SATISFACTION RELATED ELEMENTS “ '
V _ OFSURROGATE SITUATmNs
' . ASTYPIFIED BY Nuas:Nc HOME |
~ PURCHASE TRANSA£T:0Ns

 

 

_. ... .W , ;;;;

D:ssertat:on for the Degree of Ph D
“ MICHIGAN STATE uva‘Eas:TY f _::; _ ~r ‘
RICHARDW BUCHANAN

1975 ‘v '"  ‘:_7.§,:>2.‘7:A

 

  
 
  

LIBRAR y
Michigan Smm’: E
University

  

This is to certify that the

thesis entitled

Satisfaction Related Elements of

Surrogate Situations as

Typified by Nursing Home Purchase Transactions
presented by
Richard W. Buchanan
has been accepted towards fulfillment

of the requirements for

Ph.D. . Marketing
\ degree ln\

Major professor

Date A ril 21 1975

0-169

 

 

 

5><N

”Y
x l /’ ABSTRACT
. M
{No\}

SATISFACTION RELATED ELEMENTS OF SURROGATE
3 j_\ SITUATIONS AS TYPLIFIED BY NURSING HOME
kJ/’, PURCHASE TRANSACTIONS

By

Richard N. Buchanan

This work constituted exploratory research into some
origins of dissatisfaction regarding nursing homes. Its distin-
guishing features was that, unlike some other research into nursing
homes, its emphasis was not upon situations involving callous
neglect. Instead, it started with the premise that neglect, alone,
might not be the source of the seemingly universal displeasure with
nursing homes.

This approach was taken after a through analysis revealed
that most patients admitted to nursing homes do not participate in
(and in some cases actively resist) the decision to place them in a
home. They are placed there by others (children, relatives, etc.)
who are known as sponsors. These sponsors negotiate initial admit-
tance and frequently monitor the care provided throughout the
patient's stay. Accordingly, the purchase of long term nursing care
represents a surrogate situation in which one party makes a purchase
on the behalf of another who consumes it. In order for satisfaction

to result from such a purchase, both groups, consumers and surrogates,

Richard N. Buchanan

must be seeking to serve the same set of needs. Further analysis
indicated that patient needs and sponsor needs frequently conflicted
and resulted in nursing homes having to ”choose sides" in situations
which would, by definition, leave someone unhappy. Further discord
(and attendant dissatisfaction) was felt likely to stem from con-
flicts between nursing home administrators and the patients/sponsors
they served. Nursing home administrators seemed to feel that their
position as "almost doctors” justified any actions taken for medical
reasons despite the feelings expressed by patients and/or sponsors
about those actions. In light of all of these factors the following
guiding hypothesis was felt justified.

HI Guiding Marketers of long term nursing care seeking

to provide services to patients who have
interested sponsors are faced with a surro-
gate purchase situation containing conflicting
sets of needs. Among these needs are those of
the sponsor, those of the patient, and those
of the marketing organization. Conflicts
resulting in the failure to serve the needs

of the patient, his sponsor, or both are a
major contributor of dissatisfaction among
patients and sponsors that is more or less
inevitable.

Surrogate situations under conditions of conflicting needs
have not been researched previously in a consumer setting, and have
only obliquely been mentioned in industrial marketing literature.
The nursing home market was thought to represent an ideal laboratory
for research into the broader aspects of surrogate situations due to
the intensity of emotion surrounding the purchase and the geographi-

cal concentration of the surrogates and consumers involved. The

author's interests in surrogate situations concentrated in the

 

Richard N. Buchanan

following areas; (l) how do marketers faced with surrogate situations

involving conflicting sets of needs formulate market policy, (2) if

marketers ”take sides,” do the consumers and surrogates perceive it,

and (3) if marketers do "take sides," do the favored/(unfavored)

parties express more/(less) satisfaction with the purchase involved?

Accordingly, the author developed the following guiding hypotheses

and research hypotheses:

H Guid-

Marketers faced with H

Nursing homes faced

II ing need conflicts formulate 2 with need conflicts
market policy on the formulate market policy
base of their org's. according to their own
need structure. need structure.

HIII Guid- Marketer orientation H3 Consistent nursing
ing consistently favoring home orientation to
consumers or surrogates patients or sponsors
is perceived by both is perceived by both
groups. groups.
HIV Guid- The groups not favored H4 Groups not favored
ing by marketer orientation express more dissatis-

will express dissatis-
faction if favoritism is
perceived as unfair.

faction than favored
groups.

The preceding hypotheses were researched within a sample
consisting of the 257 member homes of the Health Care Association of
Michigan (a professional organization of nursing home administrators).
The subject administrators were mailed a questionnaire which probed
the need structure of their homes and asked them to resolve small
case problems representing conflict situations between patients and
sponsors or administrators and patients/sponsors. (i.e., two
residents of a nursing home have fallen in love and the sponsor of
one of them demands you ”break it up“——would you?) By studying the

responses to these cases, the basic orientation of the home (towards

Richard N. Buchanan

patients, sponsors, etc.) could be identified, measured, and analyzed.
Seventy—six percent of the sample responded.

From the respondents six of the most patient-oriented and
five of the most sponsor-oriented homes were chosen for further
analysis. These homes supplied relatively equal samples of patients
and sponsors who were studied still further.

A total of sixty-five patients were administered personal
interviews by an independent market research agency in an attempt to
measure patient satisfaction. The basic format of the interview
utilized was similar to that developed by Allen Pincus, a University
of Wisconsin sociologist.

Phone interviews with sixty-one sponsors were conducted
by the same independent agency in order to measure sponsor satisfac-
tion. The telephone interview was based upon a patient questionnaire
developed by Barbara Tomlinson of the Ann Arbor Institute of
Gerontology.

Although none of the samples were random samples, a Mann-
whitney U test was administered to all comparisons made in order to
indicate the relative importance of any differentials manifested.

Support was found for H2 (linking need structure and
orientation), and further analysis implied that the generalizations
of HII might be tenable.

Support was not found for H3. The directional emphasis of
the data did indicate perception of nursing home orientation, but
the differences manifested were not statistically significant at the

.10 level. Accordingly, the generalization of HIII could not be made.

Richard N. Buchanan

Likewise, support was not found for H4. Even though the
data conformed to the hypothesized directions of greater satisfac-
tion for groups favored by nursing home orientation, the differences
manifested were not significant at the .lO level. Once again, no
generalization like that posited by HIV was possible.

Due to the failure to find support for H3 and H4, HI could
not be supported. Conflict between patients and sponsors clearly
was ngt_a major source of dissatisfaction regarding nursing homes.

One of the reasons for the author's failure to find con—
clusive support for the above hypotheses was felt to be the relative
insensitivity (and highly subjective nature) of the instruments
utilized. The author did feel that the satisfaction related ramifi-
cations of conflict hinted at by his findings did indicate that
further research into elements of satisfaction produced by conflict

resolution might be warranted both within and without nursing homes.

 

SATISFACTION RELATED ELEMENTS OF SURROGATE
SITUATIONS AS TYPIFIED BY NURSING HOME
PURCHASE TRANSACTIONS

By

Richard N. Buchanan

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
Department of Marketing

1975

 

To Grandmother Buchanan

:1

ACKNOWLEDGMENTS

Let all who read this work know one fact with certainty--a
dissertation does not have to be a totally unpleasant experience.
Prior to beginning, the author was prepared by his peers for an
ordeal roughly approximating the Spanish Inquisition. At each step
he was prepared for a host of inequities and indignities that never
materialized. On the contrary, the author found his own experience
to be largely positive.

Though not particularly anxious to test this hypothesis
by repeating the experience, the author believes the main reason
for his positive feelings is the uniquely productive treatment
extended him by his committee. While far from being ”easy,” they
always remembered to place their emphasis on jflstruction (and not
gbstruction). Their demands were never unreasonable, and almost
always made significant improvements in the finished product. Their
encouragement and willingness to be ”on call“ (even at odd hours of
what should have been their personal time) continually amazed the
author and his negative—thinking peers. The author knows full well
how exceptional they were, and wishes to express his gratitude to
them.

So, to Dr. Stanley Hollander, go the author's deepest
thanks for the helpful guidance and personal attention which never

stopped despite times that must have been very difficult for him.

The author is indebted to Dr. Frank Bacon for his many
contributions to this project's structure and implementation.

Dr. Gerald Miller is owed a debt of gratitude for his
encouragement and insights into the science of communication.

Beyond the author's committee, there exist a host of
other individuals whose contributions to this project must be
recognized.

First among these is Mr. Harold Creal, president of the
American College of Nursing Home Administrators. Without Mr. Creal's
support this project could never have been undertaken. Without him
the author could never have secured the assistance of the American
College of Nursing Home Administrators and the Health Care Associa-
tion of Michigan, two groups who figured so strongly in this research.

To these two groups, their members and officers (particu-
larly Mr. Chuck Harmon and Mr. Ralph Schmuckle of HCAM) go the
author's sincerest regards for their generous support of his efforts.

The author wishes to express his appreciation to Mr. Sam
Anema of the Western Michigan University computer center who helped
unravel the mysteries of the computer (while adding a few of his
own!!)

Finally, I wish to thank my wife, Margaret, for being under-
standing while coping with the various pre—occupations, mood changes,

and absences prompted by this research.

iv

TABLE OF CONTENTS

Page
LIST OF TABLES . . .............. . . ...... viii
LIST OF FIGURES . . . . . . . . . ....... . . . . . . . x
Chapter
I. INTRODUCTION ..................... l
The beginnings ............ . ..... l
The aged . . . ......... . . . . . . . . . 5
The nursing home industry ...... . . . . . . . 9
The nursing home market .............. 13
The health care process .............. 21
The purchasers of nursing care .......... 26
The market for long term nursing care . . . . . . . 30
The role of private pay sponsors . . . . . . . . . 33
Surrogate purchase situations ........... 35
Beyond Kotler/Rewoldt ............ 48
Nursing homes as a laboratory for the study
of surrogate purchase situations involv-
ing conflicting need structures ........ 52
Determining market behavior in a surrogate
purchase situation under conditions of
conflicting needs ......... . . . . . 54
The perception of marketer orientation in
a surrogate purchase situation involving
conflicting needs .......... . . . 6l
Satisfaction emanating from marketer orienta-
tion in a surrogate market situation under
conditions of conflicting needs . . . . . . . . 64
II. METHODOLOGY . . . . . . . . . . . ..... . . . . . 7l
The sample . ............ . . . 75
Identification of nursing homes' orientations
and need structures . . . ........... 78

The testing and comparing of patient/sponsor
reactions to different nursing home
orientations . . . . . . . . . . . . . . . . . . 89

Chapter

III.

IV.

Choosing a sample of patient/sponsor-
oriented nursing homes . . .....
Developing a sample of patients and

Sponsors 0 0 ........ O O O O O 0

An instrument for assessing patient
response to nursing home orientation
Assessing sponsor response to nursing

home orientation . . . . . . . . . .

Application of patient/sponsor measures

to the research sample .......
Analytical techniques employed . . . .
Methodological limitations ......
FINDINGS AND ANALYSIS ..........
Introduction .............
Summary of findings ..........
Questionnaire response . . .

Assessment of questionnaire validity .
The existence of variation in marketer-
orientation choice .........
Detailed findings relative to HZA-l . .
Detailed findings relative to HZA-Z . .
Detailed findings relative to H . . .
Comparative co-operation of patignt-
oriented and sponsor-oriented homes

Page

...... 92
. . . . . 95
...... 98

...... ll4
...... ll6

...... l3l
...... 131
...... I32
...... l32

Detailed findings regarding patient/sponsor
perception of nursing home orientation

and H

H3? . 38 o o o o t o o o. .
DetaT ed an Tngs regarding patient satis-

. . . . . . I40

faction produced by nursing home orienta-

tion H A o o o oooooooo o o o o o o o o o 142
Detailed findings regarding sponsor satis-
faction produced by nursing home orienta-
tion (H48) oooooo o o o o o o o o ooooo 145
CONCLUSIONS, INSIGHTS, AND RECOMMENDATIONS ...... 147
Introduction . . . ..... . . . o . . . . . . . 147
Summary of conclusions . . . . . . . . . . . . . . I49
Variation in nursing home orientation choice . . . l50

Orientation variation in non-nursing home

surrogate situations ..... . . .

