 8 .25
2.00 ! 3.00
Extraction Method: Principal Axis Factoring.
-70
.68
-.O4 -.O5
Rotation Method: ~arimax with Kaiser ~06nalization.
-.O1
.O0
-5 1 -46
Page 22
Rotated Factor Matrix8
-RATE HOSPITAL AT KEEPING TRACK OF MEMBERS PERS. BELONGINGS
DO YOU FEAR STAFF RETALIATION ON MEMBER FOR WHAT YOU DOISAY?
HOW ARE STAFF AT CARING ABOUT YOU? HOW WOULD YOU RATE YOUR RELATIONSHIP WITH THE STAFF?
HOW ARE STAFF AT APPRECIATING YOUR HELP? -RATE STAFF AT RESPONDING PATIENTLY 1 O QUESTIONS 8, CONCERNS
-RATE STAFF AT NVOLVfNG YOU IN XANNING MEMBERS SARE?
-RATESTAFFAT (EEPING YOU NFORMED
-RATE STAFF'S >OLITENESS AND ZOURTESY TOWARDS (OU?
U T E HOSP. AT IEALING WITH ZONCERNS OR ZOMPLAINTS
(now who to talk to for nfo. ZATE HOSPITAL AT AAINTAINING AEMBERS DIGNITY. U T € HOSPITAL IN 'AKING CARE OF AEMBERS NEEDS. lATE STAFF AT 'ROVIDING TENDER .OVE AND CARE.
WTE HOSPITAL AT 'AKING CARE OF YOUR IEEDS.
IV 2
tor 3.00
-19
.ll
.19
-18
.17
-20
-18
-15
.20
.21
-.O7
-89
.87
.83
-78
.O9
.O5
Extraction Method: Principal Axis Factoring. Rotation Method: Varimax with Kaiser Nonnalization.
Page 23
Rotatsd Factor Mattix8
Extraction Method: Principal Axis Factoring. Rotation Method: Varimax with Kaiser Normaluation.
a. Rotation convergecl in 7 iterations.
A-LIV4 LIV 3
Factor Transformation Matrix
Extraction Method: Principal Axis Factoring. Rotation Method: Vanmax with Kaiser Normalization.
Factor
Factor Ana!ysis - Oblique Rotation (Direct Oblimin Method)
Factor MatAx8
1 .O0 .12 -14
--
a. 4 factors extractad. 9 item=~ required.
2.00 -18 -21
3.00 .O6 .O9
Pattern Matri*
4.00 -52 -37
RATE STAFF ON LOOKING AFTER PERSONAL PROBLEMS AND NEEDS
OVERALL- RATE QUALIN OF CARE AND SERVICES PROVJDED IS MEMBER WELL TAKEN CAR€ OF WHEN YOU ARE NOT THERE RATESTAFFAT PUlTlNG RESIDENTS' NEEDS FIRST. SPEClFlC NEEDS METENCOURAGED TO BE INDEPENDENT
Extraction Method: Principal Axis Factoring. Rotation Method: Oblimin with Kaiser Normalization.
Page 24
Pattern Ma-
DOES HOSP. TREAT MEMBER WlTH PATIENCE AND RESPECT?
WOULD YOU RECOMMEND THIS FACILIN TO OTHERS?
RATE STAFF AT KNOWING WHAT MEMBERS CAR€ REQUIREMENTS ARE
-RATE HYGIENE AND CLEANLINESS OF THE WAY THINGS ARE DONE
IAVE YOU TOLD >€OPLE THAT THE :ARE HERE IS EXCELLENT/
I O YOU FEAR STAFF ?ETALIATION ON iAEMBER FOR WHAT IOU DO/SAY?
RATE HOSPITAL AT (EEPING TRACK OF dEMBERS PERS. IELONGINGS
UT€ HOSPITAL AT 4AlNTAlNlNG EMBERS DIGNtTY. lATE HOSPITAL IN 'AKING CAR€ OF IEMBERS NEEDS. ATE STAFF AT ROVlDlNG TENDER OVE AND CARE. AT€ HOSPITAL AT AKING CAR€ OF YOUR EEDS. IV 2
- LW1 - LIV4 v 3 OW ARE STAFF AT ARJNG ABOUT YOU? OW WOULD YOU ATE YOUR
Hl C, 1 Hi R RELATIONSHIP WlTH THE STAFF?
HOW ARE STAFF AT APPRECIATING YOUR HELP?
tor 3.00
Extraction Method: Principal Axis Factoring. Rotation Method: Oblimin with Kaiser Normalization.
Page 25
-RATE STAFF AT INVOLVlNG YOU IN PLANNING MEMBERS CARE?
-RATE STAFF AT RESPONOING PATIENTLY TO QUESTIONS & CONCERNS
-RATE STAFF AT KEEPING YOU INFORMED -RATE STAFF'S POLITENESS AND COURTESY TOWARDS YOU?
RATE HOSP. AT DEALING WlTH CONCERNS OR COMPLAINTS
Know who to talk to for info.
