Care satisfaction among older people receiving public care and service at home or in special accommodation

Authors


Correspondence: Staffan Karlsson, Senior Lecturer, Department of Health Sciences, Faculty of Medicine, Lund University, PO Box 157, SE-221 00 Lund, Sweden. Telephone: +46 46 222 18 32.

E-mail: staffan.karlsson@med.lu.se

Abstract

Aims and objectives

To explore care satisfaction in relation to place of living, health-related quality of life, functional dependency and health complaints among people 65 years or older, receiving public care and service. The concept public care and service concerns formal care from the municipality, including home help, home nursing care, rehabilitation and a special accommodation.

Background

To be able to provide care and service of high quality to older people, knowledge about factors influencing their experience of satisfaction with the care is essential.

Design

Cross-sectional, including comparison and correlation.

Methods

One-hundred sixty-six people receiving public care and service from the municipality were interviewed regarding demography, functional ability, perceived health complaints and care. Health-related quality of life was measured with SF-12, and self-rated care satisfaction was measured with a questionnaire.

Results

Low self-rated care satisfaction was associated with dependency in Instrumental Activities of Daily Living, blindness, faeces incontinence and anxiety, while high self-rated care satisfaction was associated with dependency in Personal Activities of Daily Living. Those at home rated an overall higher care satisfaction and were more satisfied with care continuity and personal relations; they thought that the staff had more time and were more respectful and quiet, than the ratings by those in a special accommodation (equivalent to a nursing home).

Conclusions

Care satisfaction and health-related quality of life among older people was more associated with functional impairment and health complaints than to whether care and service was received at home or in a special accommodation.

Relevance to clinical practice

An approach using intervention focused on functional ability and health complaints is important for development of improved care satisfaction for older people receiving public care and service.

Introduction

To be able to provide care and service of high quality to older people, knowledge about home care nursing factors influencing their experience of satisfaction with the care is essential (Crow et al. 2002). As older people receiving public care and service are frail, it is of importance to investigate perceived health, functional ability and if the person is living at home or in a special accommodation is associated with care satisfaction. It is well known that perceived health complaints and impaired functional ability decrease quality of life (HRQoL) (Hellström et al. 2004, Stenzelius et al. 2004, Motl & McAuley 2010), but knowledge about how those factors are associated with care satisfaction is sparse. Previous studies have shown a positive relationship between quality in public care and service, and care satisfaction (Duffy & Ketchland 1998, Rantz et al. 1999). Knowledge about factors associated with care satisfaction is of importance in order to be able to develop public care and high quality service for older people.

It is reasonable to assume that older people perceive satisfaction with the care they receive differently whether public care and service is received in their own home or if they are living in a special accommodation. Several studies have focused on residential care. One study in the United States (n = 176) concerning older people's care satisfaction in residential care indicated that women and people who were not married were more satisfied with interpersonal aspects of care. Also, increased hours of received care in a special accommodation were associated with care satisfaction (Curtis et al. 2005), although another study (n = 996) showed only a small impact on the amount of care received on care satisfaction (Chou et al. 2003). A study by Chong (2003) showed that the residents' satisfaction was correlated with living in small facilities (n = 405). Another study (n = 195) found high care satisfaction among the residents in a special accommodation regarding staff contacts, staff support, comfortable milieu, caring approach and respect of the individual's opinion (Berglund 2007). One study (n = 76) focusing on older people living at home showed the highest level of care satisfaction with the care providers' personal characteristics. The lowest level of care satisfaction was reported for time and availability (Samuelsson & Wister 2000). A study by Woodward et al. (2004) (n = 25) found that people at home highly rated satisfaction when public care was corresponding to their needs and that the staff had suitable knowledge, skills and competence. A previous study compared perceived care satisfaction in public home-based care and care in a special accommodation. The study showed that the residents rated lower satisfaction for opportunities for activities in home-based care compared to care in a special accommodation. Staff behaviour and activity predicted overall care satisfaction among residents and did not differ between the care settings. Even if aspects like a positive contact with the staff seems to contribute to care satisfaction, independent of place of living, other aspects seem to differ and are therefore important for further exploration.