Conclusions about orientation choice and
nursing home need structure . . . . .

Orientation choice in non-nursing home
surrogate situations . . . . . . . .

. o . . . . 150
. . . . . ISI
0 ..... 152

Conclusions about patient/sponsor perception

of orientation choice

nursing home settings . . . . . . .

vi

00000 O 0 O O 0 O 0 O 153
Perception of orientation choice in non-

...... 154

Chapter Page

Conclusions regarding patient/sponsor satis-

faction resulting from orientation choice . . . . 156
Satisfaction emanating from orientation

choice in non-nursing home settings . . . . . . . 157
Conclusions about the true source of dissatis—

faction with nursing care . . . . . . ...... 160
Insights/recommendations for further research . . . 162

Appendices

A Interviews With Officers of Michigan Chapter of
American College of Nursing Home Administrators

(ACNHA) . . .................... 168
B Pretest Administrator Questionnaire .......... 169
C Final Administrator Questionnaire (Medicaid Version) . 176
D Final Administrator Questionnaire (Private-Pay
Version) . ................ . . . . . 180
E Initial Cover Letter ................. 184
F Reminder Letter .................... 185
G Patient Interview Format ............... 186
H Rating Scale for Gratification from the Home
Environment (GH) .................. 188
I Sponsor Telephone Interview .............. 189
J Patron Letter ....... . . . . . . . . . o . . . . 190
K Interviewer Instructions ...... . ........ 191
L Letter of Introduction ................ 193
M Statistical Techniques Employed .......... . . 194
BIBLIOGRAPHY ........... . ............. 199

vii

LIST OF TABLES

Table Page

l Percentage Change in U.S. Population by Age
Segment . . . ........ . . . . . . ...... 8

2 Physical/Mental Conditions of Patients in
Nursing Homes . . . . . . . . . . . . . . ..... . 25

3 Persons Responsible for Admission to a Nursing
Home . . . . . ...... . . . . . . . . . . . . . 28

4 Nursing Home Visitors by Revenue Contributed
by Patient ............ . . . . . . . . . 35

5 Results of Administrator Questionnaire Pre-Test . . . . 85

6 Administrator Questionnaire Response by Orienta-
tion and Patient Identification . . . . . ...... 118

7 Total Response to Patient vs. Sponsor Conflicts
by Patient Identification . . . . . . . . . . . . . . 120

8 Total Response to Administrator vs. Patient and/or
Sponsor Conflicts by Patient Identification . . . . . 122

9 Response to Administrator vs. Patient and/or
Sponsor Conflicts by Patient Identification--
Administrator Commitment to Health Care
Professional Role Held Constant . . . . . ...... 125

10 Response to Administrator vs. Patient and/or
Sponsor Conflicts by Administrator Commitment
to the Health Care Professional Role--Patient
Identification Held Constant . . . . . . . . . . . . 127

11 Response to Patient vs. Sponsor Conflicts by
Patient Identification Combined with Adminis-
trator Commitment to Profit--Extreme Cases Only . . . 133

12 Response to Administrator vs. Patient and/or
Sponsor Conflicts by Patient Identification
Combined with Administrator Commitment to
Health Care Professional Role--Extreme Cases Only . . 136

viii

Table

13

14

15
16

Comparative Response of Patient-Oriented and
Sponsor-Oriented Homes to HCAM Request for
Co-Operation in Research Project . . . . . . . .

Patient/Sponsor Perception of Nursing Home
Orientation .......... . . . .......

Patient Satisfaction by Nursing Home Orientation . . .

Elements of Sponsor Satisfaction with Nursing
Care by Nursing Home Orientation ..........

ix

Page

139

141
144

146

Figure

1.1
1.2

1.3
1.4
1.5
2.1
2.2

4.1

LIST OF FIGURES

Page
The Health Care Process ............ . . . . 22
Assumed Patient/Sponsor Needs Served by Nursing
Care . . . . . . . . . . . . ..... . . ..... 39
Goal Conflict in a Surrogate Purchase Situation . . . . 42
Need Conflict in a Nursing Home Purchase Situation . . 47
Need Conflict in a Surrogate Purchase Situation . . . . 50
Research Structure .................. 72
Research Structure and Administrator Question-
naire Development ........... . ..... 80
Summary of Conclusions .......... . ..... 148

CHAPTER I

INTRODUCTION

This work chronicles exploratory research into some
elements of dissatisfaction with nursing homes. Its distinguishing
feature is that, unlike other research into nursing homes, it does
not emphasize situations in which the dissatisfaction stems from
callous neglect of the homes' patients.

Chapter I shall deal with the analytical framework that
shaped the author's research. Chapter 11 shall detail the methodo-
logical considerations suggested by that analysis. Chapter III
will present the findings of the research, and Chapter IV shall set
forth the conclusions and recommendations emanating from those
findings. As shall be discussed more thoroughly later, the topic
areas covered in this study do not appear to have been researched
extensively in the past. For this reason, no single ”literature
search” section shall be presented. Instead, appropriate prior
works shall be identified and analyzed as the subject areas to which

they relate are covered.

The beginnings

 

The beginnings of the author's interests in nursing homes
are traceable to a time when a favorite grandparent (to whom this

work is dedicated) spent the last two years of her life in such a

place. The author can remember no unhappier period for him or his
family. Quite literally, nothing that took place during these two
years seemed to produce anything but unhappiness and conflict for
those involved.

Informal discussions with others in similar circumstances
prompted the realization that this was far from being a unique
experience. Indeed, it seemed that few who spoke with the author
about their contacts with nursing homes had anything good to say
about them. Subsequent research into the ”popular press“ treatment
of nursing homes revealed that this theme of dissatisfaction was a
common one.1 However, in reviewing the circumstances of his own
experience with nursing homes, the author could not agree with such
critics. Unlike them, he could not honestly say that his negative
feelings were the result of ” . . . cynical exploitations . . .” of
“ . the commercially-operated nursing homes and corporation-owned
hospitals that have sprung up to take advantage of Medicare.”2 When
being totally objective the author had to conclude that the nursing

home and staff serving his family honestly were striving to do the

 

lSee Claire Townsend, Old Age: The Last Segregation, Ralph

 

Nader's Study Group Report on Nursing Homes (New York: Grossman
Publishers, 1971); Mary Mendelson, Tender Loving Greed (New York:
Alfred A. Knopf, 1974); and Susan Jacoby, ”Waiting for the End: On
Nursing Homes," New York Times, March 31, 1974, p. 5.

 

 

2Sidney Margolis, "The Older Consumer as a Force in the
Marketplace,“ The Aging Consumer. Papers from the 22nd Annual Con-
ference on Aging (Ann Arbor: Institute of Gerontology, 1969), p. l.

 

best they could. When he objectively investigated some of the
"horror stories” told him by friends, he frequently found these
tales the result of actions that seemed in the best interests of
all.

This was not to say that the author felt that the nursing
home industry was without corruption. Rather, the impression was
that the "callous exploitation” he could find connected to those
experiences he investigated did not seem to justify the negative
feelings he and his friends felt toward the nursing home industry.

The author was intrigued by these feelings of dissatis-
faction without apparent justification. Although he realized they
could be isolated manifestations, his suspicions to the contrary
were strengthened by the current climate of public/governmental
attention to nursing home operations.

As might be expected, public disdain for nursing homes
was generating a great deal of legislative attention to the
industry.3 This attention was resulting in ever more strict regula—

tion.4 Logically, this increased governmental presence should have

 

3See U.S., Congress, Senate, Special Committee on Aging,
Hearings Before the Subcommittee on Long Term Care of the Special
Committee on A in , parts 1-15 (Washington: U.S. Government Print-
ing Office, 1971); Comptroller General of the United States, Report
to the Congress, Continuing Problems in Providing Nursing Home Care

and Prescribed Drugs Under the Medicaid Program in California
(Washington: U.S. Government Printing Office, 1970).

 

 

 

4Jonathan Spivak, ”HEW Plans to Issue Regulations to Improve
Safety and Medical Care at Nursing Homes,“ Wall Street Journal,
January 14, 1974, p. 8.

directly eliminated some callous exploitation and indirectly
limited other abuses due to the intimidation of nursing home
operators fearful of even more restrictive measures. However,
the amount of abuse directed at the industry was trending upward,
not downward (as should have been the case if it stemmed from
callous neglect alone).

This indicated that neglect, alone, might not be the
source of all the dissatisfaction directed toward the nursing home
industry and hinted at the presence of some hidden causes of
dissatisfaction not previously researched. If such were the case,
the industry was suffering unjustly from public opinion and legis-
lative action that could not be in its best interests. The chance
of correcting this injustice was interesting enough, but the
possibility of isolating these hidden factors was doubly exciting.
If hidden sources of dissatisfaction could be found, the unhappiness
associated with them might be capable of control or reduction and
this was particularly interesting to the author. So it was that
the author decided to conduct exploratory research into the causes
of dissatisfaction with nursing home purchases. He realized that
his resource limitations might preclude definitive determination of
all the satisfaction related elements. However, he did hope to develop
strong indicators of where the potential problem(s) might lie so that

subsequent research would be provided with appropriate direction.

The Aged

A logical starting point for any discussion of nursing
homes is an analysis of the aged who are the major consumers of
nursing home services.5 However, definition of ”the aged“ is
somewhat difficult. At least one author recognizes that anyone
over the age of 60 could be considered to have attained ”old age,"6
while others do not consider anyone under 75 as having reached that
stage of life.7 As it is with so many categorizations, the choice
of limits defining ”old age“ must be somewhat arbitrary.

For his purposes, the author chose to define the aged as
anyone who had attained or passed their sixty—fifth birthday--

agreeing with Sheldon that this “lower limit is sanctioned by

tradition and by legislation relating to retirement."8

 

5Division of Health Insurance Studies, Office of Research
and Statistics, Social Security Administration, Estimated Personal
Hgalth Care Expenditures by Type of Expenditure and Source of Funds
for Three Age Groups, Fiscal Years 1970-1972, cited in ANHA Facts in
Brief (Washington: American Nursing Home Association, 1972), p. 42

 

6Henry Sheldon, ”The Changing Demographic Profile,“ Hand-
book of Social Gerontology, ed. by Clark Tibbits (Chicago: University
of Chicago Press, 1960), p. 28.

 

 

7Herman B. Brotman, Who Are the Aged: A ngpgraphic View
(Ann Arbor: Institute of Gerontology, 1968), p. 2.

 

8Sheldon, p. 28.

Defined in this manner the aged currently constitute
approximately 9.8 per cent of the total United States population.9
Since 1900 this over-65 segment has grown more than twice as fast
as the rest of the population10 and is expected to constitute be-

tween 9 and 11 per cent of the total population by 1990.H

Although
these statistics portray a relatively important total aged segment
both now and in the future, what is taking place within this seg-
ment is even more meaningful for anyone studying the importance of
nursing homes.

Currently, less than 5 per cent of the total aged popu-
lation (i.e., about .5 per cent of the total population) resides

in "institutions.”12

Unfortunately, this ”institution“ figure is
a composite of jails, hospitals, homes for the aged, nursing homes,
etc., and the figures delineating all the sub—totals within these
classifications for the 1970 census are not yet available. However,

some approximation of the relative make-up of this ”institutional”

category may be derived from other sources. As of 1969 approximately

 

9U.S., Bureau of the Census, Current Population Reports,
Series P-23, No. 43, "Some Demographic Aspects of Aging in the United

States” (Washington: U.S. Government Printing Office, 1973), p. 5.

10U.S., Office of Human Development, Administration on Aging,
Nem Facts About Older Americans (Washington: DHEW, 1973), p. 1

 

HU.S., Bureau of the Census, We the American Elderly
(Washington: U.S. Government Printing Office, 1973), p. 14.

