Aged care residents’ prioritization of care: A mixed‐methods study

Abstract Background Eliciting residents’ priorities for their care is fundamental to delivering person‐centred care in residential aged care facilities (RACFs). Prioritization involves ordering different aspects of care in relation to one another by level of importance. By understanding residents’ priorities, care can be tailored to residents’ needs while considering practical limitations of RACFs. Objectives To investigate aged care residents’ prioritization of care. Design A mixed‐methods study comprising Q methodology and qualitative methods. Setting and participants Thirty‐eight residents living in one of five Australian RACFs. Method Participants completed a card–sorting activity using Q methodology in which they ordered 34 aspects of care on a pre‐defined grid by level of importance. Data were analysed using inverted factor analysis to identify factors representing shared viewpoints. Participants also completed a think‐aloud task, demographic questionnaire, post‐sorting interview and semi‐structured interview. Inductive content analysis of qualitative data was conducted to interpret shared viewpoints and to identify influences on prioritization decision making. Results Four viewpoints on care prioritization were identified through Q methodology: Maintaining a sense of spirituality and self in residential care; information sharing and family involvement; self‐reliance; and timely access to staff member support. Across the participant sample, residents prioritized being treated with respect, the management of medical conditions, and their independence. Inductive content analysis revealed four influences on prioritization decisions: level of dependency; dynamic needs; indifference; and availability of staff. Conclusions Recommendations for providing care that align with residents’ priorities include establishing open communication channels with residents, supporting residents’ independence and enforcing safer staffing ratios.


| Person-centred care
In shifting towards more person-centred approaches to care, service user involvement is increasingly recognized as an essential part of health-care provision. 1 One of the core elements of person-centred care is acknowledging and respecting service users' preferences. 2 Ensuring that service users receive person-centred care is particularly important in residential aged care facilities (RACFs) as contextrelated barriers have the potential to limit residents' involvement in their care. These barriers include organizational factors such as taskoriented care and rigid routines, 3 resident characteristics including cognitive impairment, communication problems and dependency on others, 4,5 and factors associated with the transition into residential living (eg loss of autonomy). 6 Seeking out residents' preferences for their care is a necessary, albeit sometimes challenging, process in facilitating person-centred care.

| Preferences and prioritization
Self-report tools such as the Preferences for Everyday Living Inventory for NH residents (PELI-NH), 7,8 the Resident VIEW 9 and the Minimum Data Set 3.0 Preference Assessment Tool (MDS-PAT) 10,11 have been used to elicit residents' care-related preferences. These types of assessments require residents to rate domains of care by level of importance with no restrictions placed on rankings, that is, residents can rank every item at the highest level of importance. This is a potential limitation of preference assessment tools, as they do not adequately account for the complex, resource-constrained and often pressurized environments of RACFs. 3,12 Assessing residents' priorities can overcome this limitation.
Prioritization of care, by definition, requires determinations about the relative importance of different aspects of care, in light of, for example, environment, circumstances and the availability of resources. In health-care services literature, prioritization refers to ordering care tasks by levels of importance or urgency when available resources are inadequate. 13,14 Although prioritization is primarily associated with health-care workers' delivery of care, it is also a relevant concept for resident populations in terms of establishing and understanding their priorities for their care.

| Rationale
Studies of care prioritization in RACFs have predominately focused on health-care workers' perspectives, 15 and therefore, a knowledge gap persists regarding residents' views. By understanding what and how residents prioritize, policymakers, aged care providers and front-line staff can target improvement efforts to better align care with residents' needs and expectations.

| Objectives
The objective of this study was to investigate aged care residents' prioritization of care. The study had three research questions: 1. What are residents' priorities regarding their care? 2. How do residents prioritize care? 3. What influences aged care residents' prioritization decisions?

| Study design
The research comprised a mixed-method multi-site study involving Q methodology and qualitative methods. It is part of a larger research project exploring the prioritization of care in RACFs. 16

| Sample and setting
Participants were residents living at one of five participating RACFs located in the Australian States of Queensland and New South Wales. The facilities were managed by a single aged care provider. Purposive sampling, a common convention of Q methodology, was used to recruit participants. Recruitment was guided by the following inclusion criteria: willingness and ability to provide informed consent; capacity to participate in an English-language interview; and participation in the study would be unlikely to be burdensome for residents (physically and/or emotionally). Facility managers, care managers and designated staff members identified residents who met the inclusion criteria. Participants were F I G U R E 1 Q sort grid invited to participate in the study through invitation letters delivered face-to-face by the lead researcher or a member of staff. The invitation letters explained that the research formed part of KL's doctoral studies.