Care satisfaction is most certainly dependent on the type care received and on the individual's health, illness and dependency (Crow et al. 2002). Previous studies have, for example, found a relationship between pain, distress and anxiety and poor satisfaction with public care and services (Rubinstein 2000, Rahmqvist 2001, Bair et al. 2007). Among those receiving public care and service at home, care satisfaction was associated with high functional ability (Geron et al. 2000, Sikorska 1999), while there was no such relationship among those living in a special accommodation (Chou et al. 2003, Curtis et al. 2005). However, high care satisfaction in a special accommodation has been found to be positively associated with perceived health (Chong 2003, Curtis et al. 2005, n = 405 and n = 176, respectively). Cognitive impairment was also associated with higher care satisfaction (Curtis et al. 2005). Another study showed that better perceived health predicted care satisfaction (Xiao & Barber 2007), which is in line with findings from Rahmqvist (2001) showing that those who reported poor health were less likely to be satisfied with the public care and service they received (Rahmqvist 2001). Thus, several studies indicate a relationship between care satisfaction, health, functional dependency and place of living, in older people receiving care and service. How these aspects are interrelated, however, is unclear.

Aim

The aim of the study was to explore care satisfaction in relation to place of living, HRQoL, functional dependency and health complaints among people 65 years or older, receiving public care and service (formal care from the municipality).

Methods

Sample

The study included 166 individuals who received public care and services in five municipalities in Skåne, in southern Sweden (Karlsson et al. 2008). Persons 65 years or older who had been granted public care and service at home, who were living in a special accommodation or who had at least two visits per month from home nursing care or rehabilitation were consecutively selected for the study. People who were granted only a bodily-carried alarm (alarm equipment to call for help from staff), meals on wheels (home delivered meals) or transport services (subsidised transport with assistance) were not included.

The respondents were identified and recruited by their 10 digit personal number when they were entered in a register from a national longitudinal and multi-purpose study that was initiated in 2001 in Sweden: the Swedish National Study on Aging and Care (SNAC) (Karlsson et al. 2008). Four research centres, Skåne, Blekinge, Stockholm and Nordanstig, take part and collect data in different areas. The SNAC-study contains two parts: the population part and the care and services part. In the care and services part, a systematic, individual collection of data is performed concerning the provision of care and services, functional ability, health complaints and living conditions for the recipients (Karlsson et al. 2008).

Procedure

The data collection was preceded by written informed consent from the included older persons, and the data were treated confidentially. In the cases where the person had impaired competence, the next of kin was asked for informed consent. Personal interviews were performed between October 2002 and June 2003 by specially trained registered nurses, not involved in the care and services received by the older persons. The older persons had a free choice of place for the interview. In mutual agreement, the interviews were performed in the respondents' housing, at home or in a special accommodation. During the interviews, a standardised form concerning older persons' needs, care and services was used. The form was developed by a Swedish national research group (Lagergren et al. 2004) and was based on existing literature, consultation with an expert group including researchers (geriatrics, gerontology, nursing science, social science) and tested in a pilot study (Jakobsson & Hallberg 2006). When the respondent had impaired communicative or cognitive ability as assessed by a responsible registered nurse, the next of kin or the contact person was interviewed instead, so-called proxy (n = 9). This was not to harm the older person and to secure validity and reliability. The older persons using a proxy were significantly more cognitively impaired (p < 0·001) and more often living in a special accommodation (p = 0·012), while there were no differences in age and gender compared to those answering by themselves. Instruments measuring care satisfaction (Samuelsson et al. 1993) and HRQoL (SF-12) were only used for those respondents answering by themselves. The Ethics Committee of the Medical Faculty, Lund University (LU 650-00) approved the study.

Standardised interview form

The form contained items about demographic data, functional ability, health complaints, and public and informal care. Demographic data included age, gender, marital status and living conditions (Lagergren et al. 2004).