12U.S., Bureau of the Census, Current Population Reports,
p. 27.

four individuals per thousand (.4 per cent of the total population)

"'3 Of those individuals

resided in "nursing and personal care homes.
within "nursing and personal care homes,” over 95 per cent resided

in homes offering some degree of nursing care.14 As shall be dis-
cussed later, the definition of a "nursing home” presents many
problems, but proceeding at this point with a definition requiring
only an institution offering some degree of nursing care, it appears
that residents of nursing homes constitute somewhat less than .4

per cent of the total population (i.e., .95 x .4 per cent).

Although the population residing within nursing homes is
relatively small, it may be expected to grow in size. Despite
advances in medical technology the maximum age at death has not
greatly increased, but the number of Americans attaining the advanced

stages of old age has.15

This phenomena has led to the population
trends depicted on the following page. This evidence of a rapid
growth rate for the older members of the aged population is particu-

larly significant, for the rate of institutional residence increases

 

13U.S., Department of Health, Education, and Welfare,
Characteristics of Residents in Nursing and Persopel Care Homes
(Rockville, Md.: National Center for Health Statistics, 1973),
p. 5

 

 

141b:d., p. 6.

15Ewald Busse, “The Modern Challenge of Threescore and
Ten," Journal of the American Geriatrics Society, XVII (September,
1969), p. 889.

 

rapidly for those 75 or older.16 Assuming that these older aged
segments continue to grow in size, it would seem likely that the
relative number of individuals residing within nursing homes might

also increase in the years ahead.

TABLE 1

PERCENTAGE CHANGE IN U.S. POPULATION
BY AGE SEGMENT

 

Per Cent Change
9

 

Age 1960-6
All ages +12.9
Under 5 -ll.6

5 - 24 +27.6
25 — 44 + 1.7
45 - 64 +l4.7
65+ +17.6

65 — 69 + 8.5
70 - 74 + 8.9
75 — 79 +28.2
8O — 84 +46.3
85+ +38.8

 

Source: Herman Brotman, The Older Population: Some Facts We Should
Know (Washington: U.S. Government Printing Office, 1970),
p. 3.
In light of the preceding analysis, the author felt that the

aged population residing within nursing homes merited further study.

This market's manageable size and likelihood of continued growth made

 

16U.S., Bureau of the Census, Current Population Reports,

it an attractive candidate for research both now and in the future.
Its human importance to those involved with long term nursing care
also impressed the author, and shaped his decision to further study

the specifics of the nursing home industry.

The nursing home industry

Developing background statistics for the total U.S. nurs-
ing home industry represents a definition problem every bit as
difficult as that surrounding ”the aged." The exact definition of
what is, and is not, a “nursing home” varies greatly from state to
state.17 Perhaps due to these difficulties the major resource
agency for statistics regarding nursing homes, the National Center
for Health Statistics, does not explicitly define the term “nursing
homes.” Instead this agency groups data concerning such facilities
into four loose categories: Nursing Care, Personal Care Homes with
Nursing, Personal Care Homes without Nursing, and Domiciliary Care.
Using these rough definitions there were, in 1971, a total of
22,538 such “nursing care and related homes“ in the U.S.18

The aforementioned heterogeneity of ”nursing homes"

definitions across state lines troubled the author. Although his

study would probe satisfaction issues universal to all nursing homes,

 

17Jordan Braverman, Nursing Home Standards . . . A Tragic
Dilemma in American Health (Washington: American Pharmaceutical

Association, 1970 , p. 1.

18U.S., Department of Health, Education, and Welfare, Health
Resources Statistics, 1972-73 (Rockville, Md.: National Center for
Health Statistics, 1973), p. 385.

10

the mechanical problems associated with sampling potentially diverse

populations indicated some definitional uniformity would be desirable.

Therefore, the scope of this study was limited to nursing homes

within the state of Michigan. This decision guaranteed some homo-

geneity for the institutions to be studied, and fell well within

the resource constraints of this, the author's, doctoral dissertation.
Changing the focus of analysis to the state level greatly

improves the definition of the term ”nursing home.“ Within the

state of Michigan a nursing home is defined as ”an establishment or

institution other than a hospital having as one of its functions the

rendering of healing, curing, or nursing care for periods of more

than 24 hours to individuals afflicted with illness, injury, infirmity,

or abnormality.”19 I
Using this definition, there were 338 nursing homes in

20 This same classification also included

Michigan with 35,311 beds.

County Medical Care Facilities and Hospital Longterm Care units.
The Medical Care Facilities and Hospital Units provide

approximately the same care as nursing homes, but are operated by

county governments and independent hospitals respectively.

 

19Bureau of Health Facilities, February 1974 Directory of
Hospitals, Nursing Care Facilities, and Homes for the Aged (Lansing:
Michigan Department of Public Health, 1974), p. 13.

 

 

201bid., p. :3.

11

In 1974 there were 39 county medical care facilities
(4,301 beds) and 28 hospital longterm care units (2,349 beds).21
Due to similarity in function of these units as well as a desire
to build the total research population as much as possible, the
author included these last two institutions within the scope of
his study.

At this point it should be mentioned that one institu-
tional classification, homes for the aged, serves a population
similar to that of nursing homes. In Michigan, a ”home for the
aged" is defined as follows:

. an establishment or institution other than a hospital,

hotel, or nursing home which provides room and board to
non- -transient unemployed individuals 65 yrs. of age or older.
Generally speaking, their purpose is to provide supervised
personal care for elderly persons who do not need organized
nursing care.2
Because homes for the aged do not provide any nursing care, the
author decided to exclude them from the main focus of his research
except for those cases involving nursing homes licensed both as a
"nursing home“ and as a ”home for the aged.” Given the relatively
small number of homes for the aged (119 homes with 7,680 beds)23

the author saw no harm in such an exclusion.

 

2'1b:d., p. 13.

221bid., p. 33.

231:31:11., p. 33.

12

Within the Michigan classification of “nursing homes”

there exist three different types of homes: intermediate care

facilities, skilled nursing homes, and extended care facilities.24

These facilities are defined as follows:

An intermediate care facility is for people who need some
nursing supervision in addition to help with eating, dress—
ing, walking, or other personal needs. Medicaid programs in
some states pay for intermediate care but Medicare never does.

A skilled nursing home is staffed to make round-the-clock
nursing services available to residents sick enough to require
them. Medicaid programs in all states pay for skilled nurs-
ing home care if a physician says such care is needed.

An extended care facility also provides round-the-clock nurs-
ing services as an extension of hospital care. Medicaid
programs do not apply here. Medicare pays for up to 100 days
only if patients have spent at least three days in a hospital
and extended care is recommended by a physician. 5

At least some of the preceding definitions are now academic
and were included only to provide greater clarity for any reader
familiar with the industry. As of January, 1973, the two home

classifications, ”extended care facilities“ and “skilled care

facilities," were merged into a common federal definition, "skilled

26

nursing facility,“ but this new term has not yet attained widespread

 

24U.S., Department of Health, Education, and Welfare, Nurs-
ipg_Home Care, Consumer Information Series #2 (Washington: U.S.
Government Printing Office, 1972), p. 5.

251bid., p. 5.

26U.S., Congress, Senate, Committee on Finance and U.S.,
House of Representatives, Committee on Ways and Means, Summary of
Social Security Amendments of 1972, Public Law 92-603 (Washington:
U.S. Government Printing Office, 1972), p. 15.

13

usage. For his part, the author included nursing homes which fit
any of the preceding definitions within the scope of his inquiry.

At this point in his background analysis the author
decided that the total number of nursing homes within the state of
Michigan was an interesting population of reasonable research size.
So it was that he continued to pursue this topic and next turned

his attention to the market represented by nursing home consumers.

The nursing home market

 

The expenditure of funds for nursing home care constitutes
a sizeable market. For calendar year 1972 it has been estimated that
a total of over three billion dollars was spent for aged nursing
home care in the United States.27 Broken out on an individual basis
the expenditures for aged nursing home care are even more significant.

As of 1969 the average monthly charge for nursing home
care in the United States was $328.28 Given current rates of infla-
tion, it seems highly possible that this 1969 figure is understated.
Although more current statistics are not available, some reasonable

approximation may be developed from existing sources.

 

27Administration in ANHA Facts in Brief (Washington:
American Nursing Home Association, 1973), p. 4.

28U.S., Department of Health, Education, and Welfare,
Charges for Care and Sources of Payment for Residents in Nursing
Homes (Rockville, Md.: National Center for Health Statistics, 1973),
p. 3.

 

 

14

Currently, the maximum reimbursable rate for aged nursing

29 As

care under the Michigan Medicaid program is $21.35 per day.
shall be discussed more thoroughly later, this sum is probably some-
what less than the average selling price per day, but may be utilized
as a good estimate for current nursing home fees. Using this figure,
the average monthly charge for aged nursing care is approximately
$640.00($21.35 x 30). This sum becomes still more significant in
light of the fact that most aged residents of Michigan nursing homes

stay for an average of 2.1 years.30

Thus, an average purchase of
nursing care within the state of Michigan represents an eventual

expenditure of over sixteen thousand dollars ($640 x 12 x 2.1).

Given the magnitude of this purchase and the public
interest in it, it seemed a likely candidate for extensive business
research. However, the author's literature search indicated that
such was not the case.

The author's first step, an intensive search through the

index of Dissertation Abstracts from its inception to the present,

 

yielded only four works related to the business aspects of nursing

home care.

 

29State of Michigan, Medical Assistance Progrem Bulletin
No. B—3 (Revised Reimbursement Rates) (Lansing: Department of
Social Services, 1974 .

 

 

3OJane Barney, Patients in Michigan's Nursing Homes (Ann
Arbor: Institute of Gerontology, 1973), p. 69.

 

15

In “The Nursing Home Industry in Washington State,”31

John Trainor attempted to research some economic aspects of the
nursing home market. But, assessing the contributions of his
research was extremely difficult. It proposed no finite hypotheses
and utilized mostly unstructured interviews with nursing home
administrators as its major research tool. Because these inter-
views proceeded without direction or uniformity, few general con-
clusions about nursing home care could be drawn from this work.
Trainor did mention that these operators were aware of a ”bad
image" attached to the nursing home industry, but did not attempt
to research its underlying causes.

Both ”The Effect of the Introduction of Medical Assistance
and Medicare on the Structure of the Michigan Nursing Home Industry,"

32

by L. A. Bair and “The Effect of Medicare and Medicaid on the

Supply and Demand Conditions of Nursing Homes,” by L. H. Henry33
dealt with macro economic dimensions of the market for nursing homes.
As such, they made few contributions to the micro dimensions of

purchase satisfaction of interest to the author.

 

3lJohn Trainor, I'The Nursing Home Industry in Washington
State” (unpublished Ph.D. dissertation, Washington State University,
1970).

32L. A. Bair, ”The Effect of the Introduction of Medical
Assistance and Medicare on the Structure of the Michigan Nursing
Home Industry" (unpublished Ph.D. dissertation, Michigan State
University, 1973).

33L. H. Henry, ”The Effect of Medicare and Medicaid on
the Supply and Demand Conditions of Nursing Homes" (unpublished
Ph.D. dissertation, Notre Dame, 1970).

16

Only one dissertation, Frederick Miller's "An Analysis

”34 concerned

of the Marketing Strategy of Florida Nursing Homes,
itself with issues of home marketing in a form directly relevant
to the author's interests. Using a survey mailed to administrators,
Miller derived a large amount of background information pertinent
to the marketing of nursing homes. However, given the choice of
his technique, Miller could not delve beyond the rather one-sided
purview of his sample. As such, he did not touch directly upon
the issues of purchase satisfaction. Interestingly enough,
Miller defended his choice of research technique by stating the
following:
A major restriction was the limited amount of secondary
materials available. Published information on nursing
homes is primarily on medical and other technical aspects.
Marketing receives only limited attention in nursing home
journals. The main source of information for this project
was primary research on nursing homes in Florida.

Due to state-to-state differences between nursing homes,
the author recognized that any attempt to generalize from others'
data for his own purposes represented some risks. However, as the
paucity of secondary data noted by Miller would prove to be re—

flected by his own literature search, he eventually accepted such

risks as justifiable.