| Materials
Materials for the card-sorting activity comprised a set of 34 cards (Q sort deck), each representing an aspect of care, and a forced distribution sorting grid (Q sort Grid) on which participants ordered the cards (Figure 1). 17 The Q sort deck was taken from our related studies of staff and family members' prioritization of care, 16

| Data collection procedure
Participants were first asked to sort the Q sort deck into three piles with regards to their care preferences: Least/less important, Neutral/somewhat important and Most/more important. They used these piles to order the cards on the Q sort grid from 'Least important' (−4) to 'Most important' (+4) in terms of the care they received.
During this activity, participants verbalized their decision making through a think-aloud task. 19,20 Upon completion of the card-sorting activity, participants were given the opportunity to adjust their card-sorting pattern (Q sort). They then completed a post-sorting interview which provided insights into the reasons for participants' placement of cards on the Q sort grid. 21 Participants were given the option of continuing onto the demographic questionnaire and semistructured interview questions immediately after the post-sorting interview or at a later time. The semi-structured interviews provided information about residents' views on prioritization and their experiences of unmet priorities. The first author (KL), who is experienced in conducting interviews with aged care residents, conducted the card-sorting activity and interviews. Participants' responses were audio recorded and transcribed, and photographs of participants' completed Q sorts were taken. KL took field notes at the end of each study session about participants' non-verbal behaviours and their pace/ease of card sorting, as well as any interviewer reflections on patterns in the data.
2.4.1 | Analysis: Q methodology (research questions 1 and 2) Q sort data were analysed using established techniques based on inverted factor analysis. 22,23 Specifically, centroid analysis and varimax rotation were used via PQMethod V. 2.35. 24 This analysis resulted in the identification of factors that represented shared meaning between groups of participants. 25,26 To determine the number of factors retained, the following criteria were used: the factor solution accounted for the greatest amount of variance explained while maximizing the number of Q sorts significantly loading on (ie correlating with) a single factor (factor loading ≥0.48, P < .01); each factor had an eigenvalue greater than 1; and two or more Q sorts significantly loaded on a factor. 25,27 PQMethod was used to produce a representative Q sort for each factor, known as a factor array (S1).
Factor arrays were calculated as a weighted average of Q sorts loading on a particular factor. 26 The viewpoints that factors represented were interpreted and presented as narrative accounts using participant transcripts, field notes, visual representations of factor arrays and crib sheets. 28 Qualitative data were organized using NVivo V.12. 29 Numerical factor array rankings were transformed into colour-coded visual  invited to participate in the study but did not take part due to inability to provide informed consent (n = 5), unavailability (n = 2), illness (n = 1), temporary residency at the facility (n = 1) or no reason given

| Participant demographics
The majority of participants were female (65.8%), 34.2% had been living in their current RACF for 1-3 years, and 73.6% self-rated their health as 'Good' or 'Excellent'. Participants' ages ranged from 72 to 97 years (median = 87.6 years), with the majority aged between 85 and 94 years (60.5%) ( Table 2). Participants represented a variety of residents in terms of mobility, dependency, sensory functioning and medical conditions.

| Four-factor solution
A four-factor solution accounted for 54% of study variance and 31 Q sorts. The other seven Q sorts did not significantly load on any factor. Some of the factors were significantly correlated (Table 3)  cards at the same level of importance across multiple factors, but participants' interpretation of the cards and the reasons for their placement differed between factors.

| Viewpoints
Presented below are narrative accounts of each viewpoint on care prioritization. Single quotations represent card names, followed by factor array ranking in brackets. Single and double asterisks signify distinguishing statements at P < .05 and P < .01, respectively. Participants were in agreement that 'Privacy' (+3*) was important.
Although some said that their privacy was respected, others spoke about feeling disrespected by staff on occasion. The most commonly reported privacy-related problem was staff entering residents' rooms or bathrooms without knocking and waiting for an answer. Participant 15 shared the following: Well some of them, they knock, they push the door and walk in. I told them, "Don't walk in like that," I said.
"Sometimes I'm not dressed." … Once when a fellow did that, I got angry with him. I said, "don't do this … because I am a woman." The majority of participants loading on this viewpoint expressed dissatisfaction with food in terms of 'Nutrition' (+3**), appropriateness for older adults, taste, texture, the way food was prepared and 'Meal choice' (+2). Participants discussed the difficulties they experienced adjusting to the meals provided in RAC.

| Consensus statements
Consensus statements that were non-significant at the P > .01 level (ie cards that did not distinguish between any two factors) included the following: 'Monitoring/Safety', 'Mobility', 'Respect', 'Oral care' and 'Medical condition management'. The latter two were also nonsignificant at the P > .05 level (S1).
Across the four viewpoints, clinical care, particularly management of residents' medical conditions, was a high priority.
Participants explained that their medical conditions often dictated the care that they needed in terms of assistance and medication.
For some, medical management was seen as the primary reason they lived in a RACF. Participants also communicated that respect was a high priority. When asked why respect was important, Participant

| Influences on prioritization decision making
Across all participants, four influences on prioritization decision making were identified. These were labelled: (a) level of dependency; (b) dynamic needs; (c) indifference; and (d) availability of staff.

| Level of dependency
Tasks that could be completed independently, without the assistance of staff members, were often given a lower priority.