Functional dependency for Personal Activities of Daily Living (PADL) was measured by Katz' ADL index and included dependency for bathing, dressing, going to the toilet, transfer, continence and feeding (Katz et al. 1963). Variables for Instrumental Activities of Daily Living (IADL) included dependency for cleaning, shopping, transportation, washing and cooking (Åsberg & Sonn 1988). Each variable had the response alternatives: independent, partly dependent or dependent. The data were dichotomised regarding independent and dependent following the detailed instructions in the guidelines for the instrument (Åsberg & Sonn 1988). The combined IADL and PADL, commonly known as ‘the ADL-staircase’, has shown inter-observer reliability r = 0·81–0·88 (Brorsson & Asberg 1984) and Cronbach's alpha 0·88 (Jakobsson 2008). The Berger Scale was used to measure cognitive dependency. Assessments of cognitive dependency were carried out by using seven predefined alternatives, from no cognitive dependency to bedridden and mutistic. The scale correlates well with the typical clinical course of Alzheimer's disease, and clinical experiences have revealed the scale to be a valid and reliable means of obtaining an overview of cognitive status (Berger 1980). Health complaints were measured concerning impaired mobility, vision, hearing, dizziness, incontinence, pain, anxiety, depressed mood (periodical and slight, periodical and severe, or constantly severe) and ulcer (yes or no). Most of the items have been used by Tibblin et al. (1990), but with yes or no as response alternatives throughout (Tibblin et al. 1990). The section covering Public care and services was comprised of questions about received care and services at home or/and home nursing care or living in a special accommodation (Karlsson et al. 2008).

Short Form Healthy Survey-12

The Short Form Health Survey (SF-12), was used for measuring HRQoL. The instrument is a shorter version of the SF-36 and is well documented as a HRQoL instrument validated for Swedish populations (Ware & Sherbourne 1992, Sullivan et al. 1997). The SF-12 is preferable to the longer version for use among older people because it contains fewer questions, which makes it easier to answer, and because questions about work are excluded (Resnick & Nahm 2001). The SF-12 covers a Physical Component Summary (PCS) scale, including general health, physical function, physical role limitation and bodily pain. Another section of the instrument covers a Mental Component Summary (MCS) scale, including vitality, social function, emotional role and mental health (Ware et al. 1996). Each score includes a standardised range from 0 (poorest well-being) to 100 (highest well-being). In a general population, the SF-12 has shown to be psychometrically valid and reliable, and test–retest showed correlations of 0·89 for PCS and 0·76 for MCS (Ware et al. 1996). The relationship between the summary scores for SF-12 and SF-36 has also been found to be high. More than 90% of the variance in SF-36 PCS and MCS measures was found to be reproduced in SF-12 (Ware et al. 1996). Reliability in one study among older people (age 75–105) showed a Cronbach's alpha 0·73–0·86 (Jakobsson 2007).

Self-rated care satisfaction at home or in a special accommodation

Self-rated care satisfaction was measured with a questionnaire previously used in home-help services for older people, 65+. The questionnaire was developed by Samuelsson et al. (1993) using the Multiattribute Utility Technology (MAUT) (Edwards & Newman 1982). The attributes perceived to be important to consumers receiving public care and service have been examined with the MAUT scale procedure by using semi-structured interviews. Derived from the attributes, the questionnaire covered continuity, suitability, availability/times, influence and personal relations. Continuity included staff as well as care continuity. Suitability covered personal qualities and professional competence. Questions concerning personal qualities included aspects such as if the staff was friendly and cheerful, respectful and considerate, quiet, reliable, and careful and orderly. Professional competence involved aspects such as doing household jobs, giving personal care and giving social care. Availability/time included aspects such as how well times are kept and available time for care. Each attribute was ranked on a 7-graded scale (from 1 = very dissatisfied to 7 = very satisfied) and was used to measure the evaluation of received public care and service (Samuelsson et al. 1993). In addition, an overall assessment of the home help and/or home nursing care and the number of persons visiting per week/month were included in the questionnaire.

The questionnaire was originally developed to be used for older people receiving public care and services at home only. The authors modified the questionnaire to make it suitable for those receiving home nursing care and those living in a special accommodation. For those receiving home nursing care, questions concerning giving medical service was added to the instrument. For those living in a special accommodation, the question about professional competence concerning household jobs was deleted, and the questions about overall assessment of public care and services at home and home nursing care were replaced with an overall assessment of care and services in a special accommodation. The questionnaire has not been tested for validity and reliability. However, methods have been used to achieve face and content validity by means of a literature review and interviews with older people about qualities regarded as important (Samuelsson et al. 1993).