 

34Frederick Miller, "An Analysis of the Marketing Strategy
of Florida Nursing Homes” (unpublished Ph.D. dissertation, Louisiana
State University, 1970).

35Miller, p. :2.

17

Having exhausted available business dissertations,
attention was next focused upon other business sources of secondary
data. This step proved even less satisfying than the first.

A review of the Journal of Marketing and the Journal of

 

Marketing Research for the past five years yielded no articles
about the marketing of nursing home care. A search through
Business Periodicals Index from 1969 to the present uncovered a
number of articles related to nursing homes in general, but none
devoted to unbiased research into the satisfaction issues of
interest to this project.

Finding so little material related to the business aspects
of nursing homes, the author next turned his inquiry toward similar

topics in related fields. A search through Dissertation Abstracts

 

since its inception and Sociological Abstracts since 1969 yielded

 

three works in the sociology discipline at least obliquely related
to nursing home satisfaction. As all three of these dissertations
dealt with homes for the aged, a classification already excluded
from the author's research focus, their relevance was somewhat
diluted. However, as shall be explained later, the plan was to
deal with the purchase satisfactions of nursing home residents who
were more or less healthy. As such, the importance of the nursing
care which distinguished between nursing homes and homes for the
aged might not be too great, and some of the generalizations dis-
cernible from home-for-the aged study might also be applicable to

nursing homes.

18

In "Expert vs. Consumer Viewpoints: An Organizational
Analysis of the Contrast in Descriptions of Homes for the Aged by

36 B. M. Silverstone, a

Administrators and Indigenous Residents,”
sociologist, used homes for the aged as a laboratory for research
into the difference between residents' and administrators' per-
ceptions of the environment within the subject homes. This
dissertation focused on communication linkage adequacy in explain-
ing any such differences. Silverstone's work did deal indirectly
with aged resident dissatisfaction when it zeroed in on environ-
mental deficiencies of home—for-the—aged residences of which
administrators were unaware. However, the dissatisfaction so
studied was not directly researched, but rather was the by—product
of Silverstone's main research interests. Combining this factor
and the conclusion that Silverstone's hypothesized importance of
communication linkage was not supported, it appeared that this work
had little to contribute to the study of nursing home dissatisfaction.
”A Study of Family Factors Relating to Application to a

37

Home for the Aged,“ by sociologist Sidney Saul was a comprehensive

collection of background factors relating to the admission of

 

36B. M. Silverstone, "Expert vs. Consumer Viewpoints: An
Organizational Analysis of the Contrast in Descriptions of Homes for
the Aged by Administrators and Indigenous Residents" (unpublished
Ph.D. dissertation, Columbia University, 1973).

37Sidney Saul, ”A Study of Family Factors Relating to
Application to a Home for the Aged“ (unpublished Ed.D. dissertation,
Columbia University, 1968).

19

patients to a home for the aged. Its immediate usefulness was
reduced by the fact that the homes studied admitted only blind
residents.

As only about 4 per cent of all U.S. nursing home

residents are blind,38

this factor could detract from the ability
to generalize from this study either to nursing homes or other
homes for the aged.
However, to the extent that generalizations are possible,
Saul's work was similar to Miller's in providing a wealth of data
about the admission of patients to homes. Still, Saul did not
directly deal with the satisfaction of these residents once admission
was accomplished, so its usefulness to the study at hand was limited.
Allen Pincus, also a sociologist, attempted to develop
operational tools for studying institutional environments in his
"Toward a Conceptual Framework for Studying Institutional Environ-

39 The main thrust of this work was

ments in Homes for the Aged.”
the creation and validation of tools which might be utilized to
measure different aspects of the environments within institutions.

Developing applications for these tools was, for the most part, left

 

38U.S., Department of Health, Education, and Welfare,
Chronic Conditions and Impairments of Nursing Home Residents (Rock-
ville, Md.: National Center for Health Statistics, 1973), p. 13.

 

39Allen Pincus, ”Toward a Conceptual Framework for Study—
ing Institutional Environments in Homes for the Aged" (unpublished
Ph.D. dissertation, University of Wisconsin, 1968).

20

to other researchers. As shall be discussed under “methodology,"
at least one of these tools appeared applicable to the author's
research interests and will be analyzed more completely in that
section.

Once again, having exhausted available dissertations, the
author probed more general sources of secondary data. A journey

through the Reader's Guide to Periodical Literature from 1969 to

 

the present produced many of the ”muck-raker" articles about
nursing homes discussed in the beginning of this paper. However,
it uncovered no research concerning itself with dissatisfaction
not stemming from callous neglect.

The Public Affairs Information Service Bulletins from

 

1969 to the present and a search through Western Michigan Univer-
sity's extensive gerontology collection produced a great deal of
background information from the U.S. government, etc., but no real
insights into the satisfaction issues of interest to the author.

In summary, the author discovered very little prior re-
search relating to the marketing activities of nursing homes in
general. He found virtually none dealing with nursing home purchase
satisfaction issues that did not presuppose nursing home operator
guilt. The paucity of prior work, when combined with the author's
aforementioned intuitions, indicated further research into this
dissatisfaction-without-neglect issue was merited. Thus the author
embarked on the first step of studying this issue, the understanding
of the process by which individuals arrive at the need for a nursing

home.

21

The health care process

The process by which individuals reach varying levels of
health care has been conceptualized by Harold Baumgarten, an
authority in the field of nursing home administration. His thoughts
have been summarized in the framework presented as Figure 1.1.

As shown by this framework, the individual more or less
"falls“ through a funnel of health care; coming to rest at that
level which best fits his needs. If the individual returns to
health, he is free to progress through the process anew. As shown
by Figure 1.1, the need for a nursing home is normally preceded by
some prior medical condition that necessitates professional care.
Most frequently this care would have to be administered in a
hospital setting. Once the immediate medical emergency is judged
not to necessitate hospital care, the patient is free to proceed
down the funnel.

Some parts of the health care funnel concept were well
supported by existing research. For instance, in his study Miller
found that the major source from which nursing home residents came

was the hospital.40

On the other hand, the part of the health care
funnel depicting the nursing home as a temporary stop on the road
back to health appeared to be more of a governmental "ideal” than

an actual fact. Dr. Baumgarten explained to the author that flow

 

40Miller, p. ::3.

22

Non-Institutional
i} ..

Hospital

to

\{;}7 Nursing Home

01‘

 

 

Home for the Aged
i} ..

Good Health

 

(recycle)

Figure l.l--The Health Care Process

Source: Harold Baumgarten, The First Kuttnauer Seminar on Nursing
Homes and Extended Care Facilities (December 8-9, 1967)
as related by Harold Creal, Past President of the Michigan
Nursing Home Association in a personal interview February
5, 1973.

 

23

down the funnel was due to the progressively lower costs per day

4' If indivi-

within the institutions depicted on its lower levels.
duals took the expected course of minimizing the total costs per
day of their care, they would proceed down the funnel to pro-
gressively lower levels as shown. However, it did not appear that
this was the case.

As previously mentioned, the Institute of Gerontology
found the average nursing home stay to be just over two years in
Michigan and a similar nationwide study found it to be 2.8 years.42
This apparently precluded very many short stays of the type pro-
posed by the funnel. In fact the long length of the stay when
coupled with the resident's advanced age, indicated that their stay
usually lasted until death.

Still, some aged patients do undoubtedly go home after a
brief convalescence, and some homes also serve younger individuals
recuperating from serious accidents, etc. It is plausible to
assume that those patients who utilize the nursing home only tempor—
arily would find their dissatisfaction with it less important than

those for whom it represents a last residence.

Therefore, the nursing home residents of interest to this

 

research were limited to those,patients over 65 whose stay is re-

garded as being_permanent until their condition becomes terminal.

 

41Letter from Dr. Baumgarten to R. W. Buchanan, March 18, 1974.

42U.S., Department of Health, Education, and Welfare, Char-
acteristics of Residents in Nursing and Personal Care Homes (Rockville,
Md.: National Center for Health Statistics, 1973), p. 3.

24

It would be justifiable to raise the question of whether
many patients in the above category would be well enough (in a
physical and mental sense) to feel and express dissatisfaction with
their nursing home residence. The available evidence regarding
this issue is presented in Table 2.

Though defining exact levels of physical and mental com—
petence is extremely difficult, Table 2 shows the majority of nurs—
ing home patients still possessing most of their original faculties.
This agrees nicely with an Institute of Gerontology finding that
over two-thirds of the patients in nursing homes do not need the

43 These

extensive medical and personal care available there.
figures indicate that a majority of nursing home patients are
healthy enough to both feel and express dissatisfaction with their
environment. In light of this finding it appeared both possible
and desirable to define the dissatisfaction of interest to the

author.

Webster's Seventh Collegiate Dictionary defines satisfaction

 

as “fulfillment of a need or want.” However, just inserting "non
in front of this definition does not fulfill the author's needs, as
the earliest beginnings of this study are traceable to expressions
of dissatisfaction evidenced by many parties. Granted, dissatisfaction

could exist in quantities minute enough that it might not be expressed,

 

43Barney, p. 16.

 

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26

but how important this dissatisfaction is seems a moot point.
Furthermore, an expression of dissatisfaction could take either
verbal or non-verbal form.

As the easiest form of expression to measure is verbal,
the dissatisfaction of interest to this research was defined as
nonfulfillment of wants or needs sufficiently impprtant to prompt
verbal expression on thegpart of the individual experiencing it.

It should be understood that this verbal expression mee_
pep_limited to complaints about the specific nonfulfilled need. As
shall be shown later, nonfulfillment of one need can result in
dissatisfaction expressed through complaints about others.

In recognition of the fact that the nursing home popu-
lation probably could include some patients incapable of expressing
dissatisfaction of the type defined above, the population of
interest to this study was further limited to include only those
patients cognizant enough of their environment to be able to
experience dissatisfaction from specific elements of it.

Although this limitation might sound very non-specific,
it shall be shown that it is sufficient for the research methodology

to be employed by this study.

The purchasers of nursing care

That part of the health care funnel which predicated nurs-
ing home admission upon prior hospitalization led to a suspicion that

nursing home residents might not be the ones who decided upon the

27

actual purchase of any given home. Logically, if patients were
hospitalized prior to their admission, they probably were not
physically capable of much participation in the shopping and de-
cision making preceding their admission to any given home. This
assumption was supported by a sociology study which stated, ”Crisis
situations--emotional problems or failing health—~frequently
prompt a move to an institution. The individual has little control
over the situation in such a crisis, and the move is involuntary
and often traumatic.”44
Furthermore, it has been shown that admittance to a long

term care institution is probably not very attractive to aged indi-
viduals regardless of their health. Two researchers into this
phenomenon commented as follows:

The personal meaning which institutionalization had was

dependent upon the sex of the individual. For the male

it was a severe blow to an already shaky self-concept as

an adequate, potent person; for the female it symbolized

being unwanted and rejected.45
Clearly the above findings show that the aged would not have much

enthusiasm for the nursing home purchase decision even if they were

physically capable of making it.

 

44B. A. Yawney and D. L. Slover, "Relocation of the Elderly,”
Social Work (May, 1973), p. 87.

 

45Morton A. Lieberman and Martin Lakin, "On Becoming an
Institutionalized Aged Person,” in Processes of Aging, ed. by Richard
H. Williams (New York: Atherton Press, 1963), p. 502

 

28

These two factors of physical incapacitation and lack of
desire led the author to surmise that someone other than the nurs-
ing home resident probably had to be involved in the purchase of
accommodations in any specific home. This was supported by the

following data:

TABLE 3
PERSONS RESPONSIBLE FOR ADMISSION TO A NURSING HOME

 

 

Responsible Person

 

at Admission Per Cent
Spouse 7.1
Child 38.3 I
Other: 20.2
Sibling 7.2 65'6
Other relative 9.6 I
Non-relative 3.0
Self* (Patient) 31.0

 

*Includes social worker and legal guardian (about 6 per cent)
Source: Jane Barney, Patients in Michigan Nursing Homes, p. 70.