Extraction Method: Principal Axis Factoring. Rotation Method: Oblimin with Kaiser Normalization.
a- Rotation converged in 19 iterations.
Total Variance Explained
Extraction Method: Principal Axis Factoring. a. When factors are correlateci, sums of squared loadings cannot 4.8 added to obtain a total variance.
Factor 1 2 3 4
Page 26
Rotation Sums of Squared ~oadinss~
Total 12.91 1 7.843 4.596
10.625
Structure Matrix
I l SERVICES PROVIDED
RATE STAFF AT PUTTING RESIDENTS' NEEDS FIRST.
IS MEMBER WELL rAKEN CAR€ OF WHEN YOU ARE NOT THERE
WTE STAFF ON -00KING AFTER 'ERSONAL PROBLEMS 4ND NEEDS
WTE STAFF AT CNOWING WHAT AEMBERS CARE tEQUIREMENTS ARE
iPEClFlC NEEDS dETIENCOURAGED TO IE INDEPENDENT
IOES HOSP. TREAT !EMBER WlTH 'ATIENCE AND ESPECT?
ATE HOSP. AT EALING WlTH ONCERNS OR OMPLAINTS
tATE HYGIENE AND LEANLINESS OF THE 'AY THINGS ARE DONE
'OULD YOU ECOMMENO THIS 4CILITY TO OTHERS?
4VE YOU TOLD EOPLE THAT THE 4RE HERE IS (CELLENT1
AT€ HOSPITAL AT EEPING TFWCK OF EMBERS PERS. lLONGlNGS
YOU FEAR STAFF iTALlATlON ON lMBER FOR WHAT NJ DOISAY?
'AL AT
MEMBERS DIGNITY.
RATE HOSPITAL IN TAKING CARE OF MEMBERS NEEDS.
Factor r
Extraction Method: Principal Axis Factoring. Rotation Method: Oblimin with Kaiser Nonnalization.
Page 27
RATESTAFFAT PROVlDlNG TENDER LOVE AND CARE. RATE HOSPITAL AT TAKlNG CAR€ OF YOUR NEEDS. LIV 2 A L I V l ALiV4 LIV 3 HOW ARE STAFF AT SARING ABOUT YOU? IOW WOULD YOU U T E YOUR 3ELATIONSHIP WlTH THE STAFF?
iOW ARE STAFF AT JPPRECIATING YOUR ELP? -RATE STAFF AT ZESPONDING 'ATIENT LY TO ZUESTIONS 8 :ONCERNS
RATE STAFF AT UVOLVING YOU IN 'LANNING MEMBERS :ARE?
RATE STAFF AT EEPING YOU JFORMED RATE STAFF'S OLITENESS AND OURTESY TOWARDS OU?
now who to talk to for fo.
tor 3.00 -
Extraction Method: Principal Axis Factoring. Rotation Method: Oblimin with Kaiser Nonnalization.
Factor Correlation Matrix
Extraction Method: Principal Axis Factoring. Rotation Method: Oblirnin with Kaiser Normalization.
Factor 1
Page 28
1 1 .O00
2 .573
3 .470
4 .714
I
OCopyright 1997, Sunnybrmk Heaith Science Centre/SmalIer World Communications
1
I
Long Term Cure Evaluation Survey
Family Version
Before you fiIl out this questionnaire, please read the following:
Statement of Confidentiality
Before you begin, please be assured that the information you provide is completely confidential. There are no names on this questionnaire. The ID number is used only for the purpose of linking you with your family member and hisher nursing unit. Your individual answers to these questions will not be given to the nursing w t s . Staff will only be provided with answers for the entire unit, thereby maintainhg your anonymity. Your participation is completely voluntary. The purpose of this questionnaire is to find out how you feel about this facility so that improvements can be made. Please do not hesitate to be completely honest in your response to each question.
If you have any questions about this survey and do not wish to contact the Facility, cal1 Barb van Maris at Smaller World Communications at (905) 77 1-823 1.
INSTRUCTIONS
O Please try to answer al1 of the questions in this survey
O If a question does not apply to you or you do Bot know the answer, check the "Don't know 1 NIA" (not applicable) box on the far right.
I
0 There is space provided for ~ o u r c d e n t s . 1f Lou need more space, use the back of the questionnaire or add an additional piece of paper.
O When you have completed your questionnaire, please retm it in the enclosed stamped, self addressed envelope.
LIVING ENVIRONMENT The following questions ask about the faciiity 's living environment. Don't
know/ Yes Somewhat No N/A -
1. Does your family member's room meet hisher specific needs? 0' D2 0' n9 2. Does the layout of the facility rneet your family member's O' Ut O; 0"
needs?
3. Are you encouraged to bring your family member's persona1 ai 0' 0; !J9 things into the room?
4. 1s there a cornfortable place for you to visit with your farnily 0' a2 0' Cl9 mernber?
Do you have any comrnents about the living environment?
COMMUNICATION WlTH STAFF The following questions os& about family-staff communication and reIationships.