Analysis

The first author provided the analysis in collaboration with the third author, and the second and fourth authors supervised the analysis. Nonparametric statistics were used for comparisons regarding demographic data, functional ability, health complaints, care satisfaction and HRQoL between those receiving public care at home and at a special accommodation. For categorical variables, the chi-square test (Fisher's exact test when applicable) was used between two independent groups. The Mann–Whitney U-test was applied to the analysis of differences between two independent groups measured on an ordinal scale. A p-value of 0·05 and below was considered significant. For care satisfaction questionnaire, the 7-graded scale was dichotomised in the analysis: moderate or not satisfied between grades 1–5 and satisfied between grades 6–7. Self-rated care satisfaction was measured with different numbers of items depending on the type of public care received: home help, home nursing care, combination of home help and home nursing care, and care in a special accommodation. Due to different numbers of items depending on the type of public care received, the total score for self-rated care satisfaction was standardised (i.e. observed value minus the lowest value divided with range and multiplied by 100) to make them comparable in the individual cases. For investigation of the relationship between self-rated care satisfaction and HRQoL (PCS as well as MCS in SF-12), Spearman's rank–order correlation was employed (Polit & Beck 2004). A correlation coefficient > 0·19 and < 31 was regarded as fair, > 0·30 and < 0·45 was regarded as modest and above 0·86 very good (Fowler et al. 1998). Multiple linear regression analysis was performed with self-rated care satisfaction as the dependent variable. The stepwise method was used for the independent variables: gender, housing (at home vs. a special accommodation), cohabitation, walking ability, dizziness, urinary incontinence, faeces incontinence, pressure ulcer, slow healing wound, vision, hearing, anxiety, depressed mood, cognitive ability, pain and HRQoL. Age, IADL-sum and PADL-sum were held constant by means of the enter method in the multiple linear regression analysis. For investigating the quality level of the regression model, the Kolmogorov–Smirnov test (p = 0·273 and p = 0·170, respectively) and a histogram was used regarding analysis of residuals. The spss version 14.0 (SPSS Inc., Chicago, IL, USA) was used for the statistical analyses.

Results

Of the study group, 54% received public care and services at home and 46% in a special accommodation. Those who lived in a special accommodation were older, more often women, and had more dependency and health complaints compared to those receiving public care at home (Tables 1 and 2).

Table 1. Demographic data and functional ability, comparison between types of housing
 At home, n = 90 (54%)Special accommodation, n = 76 (46%)p-valueTotal, n = 166
  1. Chi-square test (Fisher's exact test) for nominal data and Mann–Whitney U-test for interval level of data.

    Significant values are in bold.

Age, M (SD)83·2 (6·8)86·0 (7·0)0·05684·5 (7·0)
Gender, women/men, %54/4674/26 0·015 63/37
Age groups, %
 65–741280·07110
 75–84412835
 85+476455
Civil status, %
 Married22100·14617
 Widow/widower587465
 Unmarried141213
 Divorced645
 Cohabitation261 <0·001 15
Dependence on Instrumental Activities of Daily Living (IADL), %
 Cleaning 7195 <0·001 82
 Shopping 6691 <0·001 77
 Transportation 7092 <0·001 80
 Cooking 5896 <0·001 76
 Laundry 5997 <0·001 77
 IADL summary, median (q1–q3)4 (2–5)5 (5–5) <0·001 5 (3–5)
Dependence on Personal Activities of Daily Living (PADL), %
 Bathing 5870 0·015 63
 Dressing 1543 <0·001 28
 Toileting 1344 <0·001 27
 Transfer 838 <0·001 22
 Feeding 15 0·030 3
 PADL summary, median (q1–q3)1 (0–1)1 (0–4) <0·001 1 (0–3)
Table 2. Health complaints, comparison between types of housing, %
 At home n = 90Special accommodation n = 76p-value Total n = 166
  1. Chi-square test for nominal data and Mann–Whitney U-test for interval level of data.

    Significant values are in bold.

Mobility
 Ability to walk outdoors with aid5829 <0·001 45
 Ability to walk indoors with aid 213829
 Assistance with walking or bedridden42213
Vision
 Slightly impaired 19220·05221
 Severely impaired102115
 Blind031
Hearing
 Slightly impaired29280·81328
 Severely impaired344
 Deaf101
Urinary incontinence
 Occasional difficulties 34330·46334
 Severe difficulties 888
 Unable to control urine101914
Faeces incontinence
 Occasional difficulties 818 0·042 13
 Severe difficulties000
 Unable to control faeces274
Ulcer
 Slow healing wound980·7858
 Pressure ulcer211 0·046 6
Pain
 Slight pain22260·92824
 Periodic severe pain161315
 Constant severe pain121313
Dizziness
 Periodic dizziness42290·31736
 Periodic severe dizziness697
 Constant severe dizziness232
Cognitive ability
 Mild impairment (Berger 1–2)1111 0·007 11
 Moderate impairment (Berger 3–4)2168
 Serious impairment (Berger 5–6) 74
Anxiety
 Periodic anxiety 23260·07125
 Periodic severe anxiety71711
 Constant severe anxiety302
Depressed mood
 Periodic depression 41360·56239
 Periodic severe depression697
 Constant severe depression101