 

As can be seen from the preceding, the person who negotiates
the market transaction of admittance to a nursing home is likely to be
other than the patient in approximately two-thirds of the cases. As
shall be discussed later, his relative importance to the specifics of
any purchase of long term nursing care may vary with the case involved,
but the fact of his existence is undeniable.

In light of this finding the author felt it important to

include these ”other” individuals within the focus of this research.

29

Henceforth they were referred to as sponsors, a group defined as
the responsible parties who are involved with negotiating the
admittance of the patient and are the ones designated as the first
to be contacted in the event of an emergengy.

The above definition needed still further clarification
to be of use to this study. If this research was to uncover some
of the elements of dissatisfaction surrounding nursing home pur-
chases, it had to concern itself with sponsors interested enough
in the topic to be aware of any dissatisfaction throughout the
duration of the care extended.

Occasionally sponsors are appointed guardians (lawyers,
banks, or other outside parties) who may visit the patient in-
frequently, and take little interest in his day to day affairs.
Furthermore, there are other sponsors who are completely callous
to the needs of the patient and almost never concern themselves
with him.

Clearly, both these groups were less likely to express
the dissatisfaction of interest to this study than someone who was
actively involved with the issue of nursing home care. Therefore,
the sponsors of interest to this study were further limited to ppgee
interested enough in nursing home care to visit the patient they
represent at least once a month. This ”once a month” average indi-
cated a minimum level of interest to a panel of experts concerned

with the industry whose composition is presented in Appendix A.

30

In the author's opinion, this issue of continued sponsor
involvement with nursing home care was a major one. Given that the
nursing care purchased normally extended over a period of two or
more years, it was obviously important to investigate the sponsors'
impact on the long (as well as short) term dimensions of nursing
care. In order to accomplish this, some understanding of the "market"
for long term nursing care was required.

The market for long term
nursing care

 

The Michigan market for long term nursing care may be
divided into two basic segments, private pay and public pay, which
comprise respectively about l6 and 84 per cent of all Michigan

46 As their names imply, the basic distinction

nursing home patients.
between the two is the origin of the revenue supporting the patients'
stay. In the private pay sector all of the patients' expenses come
from internal resources accessible to him and his family. The public
pay sector is reimbursed mostly from public funds made available
under the provisions of original federal Medicare/Medicaid act

47 Of the

(Title l8 and l9 of the l965 Social Security Amendments).
two public sources of funds, the state directed Medicaid program is

much the more important. The original Medicare program only covered

 

46Barney, p. 7l.

47Robert J. Meyers, Medicare (Homewood, Ill.: Richard D.
Irwin, l970).

31

a maximum of lOO days in a nursing home, and the federal government

48

has been extremely reluctant to reimburse such stays fully. Due

to this reluctance many nursing homes have largely abandoned the

49

Medicare program, which now only constitutes approximately 3 per

50 As such, the author was con-

cent of all nursing home revenues.
tent to interest himself with only the Medicaid aspects of public
funding.

The amount of revenue generated by patients within the
private and public sectors is quite different. As previously dis-
cussed, if a patient is unable to pay for all his care, the maximum
which the state reimburses the nursing home housing him, is $2l.35
per day. This maximum is currently the center of much controversy
within the industry, for many nursing home owners claim that their
costs are greater than this sum. As one nursing home operator put
it, ”In most states Medicaid rates are too low to allow for any
profit, but they allow you to spread your overhead over a broader
base. Then, if you have enough private patients, you can make a

reasonable return on equity.”51

 

48Jim Hyatt, ”Medicare Woes, Nursing Home Benefits Grow
Harder to Collect,” The Wall Street Journal, April 8, l970.

 

49ANHA, "Proposed Position Paper," in ANHA Governing
Council Report (Chicago: ANHA, August l9, l973), p. 33.

 

 

50Barney, p. 25.

5lDavid A. Loehwing, “Recovery in Nursing Homes,” Barron's,
March 26, l973, p. l4.

32

The price discrimination hinted at by this operator was
also mentioned by Trainor who commented as follows:

The question may be asked how the nursing home industry has
been able to survive and grow despite levels of compensation
for the care of public assistance patients which much of the
time have not been high enough to cover a substantial pro-
portion of the efficient operators' full costs. The answer
to this important question is that nursing homes practice
price discrimination, openly and unabashedly charging their
private patients more than they receive from the state.52

In various informal interviews with nursing home adminis-
trators, the author found such price discrimination was the rule
within Michigan, as well. As such, the private-pay patient was
perceived as being the most profitable patient in any nursing home.
Under these circumstances, it seemed likely that some homes might
seek out this more profitable patient to the exclusion of all others.
But, this was not the case.

As previously mentioned, the relative size of the total
private pay market is not very great. In order to ”draw” enough
patients to fill a private nursing home, that home would probably
have to attract patients from either an extremely wide area or one
of high population density. As a majority of nursing home residents
come from a twenty-five mile radius of their nursing home,53 the

possibility of drawing from such wide areas is minimal. This market

area factor probably helps explain why the author uncovered evidence

 

52Trainor, p. 242.

53Miller, p. 63.

33

of only a few homes catering to private patients exclusively, and
these were mostly in metropolitan areas.

Given the common necessity of price discrimination
against the private sector, the attainment of sgm§_private patients
appeared absolutely essential for continued financial stability.
In light of the importance attached to attaining private pay patients,
the author felt it logical to next study any unique features of
marketing to such individuals. A major distinguishing characteris-
tic of the private pay market was found to be the role played by

private pay sponsors.

The role of private pay sponsors

In general, sponsors play two separate roles in the pur-
chase of long term nursing care. As previously introduced, they
usually seem to be the ones who negotiate the initial admittance
of their patient to any given nursing home. Furthermore, depending
upon the circumstances, some of them continue to monitor the long
run acceptability of care afforded the patients they represent.
Apparently, the extent of the sponsor's activities, as well as the
complications caused by them, can depend upon whether or not the
patient they represent is a member of the private or public pay
sectors.

Though generalizations about the nursing home industry are
difficult to make, the author sensed that publicly supported patients

were felt to be easier to take care of than private pay patients.

34

The impression received was that Medicaid patients were less likely
to have the complicating factor of sponsors whose own needs (as well
as those of the patient) had to be satisfied. The following data
supported this impression.

Table 4 clearly illustrates that Medicaid patients are
unlikely to have anyone interested enough in them even to visit.
Unfortunately, no data is available to prove that the person doing
the visiting in the above situation is always the sponsor. Obviously,
patients on Medicaid receiving few (if any) visitors would be highly
unlikely to have sponsors of the type defined as the interests of
this study. 0n the other hand, it is reasonable to assume that
some of the many visitors to private pay patients are their sponsors.
Therefore, at the very least, sponsors of private pay patients
apparently may be inclined to play a more active role in the con-
tinuing aspects of long term nursing care. This should not be
construed to mean that gnly_private pay sponsors take an active
interest in the care afforded their patients. This would very
probably be a gross overstatement of the facts. Rather it is meant
that private pay sponsors seem to take an active interest in both
the initial and continuing aspects of long term nursing care, while
such involvement on the part of public pay sponsors may be less
universal.

Given the intricacies of the preceding sections, it is

probably wise to summarize them as follows:

35

TABLE 4

NURSING HOME VISITORS BY REVENUE CONTRIBUTED BY PATIENT

 

 

Revenue Contributed by Patient

 

 

 

 

 

Person Visiting Private $151+ $51-$l50 $O-$50
Spouse l8% 5% 4% 2%
Child 54% 48% 40% 34%
Other 22% 28% 26% 15%
No one 6% 19% 30% 49%

Total 100% 100% 100% 100%

 

 

 

 

 

Source: Jane Barney, Patients in Michigan's Nursing Homes, p. 421.

 

-The purchase of long term nursing care involves two dimensions,
an initial phase in which a home is chosen and a continuing
phase (lasting over two years) during which those involved
with the care must be satisfied.

-The initial phase is not negotiated by nursing home residents,
but rather by their sponsors.

-The continuing phase of nursing home care must satisfy both
patients and sponsors if an interested sponsor is involved.

-Interested sponsors are particularly likely to be present in
the all important private—pay segment (and may be present in
others as well).

These findings indicated that nursing homes in general and

profit oriented ones in particular were frequently faced with what

seemed to be a surrogate purchase situation.

Surrogate purchase situations

A surrogate is defined as “a person appointed to act in

place of another.”

Applied to the situation at hand, it would mean

 

54

 

Webster's Seventh Collegiate Dictionary, p. 886.

36

that one party to a purchase negotiates for goods/services on the
behalf of someone else who must then ”live with them" (in this case
in both a figurative and literal sense).

Such circumstances would normally mandate that both groups
(surrogate and consumer) be seeking to serve the same set of needs
in the same manner for satisfaction to result. However, in regard
to the nursing home purchase situation, there is little to indicate
that this is the case.

The heterogeneity of individuals insures that some
differences of opinion are likely to exist in any surrogate situa-
tion. Furthermore, as shown by Rokeach, value systems differ for
different age groups.55 As sponsors are most frequently patients'

children,56

the likelihood of such age induced differentials is
particularly great.

The author felt the importance of these differentials was
further heightened by the fact that the commodity being purchased
represented an entire life for many of the patients involved.
Logically, any deviation from the patient's ideal was likely to

produce intense dissatisfaction on top of that already precipitated

by the move itself.

 

55Milton Rokeach, The Nature of Human Values (New York:
The Free Press, l973), pp. 72-82.

 

56Barney, p. 70.

37

Therefore, the author felt it likely that marketers of
long term nursing care seeking to serve patients with interested
sponsors had to satisfy two distinct sets of needs. If these needs
proved to be different, the marketer would be faced with the dilemma
of choosing which set to satisfy. Obviously, for those situations
in which the needs did conflict and one side or the other was
favored, some dissatisfaction was potentially present. In light
of these conditions the next logical step was to determine whether
sponsors and their patients did have the conflicting need structures
suggested by the preceding.

In order to research sponsor/patient need structures, the
author interviewed the panel of experts already presented as
Appendix A. This panel was composed of nursing home administrators
who formed the entire governing board of the Michigan chapter of
the American College of Nursing Home Administrators. That

association, . devoted to the professional advancement of the

long term care administrator through education, professional repre-

57 had contributed to this

sentation, leadership and research,”
project from its inception by lending professional insights and a
small ($100) research grant. These interviews yielded the list of
typical patient/sponsor needs included as Figure 1.2. A glance

through this list quickly revealed many that could be conflicting

and subsequent probing of the panel members confirmed that

 

57American College of Nursing Home Administrators, Member-
ship Information (Silver Springs, Md., l974), p. l.

38

Patient Needs

To control their own environment regarding:

care afforded them (by nurses and other professionals)

their physical mobility

configuration of physical facilities in which they reside
physical demands made upon them (rehabilitation therapy, etc.)
social contacts with their peers

recreational activities they undertake

choice of roommates

sexual/social contacts with others of the opposite sex

social contacts with members of their family

food items consumed

additional “luxury“ services they receive (beauty shop, etc.)
their continued physical existence

Sponsor Needs/Goals

 

To control their own environment regarding:

having other individuals (the patient) present or absent in
their life

guilt reduction through seeing that their perceptions of the
needs of the patients they represent are met

the continuation of their perception of their patient's physi-
cal and mental abilities (e.g., no physical restraints, etc.)

protection of previous family relationships from disturbing
new elements (such as a parent remarrying)

continuation of sibling rivalries (through keeping other
relatives from seeing a patient)

personal (or estate) finances expended to supply a patient's
needs (not met from other resources)

Figure l.2--Assumed Patient/Sponsor Needs Served by Nursing Care

39

patient/sponsor confrontations frequently do stem from such con—
flicts. In light of these facts, the following initial guiding
hypothesis for research appeared reasonable.

HI Guiding Marketers of long term nursing care seeking to
provide service to patients who have interested
sponsors are faced with a surrogate purchase
situation containing conflicting sets of needs--
those of patients and those of sponsors. Con-
flicts resulting in the failure to serve one or
the other of these sets is a major contributor
of dissatisfaction among patients and sponsors
that is more or less inevitable.

