Nursing homes: In the eye of the beholder

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

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

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

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

Voices of residents, families

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

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

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

Satisfaction is not engagement

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

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

The judgment of state surveyors

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

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

Nursing home life

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

Second, both residents and families record their highest satisfaction in two areas, Resident Safety and Staff Show Respect for the resident. These seemingly small details add up to a compelling evidence that the workaday life in a nursing home is very different from the dark and distorted image in the public mind that portrays seniors as being warehoused, neglected, and abused in nursing homes. Care receivers and frontline witnesses continue to testify to the devotion and respect with which caregivers serve our seniors and make them feel safe, secure, and satisfied. Nevertheless, the outside world cruelly distorts, denigrates, and derogates that extraordinary accomplishment.

Third, the residents, their families, and the state surveyors take strikingly congruent approaches to their nursing home. Residents and families register their highest and lowest satisfaction in the same areas. Residents, families, and state surveyors independently judge their nursing home and draw consistent conclusions; family opinion, however, dovetails more tightly with the opinion of the state surveyors.

Providers, surveyor antagonists

The disjunction that we noted above between what residents want and families prize should pique the curiosity of advocates. The fact that resident and family sentiment echoes surveyor thinking, and that the families agree more with the surveyor’s verdict, will not strike a chord with providers. It is common knowledge that there is no love lost between care providers and state surveyors. Far from being mutually supportive colleagues, the two sides see each other as antagonists and interact with latent hostility.

The care providers’ familiar moan is heard throughout the long-term care land. State surveyors come with an attitude. Their preoccupation with picayune detail questions caregiver professionalism. Their fetish for documentation ignores the good intent and devotion being practiced. The system makes them eager to ferret out lapses (sometimes ridiculous or contrived) but not to applaud innovations in quality. Surveyors’ measure of quality is compliance to minimum standards even when it serves as a roadblock to excellence.

This litany of charges should not obscure some elementary facts. State surveyors are no strangers to long-term care; many come from the ranks of long-term care professionals. Their training tutors them in the intricacies of the State Operations Manual. The team assigned to inspect a nursing home readies for the task by studying its past performance. It spends days on site, it observes caregiving, it interviews relevant informants, and it reviews records. The surveyor team pools the findings and determines how much the nursing home is in compliance with the standards. It is reasonable to conclude that even with the flaws in the system, and despite the misgivings of care providers, state surveyor judgment essentially and accurately summarizes the state of caregiving. Residents and families validate the surveyors’ judgment.

Like their families, residents too ask for competent care-the third strongest influence that earns the nursing home their allegiance. What they long for, however, is not high-tech cures that mend the body but neglect the soul, but the low-tech human touch that tells them that you really care, that assures them that they do matter, and that convinces them you recognize that they too have the same universal human need to be appreciated and to belong. Thus, in this study, it is Staff Care and Concern that residents long for above all else and what nursing homes will have to deliver to win their loyalty.

Watchdog of quality

The family juggles two roles vis-a-vis the nursing home. Its kinship role urges families to empathize with the residents and to share their concerns. Thus, the following four areas stir both residents and families. Staff Show Respect (recognizes the resident as a person), Management Responsiveness (affirms individuality), Staff Care and Concern for resident (recognizes dignity of resident), and Keeping Self and Family Informed (enhances residents’ sense of control).

Its second role places different obligations on the family and leads it to take a stance different from the residents’ priorities. Unlike residents, families are not recipients of services; they are observers, bill payers, and judges of the care their relatives receive. As monitor and judge, they see the nursing home through a different prism. They now feel pressed to ask questions and to attend to issues that resonate differently with residents. Like residents, families may desire that only caring, concerned, and devoted staff should care for residents. In their role as payers of bills and watchdogs of quality they can rightfully demand that their nursing home meet accepted standards of care.

Their collective critique as visitors, observers, and judges of quality is likely to be more detached and more objective, and, by the same logic, more consistent with the conclusions surveyors reach after a comprehensive investigation.

Surveyors and the QoC mind-set

Introduce into these dynamics state surveyors-the designated critics of a nursing home’s operations. Unlike the two other groups, state surveyors bring to their task a cultivated mind-set with a pronounced tilt towards the Quality of Care (QoC) model. This school of thought promotes an objective approach to quality; it assesses quality by its supporting structure (e.g., adequate, competent staff), by the protocols it follows (e.g., compliance to accepted standards), and by its measurable outcomes (e.g., functional independence, discharge to home). This paradigm dominates nursing home regulation and inspection.

Here are three parties eyeing the same nursing home from three different social settings. Each has a different stake and each desires different results. Residents and families may know little about state surveyors and the rules that guide them. The three groups reach conclusions independently. Curiously, however, their conclusions complement each other’s. Residents and families may agree or disagree depending on the social psychology of the situation. Still, their satisfaction is a signal of what the state survey is likely to have in store for their nursing home.


As person-centered care emerges as the guiding principle in long-term care, the necessity to heed the voice of the customers becomes urgent. Long-term care has different customers and stakeholders. Each takes a different stance, views you from a different angle, desires different results, and does not always convey a message consistent with the message from others. However, they all speak the truth as they experience it in their distinct social-psychological ambience. Keeping tuned in to the customer’s voice fortifies us with good information. Still, this is only the first step. We turn that information into knowledge, and then into wise policy by understanding the hidden drivers and dynamics behind the customer’s message.

V. Tellis-Nayak, PhD, is a medical sociologist. He has been a university professor, has conducted research in the United States and abroad, and has authored books and articles. He can be reached at Bradley N. Shiverick, CPHQ, is Senior Vice President-Health Care Services, Team TSI Corporation; and Mauro Hernandez, PhD, is Chief Executive Officer, Concepts in Community Living, Clackamas, Oregon. Long-Term Living 2010 December;59(12):28-31

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