Don't Verv Excellent g d G d Fair J%or %?A
5 . How would you rate staff at keeping you infomed about your family member?
6. How would you rate staff at involving you in os a4 0 5 U T 01 09
planning your family member's care?
7. How would you rate the staffs politeness and Os 0": C 3 2 0' 0 9
courtesy towards you?
8. How would you rate staff at responding patiently - - . - 0 1 04 13: 02 01 09
to your questions md concerns?
9. How are staff at appreciating your help? - BS O* 0' o9 * . --
1 O. w o w are staff at k i n g about you? os 0 4 0; 0 2 0' 0 9
1 1. How would you rate your relationship with the os 0 4 0 5 a' 01 0 9
staff! .. -.-
Do you have any comments about communication or your relationship with staff?
ALlTY AND SERVICES The follo wing questions osk about certain aspects of the quafity of care and services provided
How would you rate the facility at keeping track of your family member's persona1 belongings?
How would you rate the hygiene and cleanliness of of the way things are done around here?
How would you rate the facility at providing you with -- - a way -- to - -- deal with concems or complaints ~ O U have?
How is your comfort level with knowing that your family mernber is well taken care of when you are not there?
How would you rate the staff at putting residents' needs first?
How would you rate staff at knowing what your family member's care requirements are?
k Y Excellent good
i Does your family member receive the help he/she needs to
7 : - eat? O /'
Y f l Do the staff take the proper arnount of time to feed your . family member?
f 20. ? - ' W o u know who to talk to in order to get information about , ' your family member? - -
r 2 1. Do you fear that staff might punish your family mehber because of something you Say or do?
I
. -- d
Are there any comments you wish to make?
Good Fair -- cl'
O'
ni
O'
CI'
O'
Don' t - Poor WA --
Don? -
RESIDENT CARE The following questions us& about Iiow yow f a m e member is cared for.
It is important to treat al1 residents with respect, to be patient with them and address them in an appropnate manner. How would you rate the facility in these areas?
' Excellent Fair - Don't know
Poor - N/A
It is important that residents are treated according to their specific needs, are encouraged to be independent, are offered appropriate activities and that the proper amount of time is taken to feed them. How would you rate the facility at providing this type of individualized care to your family member?
Excellent IZQ ""(; Fair Poor 9P=
In order to maintain resident dignity, certain care processes must take place. These include such things as keeping residents changed and clean and prepared for the day, toileting them when needed, ensuring they get the help they need to eat and ensuring residents are kept physically cornfortable. How would you rate staff at tooking afier these things for your family member?
Good Fair
Are there any comments you wish to make about the care that is provided to your family mem ber? t
GLOBAL QUESTIONS Thefollowing questions willprovide us with an overallpicture of how satisfiedyou are with l i s fucility.
Don't YaY knowl
Excellent good Good Fair Poor FA
25. How would you rate the facility at taking care of o5 0": n2 ni n9 your farnily rnember's needs?
26. How would you rate the facility at maintainhg 0' n4 0: 02 01 0 9
your farnily rnember' s dignity?
27. How would you rate the staff at providing tender, 0' 0-5 0' 00
loving care?
28+ How would you rate the faciliîy at taking care of OS o4 0 3 a2 17' ~ 3 9
your needs?
29. Overall, how would you rate the quality of care O' 0 4 C]; 0 2 01 0 9
and services provided?
Definitelv Probablv Probablv not de finit el^ no ecommend Recommend Recommend Recommend
30. If this type of care were required O' 0" 0' al. O' ' -=
for another farnily rnember or friend, would you recommend this fac ility?
3 1. Have you told people that the care here is excellent?. -
Don't Yes - NQ know
l
Are there any additional comrnents you wish tcfmake? *
UNDERSTANDING WHO OUR RESPONDENTS ARE
32. What is your relationship to your farnily member? The resident is my:
iJ1 husband/wife D5 child Oz brothedsister (in-law) O6 other farnily member 0' mothedfather (in-law) 0' other, specify: O4 grandparent
Don't Verv know/
Excellent good Good Fair Poor NIA 33. Compared to other residents in your family Os 0 4 0 3 0 2 a9
member's facility, how would you rate your farnily member's health?
THE QUESTIONNAIRE Please he@ us tu improve this questionnaire by answering the fdowing 3 questions.
Yes - No 34. Did you have difficulty answering any questions? O' 0'
If so, which question numbers:
35. Did you have difficulty understanding any questions? 0' 0' If so, which question numbers:
36. 1s there anything missing that is important to you that the questionnaire did not ask about?
If yes, please explain:
I
Are there any final comments you wish to make?'-
Thank-you for taking the tirne tu complete this questionnaire. Please double check to make sure you answered all of the questions thut you couid
Then mail tire questionnaire in the enclosed postage-paid envelope. Remember to ask the facility about tire resultk!
E m TO Smaller World Communications
116 Westwood Lane Richmond Hiil, ON
L4C 6Y3