The notion of such conflicting value systems within an
aged consumer surrogate purchase decision situation has not been
extensively researched. One nursing-home-administration-manual
writer theorized that problems of dealing with resident relatives
could be expected to emerge from the emotion-laden admission of a
patient, but did not present any research into the origins of these
problems.58 One work was uncovered which concerned itself with
surrogate management of the assets of the aged. However, this re-
search dealt with the process by which aged individuals were declared
mentally incompetent so that their assets could be usurped by others.59
Because the topic was so far removed from the author's interests, the
only useful input gained from it was a cynical observation that

sponsors do not always act in the best interests of those they repre-

sent.

 

58Harold Baumgarten, Concepts of Nursing Home Administration
(New York: Macmillan, l965), pp. l2l-25.

 

59George Alexander and Travis Lewin, The Aged and the Need
for Surrogate Management (Syracuse, N.Y.: Syracuse University, l972).

40

Within the field of consumer marketing little prior re-
search into surrogate market situations was found. In fact, only
one marketing scholar, Dr. Stanley Hollander, appears to have
evidenced much interest in this topic area.

In one essay Dr. Hollander exhaustively traced the
historical background of consumer purchase surrogates. However,
the surrogate situations dealt with in this work were of “interior
decorator” or “professional shopper“ situations that didn't seem

60 In a later journal

directly analogous to the author's interests.
article Dr. Hollander further detailed a number of different con-
sumer surrogate classifications. Among these were the following:

-Evaluators and Appraisers

-Diagnosticians and Recommenders

-Service locating agencies

-Product finding agencies

-Package suppliers
Only one of the preceding categories, the “Diagnosticians and
Recommenders“ seemed even remotely analogous to the interests of
this study. Conceivably, doctors could be involved in surrogate
situations in which their needs might conflict with those of the
relatively powerless consumers they serve (i.e., a physician might
choose treatments for their convenience of application, not the

consumer's pleasure or comfort). However, this recognition of a

similar situation lent few insights to the problems at hand. In

 

60Stanley C. Hollander, “The Shops for You or with You,‘l
in New Essays in Marketing_Theory, ed. by George Fisk (Boston:
Allyn and Bacon, Inc., l97l), pp. 2l8-40.

41

this same article Hollander noted that almost no research into surro-
gate situations had been conducted despite their potential importance.61

Finding so little prior work concerned with consumer surro-
gate purchase situations, attention next turned to the field of
industrial marketing. Fortunately, this field, which frequently is
concerned with surrogate purchase agents, has dealt with surrogate
purchase conflicts in terms meaningful to the author's interests.

One theoretician, Philip Kotler, has suggested that con-
flicting sets of goals between the purchasing agent and the
organization he represents often exist in industrial surrogate

62 Rewoldt, Scott, and Marshall have built Kotler's

purchases.
concept into a model by showing how these sets of goals may be
conceptualized by Venn diagrams showing individual/organizational
goals and the areas of agreement and conflict between them.63
Figure 1.3 is a depiction of three possible alternatives for such
a situation.

Although this model was intended to deal with conflicts
(over gifts, entertainment, etc.) between purchasing agents and

their respective firms, it did seem applicable to the purchase of

nursing care for a number of reasons.

 

61See Stanley Hollander, ”Buyer Helping Business . . . and
Some Not-So-Helpful Ones,” MSU Business Topics, Summer, l974, pp. 52-68.

 

62Philip Kotler, ”Behavioral Models for Analyzing Buyers,”
Journal of Marketing, XXIX (October, l965), p. 45.

63Stewart H. Rewoldt, et al., Introduction to Marketing
Management (Homewood: Richard D. Irwin, Inc., l969), p. 95.

 

42

 

Figure l.3—-Goal* Conflict in a Surrogate Purchase Situation

Note: Individual Goals (I), Organizational Goals (0) and areas of
goal mutuality (M).

*The author assumes that, for the purpose of this research, goals
and needs are interchangeable.

First, both situations deal with purchase being made by
one individual for use by others. True, the industrial purchasing
agent is paid for his efforts, while the surrogate purchaser of
nursing is not. However, the “for pay” aspects of the purchasing
agent seem obviated by the model which assumes the financial rewards
of his job are not enough. Were his rewards adequate, he would not
have as much need to seek fulfillment of his personal goals through
manipulating his professional position. For his part, the sponsor
may have a financial stake in the situation (see needs) either
directly (by assuming some responsibility for some costs of the
care) or indirectly (by seeking to avoid any costs or by striving to
protect an estate from erosion). As such, the sponsor and the pur-
chasing agent appear to approach similarity; albeit from opposite

directions.

43

Although the Kotler model does not specifically state
this fact, it seems to imply a situation in which the purchasing
agent can capitalize upon his position by awarding business to one

of several competitors perceived as equals (or near equals). Were

 

this not the case it would be hard to see how the purchasing agent
could accrue much personal benefit without making purchases repre-
senting disproportionate risk to his continued employment.

This choice among perceived equals seems to be the
situation for nursing care, as well. The state, through a stringent
set of standards,64 tries to put a floor on the minimum acceptable
level of care. This ensures that all the competitors are likely
to be more or less uniform in terms of minimum quality. This
”floor“ provided by the state helps ensure that the sponsor's
probable lack of detailed knowledge about the “product“ of nursing
care65 is not a major factor in its purchase. In effect, the state
tries to ensure that what is not known by purchasers hurts no one.
Except for the cases of dishonorable neglect already excluded by

the author's interests and his choice of methodology (to be dis-

cussed later), it appears that this end has been accomplished.

 

64See Michigan Division of Health Facilities Standards and
Licensing, Rules and Regulations for Nursinngomes and Homes for the
Aged (Lansing: Department of Public Health, 1974).

65Stephani Fenelon, ”Patients' Families Need Information,”
Modern Nursing Home, January, l974, p. 8.

 

44

Frequently industrial purchases (particularly of fabricating
materials and parts) represent more or less long run relationships
between producer and consumer where the emphasis is placed upon the
continuing nature of the market transactions being conducted. This
appears to be the case for nursing homes, as well, where the initial
purchase decision must be followed by continued satisfaction for a
relatively long period of time after the initial purchase.

Finally, a great deal might be made of the fact that
industrial purchases are more ”rational“ (in the sense of being
economically motivated) and consumer purchases less so. There can
be no denying that the purchase of long term nursing home care is
probably packed with emotion. However, by its very nature, the
Kotler model seems to insure that the industrial purchase decision
it depicts is somewhat emotional as well. Of course, the organiza-
tional goals to be serviced by an industrial purchase are usually
highly economic in nature. However, the situation conceptualized by
Kotler is one where satisfying those goals alone may not be enough.
Presumably, the personal goals of the purchasing agent must be satis-
fied as well. It is hard to conceive of any situation where these
personal goals could be deemed less than partly emotional. As such,
the industrial purchase decision focused on by Kotler would seem to
have its emotional elements too. The only difference might be in
their degree of intensity.

Actually, the only place where the author sees the analogy

drawn between patient/sponsors and purchasing agents/organizations

45

as encountering any difficulty is in the arena of prior relational
dynamics between these two ”actors” of typical surrogate situations.
As so many sponsors are the children of the patients they repre-
sent, prior emotional ties and guilt over placing the patient in a
home could be seen as making the sponsor more dedicated to the
patient's needs than their own. This would be in stark contrast

to the situation of purchasing agents and the organizations they
represent.

This possibility would certainly lessen the dissatisfaction
that might attend the surrogate not getting his own way. However,
the aged parent/adult child relationship is not uniformly positive.66
Nhat relational dynamics might emerge from occasionally antagonistic
parent/adult child relationships are not clear, but it is certain
they would probably not always motivate the sponsor to give up his
needs for those of the patient he represents.

The issue of guilt is equally hard to assess. There can
be no denying the presence of sponsor guilt--its universality is so
great that the “popular press“ is now devoting articles to ways of
coping with it.67 However, the behavior emanating from this guilt

is difficult to predict.

 

66Bertha Simos, ”Adult Children and Their Aging Parents,”
Social Work, XVIII (May, l973), 78-85.

 

67See Jim Gallagher, ”Family Faces Guilt Feelings——Easing
Parent's Move to Nursing Home,‘I Detroit Free Press, November 10,
1974, pp. lC, 9C.

 

46

Baumgarten sees intense sponsor guilt over placing a
patient in a home as being likely to result in one of two extremes:
(1) total abandonment of the patient involved, or (2) total domina-
tion of the patient through constant visiting, often coupled with

68 The first of these

criticism of the nursing home and its service.
alternatives would clearly exclude the parties involved from the
defined interest of this research. The second could result in the
sponsor's making his interests subservient to those of the patient,
but it is not clear that this would always be true. For instance,
the patient might not want to be dominated, or might want things of
which the sponsor was unaware. Thus, such guilt motivated behavior
could result in dissatisfaction of the type to be researched by
this paper.

For his part, the author was content to accept that
sponsor motivations might represent a flaw in the analogy between
sponsors/patients and purchasing agents/industrial organizations.
However, the seriousness of the flaw was felt to be mitigated by
the above considerations.

In light of his total analysis, the author decided that
the Kotler/Rewoldt et_al, model did represent a fair depiction of
nursing home purchases. Changing the ”individual" to "sponsor'' and

”organization" to ”patient,” the author arrived at Figure 1.4, need

conflict in a nursing home purchase situation.

 

68Baumgarten, Concepts of Nursiflg Home Administration,

 

p. l23.

47

Figure l.4--Need Conflict in a Nursing Home Purchase Situation

Note: Sponsor's Needs (S), Patient's Needs (P), and areas of
mutuality (M).

The Kotler/Rewoldt model typified by Figures l.3 and l.4
struck the author as being somewhat lacking. Although it illustrated
the dilemma of conflicting consumer/surrogate needs, it proposed no
operational strategies for dealing with such conflicts, and yielded
no assessments as to the costs of any alternatives that could be
chosen. Furthermore, as shall be shown later, it overlooked a third
possible area of goal conflict. For these reasons the necessity of
constructing further theoretical devices with which to research the

purchase of long term nursing care became apparent.

48

Beyond Kotler/Rewoldt

The Kotler/Rewoldt conceptualization apparently assumes
that marketers facing its situations have only the goals of surro-
gates and those whom they represent to consider in developing a
marketing program to meet them.

Of course, the marketing concept proposes that the
ultimate goal of any marketing plan must be to satisfy the needs
of the consumers it serves.69 However, the Kotler/Rewoldt model
poses the questions of ”Who is the consumer?” and “Whose needs
shall be served?” A simple answer to these questions is quite
difficult, for if a marketer served only the needs of the actual
consumer and ignored those of the surrogate doing the buying, he
might never make a sale. At the other end of the spectrum, were a
marketer to service the needs of a surrogate to the extreme of con-
spiring with him to defraud those consumers he represents, the
ultimate loss of the customer (and possible legal action) would be
likely.

The non—acceptability of the preceding extremes hints that
a marketer faced with a surrogate purchase situation has a set of
his own needs to consider in formulating appropriate market action.
This is nothing new to marketing science which presupposes marketers'

objectives as an important foundation of any attempt to serve

 

69William J. Stanton, Fundamentals of Marketing_(New York:
McGraw-Hill, 1971), p. 9.

 

49

consumer needs.70

What is new is the integration of this third
set of needs into a situation where the identity of the "consumer“
to be served is not clear. This inclusion implies that how a
marketer resolves a surrogate/consumer conflict may be a product
of both his own organizational needs and those of the parties he
serves.

The integration of marketer needs with those of consumers
and surrogates was conceptualized as Figure 1.5. This figure
illustrated the most general case in which the needs of the market-
ing firm could share mutuality with those of the purchasing agent
surrogate, the consuming organization represented, both consumer
and surrogate, or neither of them.

As has already been discussed, the purchasing agent/con-
sumer conflict seemed analogous to that of the sponsor and his
patient. Furthermore, as shall be discussed in depth later, the
author was convinced of the existence and importance of nursing
home organizational inputs to the marketing of nursing care to
patients and sponsors. What was deemed “proper” for any situation
appeared to vary with the individual orientation of the organization

delivering the nursing care. For this reason the author believed

that the situation of sponsor/patient conflict might be utilized

 

70Philip Kotler, Marketing Management (Englewood Cliffs:
Prentice-Hall, 1972), pp. 229-34.