| Indifference
Participants sometimes expressed indifference towards some as- They don't spend much time with you because they're busy, busy, busy. When they're chatting with you, somebody will press the buzzer [call bell].
'Call bell' was ranked as either a neutral or high priority across viewpoints. Although some participants said that their call bells were answered immediately, often because it was rare for them to ring their call bell, other participants communicated that they were left waiting.
For some, like Participant 9, 'Call bells' was a high priority because they recognized the urgency of needing help: Well I've had plenty of incidences. You know, they take at least an hour whenever you ring. And it's not good enough, you know, really. You could be dead on the floor.
Other participants acknowledged that staff members were busy attending to other residents who might be in greater need and therefore understood they needed to 'wait their turn'. Some participants also acknowledged that problems generated by inadequate staffing were an organizational or systems issue and not a reflection on front-line staff. On the whole, participants spoke extremely highly of staff members, describing them as 'kind', 'sweet', 'caring', 'friendly', 'patient' and 'supportive'. For example,

| Residents' priorities and prioritization of care
This study explored residents' priorities for their care, how they prioritize care and influences on their prioritization decisions.
Residents were able to identify their priorities and communicate why certain aspects of care were more or less important to them. Residents' prioritization of care was found to be a reflection of their need for assistance, experiences, preferences and views about receiving support from others. While residents' prioritization of care was based on individual circumstances, four overarching viewpoints on prioritization were identified: maintaining a sense of spirituality and self in residential care; information sharing and family involvement; self-reliance; and timely access to support.
Across the four viewpoints, two common priorities emerged: being treated with respect by staff members and the management of medical conditions. Our findings are in accordance with Bangerter et al who found that one of residents' highest preferences for care was staff members showing respect, reflected in staff members' attitudes, communication, professionalism, etiquette, greetings, person-directed care and reciprocity. 33 Our findings also provide some evidence of alignment between residents' and staff members' priorities as 'medical condition management' and 'respect' were also high priorities for the majority of participants in our related study on staff members' prioritization of care. 34 While independence was not identified as a consensus state-  Participants conveyed that staff members appeared busy and rushed due to staffing shortages. We found that perceived lack of staff availability influenced participants' prioritization decisions, particularly in relation to having conversations with staff members and call bells answered in a timely manner. 'Conversations' was often viewed as a lower priority, with residents explaining that staff members were often too busy to engage in meaningful conversation.

| Influences on prioritization decision making
Talking with residents has previously been identified as a commonly reported missed and rushed care activity in Canadian RACFs. 41 Additionally, Meagher et al 39

| Recommendations for policy and practice
In order to deliver care that aligns with residents' priorities, we put forth the following recommendations for policy and practice:

| Strengths and limitations
The study design enabled residents with varying needs to participate in the study, including those with hearing loss, mobility issues, speech impairment, vision impairment and mild cognitive impairment. During the card-sorting activity, cards could be manually sorted by participants or read out and placed on the board by the interviewer. The cards were tailored to meet the needs of older adults: large text was used, they were printed on thick cardboard to avoid skin cuts, and representative images were used to help residents easily identify cards.
The recruitment criteria excluded residents who were unable to give informed consent or those that may have been physically or emotionally burdened by the study. Consequently, the sample was biased towards residents who had higher cognitive capacity and physical health. As Q methodology can be a cognitively demanding tasks, we recommend that future studies include residents with cognitive impairment in studies of care prioritization using survey methods, 49,50 interviews 51 or family proxies. 18,52 Despite this limitation, the sample comprised residents with a variety of needs, self-perceived levels of health, medical conditions and functional abilities. While the sample was limited to a single provider, participants were recruited from five RACFs across two Australian States in an attempt to reduce the influence of environmental context.
Another limitation was that the study captured residents' priorities at a single point in time. Participants acknowledged that their needs were dynamic and were expected to change in the future. To provide a more accurate representation of prioritization, longitudinal studies that map residents' prioritization of care over time are needed.

| CON CLUS IONS
Our study demonstrated that residents meeting the participant in-

ACK N OWLED G EM ENTS
We would like to thank the participating residential aged care facilities for assisting with the identification of eligible participants, as well the residents who participated in the study for welcoming us into their homes and sharing their lived experiences. We would also like to thank Dr Wendy James for her editorial feedback on the manuscript.

CO N FLI C T S O F I NTE R E S T
The authors have no conflicts of interest to declare.

AUTH O R CO NTR I B UTI O N S
KL conceptualised, designed and led the study. KC, VM, LAE and JB contributed to the study design. KL, KC, VM and LAE developed the study materials. KL recruited participants, and collected, analysed, and interpreted data. KC assisted with the interpretation of data. KL drafted the manuscript with all authors contributing to manuscript revisions. All authors approved the final submission.

E TH I C S A PPROVA L A N D I N FO R M E D CO N S E NT
The study was developed in accordance with national ethics guidelines. 17

PATI E NT O R PU B LI C CO NTR I B UTI O N
Individuals who had a parent residing in residential aged care piloted the card-sorting activity to ensure that cards and the care they represented were appropriate for aged care residents in terms of imagery and language.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.