In total, those receiving public care and services at home were more satisfied with their care (m = 92) compared to those in a special accommodation (m = 86) (p = 0·004). Those in a special accommodation were least satisfied with the staff's amount of time (md = 5), the older persons own influence over the care (md = 5), medical service (md = 6) and social service (md = 7, q1/q3 = 5/7), while those at home were least satisfied with staff's ability to do housework (md = 7, q1/q3 = 5/7), own influence over the care (md = 7, q1/q3 = 5/7), staff's amount of time (md = 7, q1/q3 = 5/7) and that times were kept (md = 7, q1/q3 = 6/7) (Table 3, Figure 1). Persons at home were, compared to those in a special accommodation, significantly more satisfied regarding care continuity (md = 7, q1/q3 = 6/7, 85% satisfied vs. md = 7, q1/q3 = 6/7, 80% satisfied, p = 0·027), the staff's amount of time (md = 7, q1/q3 = 5/7 vs. md = 5, q1/q3 = 4/7, p = 0·012) that the staff was respectful (md = 7, q1/q3 = 7/7 vs. md = 7, q1/q3 = 6/7, p = 0·006) and quiet (md = 7, q1/q3 = 7/7 vs. md = 7, q1/q3 = 6/7, p = 0·002), and personal relations (md = 7, q1/q3 = 7/7 vs. md = 7, q1/q3 = 6/7, p = 0·036). No significant differences for HRQoL were seen between those living at home and those in a special accommodation (Table 3).

Table 3. Self-rated care satisfaction and health-related quality of life, comparison between types of housing, n = 166
%aAt home, n = 90 (54%)Special accommodation, n = 76 (46%)p-value
Not satisfied, 1–5Satisfied, 6–7Not satisfied, 1–5Satisfied, 6–7
  1. Chi-square test, Mann–Whitney U-test.

  2. a

    Self-rated care satisfaction = 7-graded scale (7 = very satisfied, 1 = very dissatisfied).

  3. b

    Standardised to range between 0 and 100.

    Significant values are in bold.

Satisfaction with number of providers138723770·055
Care continuity15852080 0·027
Staff continuity138724760·288
The staff arrives when needed118920800·666
Times are kept1882   
The staff has plenty of time28725446 0·012
The staff is friendly2988920·260
The staff is respectful9 912278 0·006
The staff is quiet9 912278 0·002
The staff is careful and orderly138718820·591
The staff is reliable5958920·396
The staff's ability to do housework32 6816840·332
The staff's ability to give personal care138715850·283
The staff's ability to give medical service198133670·072
The staff's ability to give social service148630700·063
Influence over the care307052480·097
Personal relations9911684 0·036
Overall assessment of home help9 91   
Overall assessment of home nursing care595   
Overall assessment of care in a special accommodation  1288 
Total score, M (SD)b91·7 (9·4)85·9 (13·7) 0·004
SF-12 scales, M (SD)
 Physical component score (PCS) 34·4 (10·3)34·0 (11·0)0·460
 Mental component score (MCS)54·4 (11·1)55·2 (9·5)0·460
Figure 1.

Self-retaed care satisfaction at home and in a special accommodation (1 = very dissatisfied, 7 = very satisfied).

Low self-rated care satisfaction was associated with dependency on IADL (B = −1·338), assistance with walking or being bedridden (B = −12·579), blindness (B = −26·143), occasional faeces incontinence and being unable to control faeces (B = −11·898 and −17·529) as well as periodic and constant severe anxiety (B = −6·105 and −27·197). High self-rated care satisfaction was associated with dependency on PADL (B = 2·109). The regression model showed adjusted R2 32·1%, and the p-value varied between < 0·001 and 0·047 (Table 4).