 

50

to study the broader issues of purchasing agent/organizational con-
flict. With this in mind, the sponsor/patient labels were included

in Figure 1.5.

 

Figure l.5-—Need Conflict in a Surrogate Purchase Situation
Note: Individual (Sponsor) Needs, Organizational (Patient) Needs,
Marketer firm/Organization Needs, and areas of Mutuality.
At this point it should be mentioned that ”organization“
was included in Figure l.5 to cover those instances (approximately

16 per cent)71 in which non-profit institutions sponsor the nursing

 

71U.S., Department of Health, Education, and Welfare, Health
Resources Statistics, p. 327.

P‘

51

homes. Whether or not such charitable organizations could properly
be included in a marketing analysis was known to be a matter of

some debate.72 The author was content to accept that they were with-
in his interests. As shall be shown, he expected non~profit goal
orientation to produce behavior somewhat different from their
commercial counterparts.

As was the case with surrogate/consumer needs, the intro-
duction of marketer needs to the surrogate transaction need not
mandate dissatisfaction unless some of the three groups of needs
are conflicting. In the case of nursing homes, such conflict
appeared likely.

In interviews with the aforementioned administrators, the
author developed the following list of needs that represented the
determinants of nursing home action:

-The need to make a profit or (in the case of non-profit
homes) to maintain financial solvency.

-The need to comply with various legislative regulations.

-The need to protect the home from threats to its
existence (e.g., law suits, etc.).

-The need to be well thought of by fellow health care
professionals (doctors, other nursing homes, etc.).

-The need to be well liked by staff, patients, and sponsors.

-The need to feel that ”the right thing" is being done for
patients in terms of their individual care.

 

72See Philip Kotler and Sidney Levy, l'Broadening the Concept
of Marketing,” Journal of Marketing, XXXIII (January, 1969), pp. 10-15;
and David J. Luck, "Broadening the Concept of Marketing--Too Far,"
Journal of Marketing, XXXIII (July, l969), pp. 53-55.

 

52

It took little time for the participating administrators
to describe possible incidents of potential conflict between the
needs of sponsors, patients, or both. This fact necessitated
additions to HI Guiding which resulted in the following:

HI Guiding Marketers of long term nursing care seeking to
provide services to patients who have interested
sponsors are faced with a surrogate purchase
situation containing conflicting sets of needs.
Among these needs are those of the sponsor, those
of the patient, and those of the marketing organi-
zation. Conflicts resulting in the failure to
serve the needs of the patient, his sponsor, or
both are a major contributor of dissatisfaction
among patients and sponsors that is more or less
inevitable.

By testing this guiding hypothesis the author believed many truths
about the dissatisfaction surrounding the purchase of long term
nursing care could be uncovered. Hopefully, some new light would
be shed upon previously unresearched aspects of surrogate purchase
situations as well. The latter seemed likely as the nursing home
industry proved to be an almost ideal laboratory for conducting re-
search into surrogate situations.

Nursing homes as a laboratory

for the study of surrogate

purchase situations involving
conflicting need structures

 

 

 

As discussed earlier in this paper, the purchase of long
term nursing care does represent an almost classical surrogate pur-
chase situation (particularly in the private sector). Furthermore,
several unique attributes surround nursing care purchase dynamics.

These unique characteristics help make research into nursing home

53

markets generalizable to the broader issues of conflicting-need

surrogate transactions as a whole. These characteristics include

the following:

Importance of
Purchase
Satisfaction

 

Likelihood of
Conflicting
Needs

 

 

Ease of
Identifying/
Studying
Marketer
Policy Makers

 

 

Ease of Studying

 

Surrogate
Purchase

Participants

 

Ease of Studying

 

the Resolution
of Surrogate
Dilemmas

 

 

It would be hard to think of any surrogate
situation in which the product being pur-
chased would be more important than the
nursing home is to the patient residing in
it. For him it represents an entire way of
life. As such, it is likely to strongly
exhibit any dynamics typical of such situa-
tions.

Although the sponsor's insistence upon his
own way may be diluted by guilt, etc., the
already discussed differences between spon-
sors and the aged they represent is likely
to be great. This facilitates study of
these differences for such surrogate situa-
tions.

Given the complexity of industrial personnel
structures, it might be nearly impossible to
isolate the main formulator of market policy.
This is not the case for nursing homes which,
due to their small size, have only one easily
identifiable policy maker, the administrator.

Unlike industrial situations which could find
suppliers, surrogates, and consumers scattered
geographically, all participants in the nurs-
ing home purchase situation are congregated
together. Patients/consumers are all present
within the home and, by research definition,
sponsor/surrogates must pass through the same
area at least once a month; this makes their
study considerably easier.

Because of the above mentioned geographical
dispersion of industrial surrogate situations,
studying marketer response to conflict dilemmas
might be difficult. This is not true for
nursing homes in which the resolution of such
conflicts must take place within the narrow
confines of the nursing home, itself.

54

The preceding analysis indicated two things: (1) that
nursing home purchases should strongly demonstrate typical surro-
gate purchase characteristics and (2) studying nursing home pur-
chase dynamics appeared easier than studying other types of surro-
gate situations. As such, using nursing homes as a laboratory for
the study of surrogate situations seemed a good idea. Reflection
upon the most important unstudied issues of surrogate purchase
situations produced the following list of questions:

-Given the existence of conflicting needs between surro-
gates, consumers, and marketers, how does a marketing
firm choose which sets of needs to serve?

-If a marketer favors any set of needs consistently, are
those parties favored/(not so favored) aware of the
fact that they are receiving more/less than the other

group?

-Is the group favored/(not favored) appreciative/(resent-
ful) of the marketer's actions and do they develop

greater/(less) satisfaction over the purchase involved?
(Or do they just accept it as the way the world is?)

Determining market behavior in
a surrogate purchase situation
under conditions of conflicting
needs

 

 

 

As developed thus far, the surrogate market situation repre-
sented by nursing homes contained three possibly conflicting groups of
needs which any marketing had to satisfy. It was reasonable to assume
that whom a marketer in such a situation chose to satisfy was probably
a product of how the need satisfaction of consumers or surrogates
would fit into the structure of needs of the firm doing the marketing.

In other words, a marketer would probably satisfy the consumer's needs

55

over those of his surrogate if so doing would best satisfy the need
structure of the marketer. This not too profound conclusion re-
sulted in the following:

HII Guiding A marketer confronted with a surrogate purchase
situation containing conflicting needs of con—
sumers and surrogates will formulate actions
that best satisfy the need structure of the
marketing organization.

The apparent similarity between nursing homes and surro-
gate purchase situations indicated that HII could be tested through
the following research hypothesis:

H2 A nursing home confronted with conflicting needs of
patients and sponsors will tend to satisfy the group
whose satisfaction will best serve the nursing home's
need structure.

Under typical market conditions it would be extremely
difficult to test H2. Normally, the profit motive would be the
number one motivation of all marketers, and the uniformity of such
a situation would deny the kind of comparisons that make hypothesis
testing possible. Fortunately, this was not the case for nursing
homes which, as previously mentioned, are comprised of both pro-
prietary and non-profit organizations.

Presumably, the key distinction between these two, their
respective emphasis on profit, should be reflected in their market
orientation. Logically, the non-profit homes would have no parti-
cular reason to favor either patients or sponsors. If the profit

motive was as unimportant as their non-profit name implied, they

could "afford” to favor either group (or neither) at their leisure.

56

Conversely, proprietary homes had ample cause to lean
toward favoring the private-pay segment. Therefore, proprietary
homes were expected to favor private-pay sponsors more than non-
profit organizations favored sponsors in general.

The predicted difference in orientation was thought to
be particularly great for comparisons between non-profit orienta—
tion to Medicaid sponsors and proprietary treatment of their
private-pay equivalents. Clearly, non-profit homes had two good
reasons not to favor Medicaid sponsors: (1) Medicaid sponsors
respresented a plentiful group of patients who were comparatively
unimportant to profits, and (2) profits were supposedly unimportant
to non-profit institutions anyway. As just the opposite was true
for proprietary homes and private-pay sponsors the following hypo-
thesis seemed reasonable.

H2A-l Proprietary homes will be more sponsor oriented when
dealing with private-pay patient/sponsor conflicts
than non-profit homes are in similar conflict situa-
tions involving Medicaid patients/sponsors.

The author was concerned that the small number of non-profit
liomes available to test H2A-l might not prove sufficient. Therefore,
lie was anxious to have another test available for H2 which would pro-
Ceed along similar lines.

A good basis for such a stand-by test was thought to be in
'the dynamics surrounding proprietary homes' treatment of patients/
SPonsors. As sponsors of private-pay patients were apparently more

1important to profits than sponsors of Medicaid patients, a prediction

that for—profit homes would favor private-pay patient sponsors more

57

than Medicaid patient sponsors made good sense. Furthermore, if

the key mechanism affecting choice of orientation were profits, then
highly profit oriented homes should demonstrate this favoritism
more than homes less committed to the profit motive. Putting the
preceding together, the greatest differential in orientation should
be displayed by comparing highly profit oriented homes' treatment

of private-pay patients/sponsors with the treatment of Medicaid
patients/sponsors by homes less motivated by profit. This resulted
in the following:

H2A-2 Proprietary homes run by administrators totally

committed to the profit motive will be more sponsor
oriented when dealing with private-pay patient/
sponsor conflicts than homes run by administrators
less motivated by profits are in dealing with simi-
lar conflicts involving Medicaid patients.
The author believed that the preceding hypotheses adequately
dealt with the dilemma between patients and sponsors. However, as
was evident from the preceding analysis, the only marketer need utili—
zed to determine patient/sponsor orientation was the profit motive.
As was introduced earlier, other needs (i.e., legal, professional,
personal, etc.) could also influence marketer orientation.
The indications were that these ”other“ needs (not related
to profit) were particularly powerful for the nursing home industry.
Though difficult to prove, the assessment was supported by the follow-

ing observations about the industry:

-The industry didn't seem highly competitive (at least when
compared with other industries).

-The industry apparently was very profitable and could ”afford”
to be interested in things other than profit.

58

-Many administrators were not businessmen, but instead
exhibited a variety of backgrounds (sociology, the
clergy, ex-nurses, etc.) not normally committed to
profits, alone.

Taken altogether, the preceding implied that some orienta-
tion other than the profit motive might be present in the nursing
home industry. Subsequent probing showed that this might be true.
The majority of the administrators the author interviewed indicated
that they considered themselves health care professionals first and
businessmen second. This same theme was evidenced by the nursing
home journals examined during the author's literature search. Most
of them emphasized things other than business profits as their main
focus.

This health care orientation was understandable given the
industry's profit picture and close relationship with the medical
profession. Those administrators embodying this orientation seemed
to place a very high priority upon operating their homes like a
hospital. Apparently, they were willing to deprecate the profit
motive in order to “do what's right” no matter what the market impli-
cations of their actions. The author's impression was that they
thought of themselves as ”almost doctors" handing out what they con-
sidered to be “correct” to individuals who obviously did not know
what was good for them. As this lofty orientation could be expected
to sometimes conflict with the needs of patients and/or sponsors, it
was thought important enough to study.

Obviously, if this role as a health care professional did

conflict with the needs of patients and/or sponsors, it could be

59

expected to threaten profits (if patients or sponsors became angry
enough to change homes). Therefore, administrators of proprietary
homes could generally be expected to manifest this “professional"
orientation more with Medicaid patients/sponsors than with their
private-pay counterparts.

Furthermore, those individual administrators who were
committed to such an orientation would presumably manifest this be-
havior more than those who didn't. Putting the above together in-
dicated that the most “administrator” oriented behavior should be
found in the treatment afforded Medicaid patients/sponsors by homes
placing great emphasis on the administrator's role as a health care
professional. And, the opposite extreme should be registered by the
care afforded private-pay patients/sponsors by homes assigning a low
priority to the administrator's role as a health care professional.
Combining the preceding resulted in the following hypothesis:

H2B Proprietary homes run by administrators totally committed

to their role as a health care professional will be more
oriented to behavior associated with this role when it
conflicts with the needs of Medicaid patients and/or
sponsors than will homes run by administrators with lesser
commitments to this role when faced with similar private-
pay patient and/or sponsor conflicts.