Table 4. ADL dependency, health complaints, health-related quality of life (HRQoL) (SF-12) associated with self-rated care satisfaction (total score)
Independent variables B Adjusted R295% confidence intervalp-value
  1. Variables entered in the regression analysis: age, gender, housing (at home vs. a special accommodation), cohabitation, IADL-sum, PADL-sum, walking ability, dizziness, urinary incontinence, faeces incontinence, pressure ulcer, slow healing wound, vision, hearing, anxiety, depressed mood, cognitive ability, pain, HRQoL physical component score (PCS), HRQoL mental component score (MCS). Age, IADL-sum and PADL-sum were held constant during the analysis.

    Significant values are in bold.

Self-rated care satisfaction, total score
 Age0·0580·321−0·1900·3070·642
 Instrumental Activities of Daily Living (IADL)-sum−1·338 −2·656−0·021 0·047
 Personal Activities of Daily Living (PADL)-sum2·109 0·1304·089 0·037
 Assistance with walking or bedridden−12·579 −22·635−2·523 0·015
 Blindness−26·143 −44·738−7·548 0·006
 Faeces incontinence, occasional difficulties−11·989 −18·278−5·700 <0·001
 Faeces incontinence, unable to control faeces−17·529 −26·968−8·089 <0·001
 Periodic anxiety−6·105 −10·225−1·984 0·004
 Constant severe anxiety−27·197 −40·393−14·003 <0·001

The analysis of the relationship between self-rated care satisfaction and HRQoL showed a moderate correlation between self-rated care satisfaction and HRQoL regarding the mental component (rs = 0·30) and fair correlation between care satisfaction and HRQoL regarding the physical component (rs = 0·23). High correlation was found between the physical and mental component (rs = 0·92) in HRQoL.

Discussion

Methodological considerations

The sample consisted of older people receiving public care and service at home as well as in a special accommodation, and the distribution was found to be skewed regarding housing, which may be a threat to external validity. In this study, more older people living in a special accommodation were included (46%) compared to the official statistics (40%) (National Board of Health and Welfare 2007). The higher proportion living in a special accommodation indicates that more older people with impaired functional ability were included, which implies that the results may have limited transferability to the group older people receiving public care and services at home. All older persons receiving public care and services were consecutively included, as well as those with impaired communicative ability. For nine persons (5%), proxies answered the questionnaire regarding public care and services, while they were excluded from the HRQoL and self-rated care satisfaction assessment. Thus, answers from the proxies probably do not affect the results, but rather give a more comprehensive view of older people receiving public care and services. Registered nurses performed the data collection after training on how to use the instruments during the interviews. The older peoples' dependency on care and services may have influenced their responses, which may have implied that they tended to underreport dissatisfaction. However, to minimise such influence, the interviews were not carried out as a part of the older persons' care and services. HRQoL was measured with SF-12, which is a well-known instrument and also tested for reliability as well as for validity. The instrument has been used in previous studies and is particularly suitable in settings including older people (Jakobsson 2007). For the questionnaire measuring public care and services, the inter-rater reliability, for instance, was not tested as a whole, although it included reliable and valid instruments such as the Berger Scale (Berger 1980), the Katz ADL Index (Katz et al. 1963) and the Hulter-Åsberg Index for IADL (Åsberg & Sonn 1988). The instrument measuring self-rated care satisfaction was developed for use for older people receiving home help (Samuelsson et al. 1993). In this study, it was also used for home nursing care, for a combination of home help and home nursing care, and for those living in a special accommodation. Questions were added or deleted to adapt the questionnaire to the received public care in the individual case. These modifications may not affect the results, as only a few questions were changed and the total score was standardised. One drawback of these modifications is that they make it difficult to compare the results to other studies but, at the same time, the modifications made the study applicable to a wider sample of older people. The dichotomising of the 7-graded scale in the analysis could be questioned. The scale was dichotomised into grades 1–5 for not satisfied vs. 6–7 for satisfied. The high breakpoint for satisfaction was applied to discriminate possible less satisfied individuals, because previous studies indicate a high level of self-rated care satisfaction in general among older people receiving care and services (Martin-Mathews 1995, Helset 1998, Chen 2001, Chesterman et al. 2001, Andersson et al. 2007). Also the high level of dependency in ADL for the total sample may, in turn, have had an impact on the self-rated care satisfaction. Earlier studies have found that dependency on ADL was associated with high self-rated care satisfaction (Townsend & Kosloski 2002, Andersson et al. 2007). In addition, it may be related to low expectations on the provided public care and services. Such relation has been found among older people in a special accommodation in a previous study (Atkinson & Medeiros 2009). The instrument has not been tested for validity and reliability. However, methods have been used to achieve face and content validity by means of a literature review and interviews with older people about qualities regarded as important (Samuelsson et al. 1993).

Self-rated care satisfaction and HRQoL among those living at home compared to those living in a special accommodation

The findings indicate that those receiving public care and services in a special accommodation perceived lower care satisfaction. This was shown in aspects regarding care continuity, personal relation, staff's amount of time and staff being respectful and quiet. Previous studies have shown a high level of self-rated care satisfaction in public care and services at home (Martin-Mathews 1995, Helset 1998) as well as in a special accommodation (Chen 2001, Chesterman et al. 2001, Andersson et al. 2007). However, previous studies looked only at care in nursing homes or only at public care and services at home, without comparisons. In this study, there was no direct relationship between place of living and self-rated care satisfaction. Persons in a special accommodation were more functionally impaired and thus more dependent on help, which in turn was associated with low self-rated care satisfaction. Thus, self-rated care satisfaction seems to be related more to functional impairment and health complaints than to whether public care is received at home or in a special accommodation. It is also worth noting that there was no difference in HRQoL for those receiving public care and services at home as compared to those in a special accommodation. The physical component score (PCS) was below the mean for a general Swedish population (n = 647) in the same age group (34·2 vs. 44·4), while the mental component score (MCS) was above the mean (54·8 vs. 53·7) (Sullivan et al. 1997). Another study including a population 75 years and above (n = 4278) showed the same pattern, PCS mean 37·5 and MCS mean 50·3 (Jakobsson 2007). Thus, the HRQoL was in this study overall lower for the physical component score, which makes sense since this sample consists of people with high dependency whilst the other two samples referred to were mixed in terms of dependency on care. Thus, whilst the findings point at more dissatisfaction among those in a special accommodation, dissatisfaction is not explained by where care and services is provided but rather by the level of dependency.

High self-rated care satisfaction

Overall, the older people seem to be satisfied with public care and services. At home they were most satisfied with characteristics among the staff, such as having a personal relation (91%) and that the staff was friendly (98%), respectful (91%), quiet (91%) and reliable (95%). A previous study showed that staff attitudes or personal relations are of key importance to older people receiving public care and services at home (Edebalk et al. 1995). The staff's reliability and attitudes have been found to be highly valued domains in self-rated care satisfaction for those receiving public home care (Qureshi & Henwood 2000, Sinclair et al. 2000, Francis & Netten 2004). Also, older people living in a special accommodation were most satisfied with personal relations (84%) and that staff was friendly (92%) and reliable (92%). Earlier studies have shown that the staff's attitude and respect plays a central role in determining other aspects of satisfaction in a special accommodation (Chou et al. 2002, Bostick et al. 2006, Berglund 2007). Also, the results showed high self-rated care satisfaction with the staff's ability to give personal care in a special accommodation (85%) as well as at home (87%); in addition, dependency in PADL was positively associated with self-rated care satisfaction. However, it is an open question to decide what should be an acceptable level of self-rated satisfaction. Some items like ability to provide personal care, medical service, respectful and friendly behaviour should perhaps include very few individuals rating low satisfaction since it is an intimate part of the older person's life. Thus, also in these areas, mainly positively rated, there is room for improvement.

Low self-rated care satisfaction

Several aspects of care were rated as moderate or not satisfactory by one-fifth of the respondents or more. This indicates that there are important areas for improvements. Those areas differed highly between those living at home and those living in a special accommodation. The respondents rated their influence over the public care and services as insufficient. A large amount of the older persons were dissatisfied with their influence over the care: at home (30%) as well as in a special accommodation (52%). A previous study by Hellström and Sarvimäki (2007) showed that being dependent on care and services in a special accommodation implied feelings of resignation, not being valued and having no influence. Another study regarding home care showed that receiving public care and services concerned taking charge as well as feelings that things were out of control, resigning and adapting when the care was dissatisfactory (Aronsson 2002). Thus, to improve self-rated care satisfaction, older people being dependent on help need to be supported and empowered by the care system. Such improvements require increased knowledge and competence among the staff, but also continuity of care. Also, the older persons reported dissatisfaction related to lack of time among the staff when providing care, 54% in a special accommodation and 28% at home. This may be due to shortage of resources, but could also be related to how the staff members prioritise their tasks when providing care. Concerning public home care, a previous study reported that the lowest level of satisfaction was reported for time and availability (Samuelsson & Wister 2000). However, another study showed that increased care hours were associated with only a small improvement in self-rated care satisfaction in a special accommodation (Chou et al. 2003). The staff's personal qualities and skills have been graded to be the most important by people receiving public care. However, 22% of those living in a special accommodation stated that the staff was not respectful and quiet enough. This cannot be considered acceptable as previous studies have shown that the staff's attitudes and respect play a central role in determining other aspects of satisfaction in a special accommodation (Chou et al. 2002, Bostick et al. 2006, Berglund 2007). Those living in a special accommodation were also dissatisfied with the staff's ability to give medical (33%) and social service (30%). Of those receiving public care at home, 32% were not satisfied with the staff's ability to do housework. Also dependency in IADL was associated with decreased self-rated care satisfaction. As older persons have been granted to receive public care and services from trained staff, this is a crucial and noteworthy finding, indicating that this is not the case. Earlier studies have shown that people receiving public care at home highly value care which corresponds to their needs and is delivered by staff with suitable knowledge, skills and competence (Raynes et al. 2001, Woodward et al. 2004). It seems like the staff needs improved competence to provide care and service matching the older peoples' needs.

Further, functional impairment and health complaints seem to be associated with low care satisfaction. The results showed that IADL dependency and a number of health complaints were negatively associated with self-rated care satisfaction. This is in line with earlier studies showing that a reduced functional ability and health problems are related to low care satisfaction (Geron et al. 2000, Chesterman et al. 2001). However, in this study there were no differences in HRQoL between those living in a special accommodation and those living at home, despite the fact that those living in a special accommodation were more functionally impaired and had more health complaints. Furthermore, HRQoL was not associated with self-rated care satisfaction, which is in contrast to previous studies that have found self-rated care satisfaction to be positively associated with HRQoL and especially to mental well-being (Pifer et al. 2003, Joseph & Nichols 2007). Although older people receiving public care overall are satisfied with the care and services, there are areas in need of improvements, which may have an impact on self-rated care satisfaction as well as on HRQoL.

Conclusions

The findings concerning the associations between low care satisfaction and health complaints and IADL dependency were confirmed by previous research, while the association between high care satisfaction and PADL dependency was regarded as a new finding. Overall, the care satisfaction was rated higher among older people receiving public care and services at home than among those in a special accommodation. The lower care satisfaction in a special accommodation concerned continuity, timing, the staff's personal characteristics and ability to give service while low care satisfaction at home concerned the staff's ability to carry out housework and providing medical care, amount of time and own influence over the care. HRQoL as well as care satisfaction was related to the older persons' functional ability rather than place of living.

Implications for practice

The study highlights the importance to take functional ability and health complaints into account when measuring care satisfaction in older people receiving public care and services. Older people receiving care in a special accommodation were more dissatisfied with the public care and services compared to those at home. However, dissatisfaction among those in a special accommodation was not explained by where the public care and services was provided, but by impaired functional ability and more health complaints, since those in a special accommodation were frailer. Those findings have to be considered when self-rated care satisfaction is compared between older people receiving public care and services at home and those in a special accommodation. Self-rated care satisfaction was related to functional ability and health complaints. Consequently, an approach using intervention focused on functional ability and health complaints is highly important for development of improved care satisfaction for older people receiving public care and services. As self-rated care satisfaction was highly related to the staff's competence and supportive means, further education for nurses working in municipal care seems essential to improve the care quality for older people.

Acknowledgements

The Swedish National study on Aging and Care, SNAC, (www.snac.org) is financially supported by the Ministry of Health and Social Affairs, Sweden and the participating county councils, municipalities and Lund University. We are grateful to the participants and to the participating counties and municipalities. We acknowledge the support of the KK-stiftelsen (Knowledge Foundation), Johanniterorden (The Swedish Order of St. John), and the insurance company Länsförsäkringar and are most grateful to Emily Jamison Gromark for her revision of the English.

Contributions

Study design: IRH; data collection and analysis: IRH, SK, UJ and manuscript preparation: SK, IRH, A-KE.

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