H2A-B proposed several situations in which the needs of
sponsors, patients, or both might be neglected. However, the author
did got intend to test for or uncover any cases of gross neglect of
either group. He recognized the futility of hoping that any method—

ology could persuade any marketer who was doing this to admit it.

60

Furthermore, as proposed during the discussion of the
Kotler model, there almost always are definite limits upon how far
a marketer can go in favoring surrogates or consumers before the
situation becomes intolerable. This is definitely the case with
nursing homes. As previously mentioned, the state-mandated minimum
limits of care do define a “floor” for nursing home operations.
Clearly, this would limit how far a nursing home marketer could go
in satisfying needs other than those of the patients. Finally, as
shall be discussed under ”methodology,” the author's choice of
sample would seem to obviate the marketers who might be guilty of
any such gross neglect.

Apparently, the surrogate—situation favoring of needs that
interested the author had to be of a very subtle type-~more of a
philosophy or orientation than overt action. The author hoped that
such an orientation would be significant enough to display its
presence through the workings of the research methodology. However,
given its assumed subtlety, he was not certain that its presence was
at all obvious to those patients and sponsors affected by such
favoritism. Consideration of this possibility led to the issue of
consumer/surrogate perception of marketer orientation in situations

involving conflicting needs.

61

The perception of marketer
orientation in a surrogate
purchase situation involving
conflicting needs

As previously discussed, if a marketer “chooses sides"
in a surrogate purchase situation the behavior manifesting his
choice is likely to be of an extremely subtle nature. In some
industrial situations in which the surrogate might be favored, such
behavior could take some time to be recognized by the consuming
firm. In such cases, there would be no one (purchasing agent or
salesman) who would be likely to talk about gifts, entertainment,
etc., that might be “consumated” far from the eyes of the firm em-
ploying the surrogate. Furthermore, the firms represented by the
agent might be too occupied with other matters to take immediate
interest in such behavior unless it directly threatened their wel-
fare. However, even the most oblivious consuming firms would (at
some point) probably realize that such behavior was taking place.
Likewise, were the orientation to run toward the consuming firm
disproportionately, eventual discovery of this bias by the involved
purchasing agents (through conventions, the grape-vine, etc.) was
probable.

Speculation about such perception produced H as follows:

III

III Guiding Marketer orientation favoring the needs of
either consumer or surrogates in a surro-
gate market situation is eventually per-
ceived by both groups indigenous to that
situation.

H

Fortunately, the nursing home market appeared likely to
perceive such actions more quickly, and this made it highly suited

to any research related to H111“

62

As mentioned earlier, all elements of the nursing home
surrogate purchase come together under one roof where any “covering
up“ would be unlikely. Furthermore, for the patient/consumers, the
purchase activity involves their whole life style and so might be
considered even more important than normal. For some sponsor surro—
gate as well, the emotional importance of the situation is likely
to command their attention greater than would normally be the case.

Thus, in the author's opinion, perception of marketer
orientation was likely to be displayed by nursing home consumers/

surrogates if it was present at all. This resulted in H3.
H3 Nursing home orientation consistently favoring the
needs of patients or sponsors in situations involv-
ing need conflicts between these two groups is
eventually perceived by both groups indigenous to
the situation.

Reflection upon the issues involved in H led to the following re-

3
search hypotheses:

H3A Patients in patient-oriented homes will perceive
more attention to their needs (vs. those of their
sponsors) than will patients in sponsor-oriented
homes.73

H3B Sponsors of patients in sponsor-oriented homes will
perceive more attention to their needs (vs. those
of their patients) than will sponsors of patients
in patient-oriented homes.

Despite interest in the perceptual issues summarized by the

above, no similar test for perception of nursing home orientations

 

73For the sake of convenience “patient oriented” and “sponsor
oriented" shall be used forthwith to refer to those homes consistently
favoring the needs of patients or sponsors in situations involving need
conflict between these two groups.

63

favoring organizational/personal needs was proposed. Quite frankly,
the author was at a loss to tell how awareness of this orientation
might be demonstrated by the methodology available to him. Further-
more, he was extremely doubtful that conscious awareness of such an
orientation was likely to be present.

Presumably, both the patients and sponsors defined to be
the focus of this research would have a multitude of experiences
which would demonstrate to them which of these two groups the home
favors (e.g., I'On a number of occasions, my sponsor got his way and
I didn't,” or vice versa). Experiences of the same type are not
likely to be present in a marketer orientation to personal/organiza-
tional goals. In this case all the non—favored person is likely to
be certain of is ”I didn't get my own way” and he probably does not
have enough experience with other nursing home operations to know
why (or to recognize that such is not always the case).

Viewed from another perspective, that of marketing science,
such extreme orientation to organizational needs other than profit
is probably not common outside of the walls of nursing homes. There-
fore, the failure to test for the perception of such an orientation
does not detract seriously from the general utility of the author's
research.

The possibility that marketer orientation toward any group's
needs might go undetected at the conscious level was believed to be
great. This was due to two factors: (l) the assumed subtlety of such

favoritism, and (2) sponsors' conscious or subconscious suppression

64

of their favored status due to the emotional pressures calling for
favoring of patient's needs. However, whether or not conscious
perception of marketer orientation was visible, satisfaction re—
lated issues could still be present. Conceivably, any consistent
favoring of one group's needs over those of another could result in
satisfaction/dissatisfaction regardless of whether or not its true
focus was understood. Given the interests of this research, investi-
gation of this satisfaction related issue was thought most crucial,
and attention was next focused on it.

Satisfaction emanating from

marketer orientation in a

surrogate market situation

under conditions of
conflictingoneeds

 

 

 

 

 

If a marketer chooses to favor one group's needs over those
of another, two issues of interest develop whether that action is per-
ceived on the conscious level or not. They are:

-Do the favored parties express more satisfaction with

the purchase involved than those not favored in similar
circumstances?

—Do the groups whose needs are neglected in favor of

another become less satisfied with the purchase in-
volved than those whose needs are favored?

If favored parties do not express more satisfaction with the
purchase involved than those not favored there would be much less justi-
fication for taking this action. However, it does not seem obvious
that such must necessarily be the case as the ”favoring“ might be con~

sidered so minor to the individuals involved as to be unimportant to

overall purchase satisfaction.

65

Conversely, if one group's needs are consistently favored,
then another group's must be ignored. Logically the non-favored
group could be expected to develop dissatisfaction over being ignored
consistently by the marketer's orientation. Once again, however, it
does not seem certain that this dissatisfaction would ”carry over“
to the purchase involved as it might be considered unimportant (or
even justifiable) to those ignored.

Consideration of whether or not purchase satisfaction/
dissatisfaction might stem from marketer orientation forced this
research to look beyond marketing for disciplines which have re-
searched such situations in general terms. Fortunately, the field
of communication science has dealt with situations of conflict
similar to the surrogate/consumer/marketer dilemma in highly meaning-
ful terms.

One of the most useful treatments of conflict was found in
Gerald Miller's discussion of interpersonal communication. Accord—
ing to Miller, the basis for communication science's analysis of
conflict is to be found in its definition of the basic function of
communication. He has summarized this basic function as being ” .
to control the environment so as to realize certain physical, economic

74

or social rewards from it.“ Miller perceives successful environmental

 

74Gerald Miller and Mark Steinberg, Between People: A New
Analysis of Interpersonal Communication (Palo Alto: Science Research
Associates, l975), p. 62.

 

 

66

control as being vital to the self concept of all individuals.
Those instances of successful environmental control in which ” .
desired and obtained outcomes of the communicator correspond

exactly“ are defined as compliance situations.75

 

However, Miller recognizes that all individual attempts
at compliance cannot be successful, for not everyone can have his
own way at once. Thus, the element of conflict between individuals'
desires must be dealt with.

There are a number of ways in which a conflict between
two or more individuals might be resolved. One alternative, con-

flict resolution, is defined as occurring . when two or more
competing parties reach a solution about the allocation of some
physical, economic, or social resource, and the solution is per-

76 The

ceived as relatively equitable by the competing parties.”
converse of this situation, conflict management, is a forced com-
pliance situation in which the competing parties do not perceive

the solution as being relatively equitable. Miller then theorizes
that such dampening is likely to result in the aggrieved party be—
ing so dissatisfied as to bring up the conflict again at a later
date, or to stimulate conflict about other matters. In other words,
if one party does not perceive himself as being treated fairly, he

will exhibit dissatisfaction not only with the conflict involved,

but also with other items indirectly related to it.

 

7SIbid., p. 66.

761bid.

67

Miller's analysis seemed very appropriate for the interests
of this research. Its foundation, the conception that communication
was an attempt to control one's environment nicely paralleled the
motivating factors behind the self serving purchasing agent behaviors
alluded to by Kotler. The recognition that conflict could result
from the failure to serve all needs was similar to the situations
conceptualized by Rewoldt, gggal. Finally, the assertion that such
conflicts could result in either resolution or management lent pre-
dictive insights to the issues at hand. If conflict resolution
stemmed from marketer orientation to conflicting needs, no dissatis-
faction need stem from it. This was congruent with the author's
earlier reflections. However, if marketer orientation was perceived
as unfair and conflict management between sponsor and surrogate re-
sulted, then dissatisfaction with the implied favoritism could exist.
According to Miller, this dissatisfaction would be directed at both

the marketer's orientation as well as other items related to it.

 

Given the communications discipline from which this analysis ensued,
the dissatisfaction to be expressed presumably would take the verbal
form already defined as the interest of this research. Furthermore,
one of the "other" items to which this dissatisfaction could be
addressed was clearly the item being purchased by the surrogate (for
what other criticism could harm an ”unfair“ marketer more?). The

preceding reflections were synthesized into the following:

68

HIv Guiding In a surrogate purchase situation containing
conflicting needs, the group not favored by
marketer orientation will express greater
dissatisfaction with the purchase involved
than the favored groups if the favoritism is
perceived as unfair.

The author felt many of the surrogate situation variables

contained in the above could be tested in the “laboratory“ repre-
sented by nursing homes. Therefore, he proposed H4 as follows:

H4 Marketers of long term nursing care faced with
conflicting needs of patients and sponsors create
dissatisfaction on the part of one of these groups
when the needs of the other are favored as this
favoritism is perceived as unfair.

At this point it was well understood that H4 contained two
major weaknesses: (l) only one—half (that involving orientations
perceived as unfair) of HIV could be tested, and (2) even that one-
sided investigation rested upon an assumption that the ”actors"
involved in sponsor/patient conflicts perceived the nursing home's
orientation to be unfair.

The first defect caused no great concern—~situations likely
to result in dissatisfaction were more interesting research subjects
than those that were not. The second weakness struck the author as
more serious, but the “unfair“ premise involved was thought justified.

In the most general case finding a surrogate situation with
definitive external indicators of whether or not the conflict “actors”
thought any favoritism just or unjust would be unlikely. But, for
the special situation of nursing homes such was not the situation.

As nursing home patients are frequently institutionalized

against their will, a belief that they would view any further

69

orientation to needs other than their own with great hostility
seems justified. Though the reactions of sponsors are more diffi—
cult to predict (due to the ”moral issues” surrounding patient
care) it is not apparent that inattention to sponsor needs would
be viewed with any favor, either.

Therefore, the following hypotheses ensued.

H4A Patients in sponsor—oriented homes are more

dissatisfied with the nurSing care prov1ded than
are patients in patient-oriented homes.

H4B Sponsors of patients in patient-oriented homes

are more dissatisfied with the nurSing care
provided than are sponsors of patients in sponsor-
oriented homes.

The author regretted that his limited resources would not
allow the proposal or testing of a similar set of hypotheses deal—
ing with dissatisfaction stemming from orientation to administrators'
roles as health care professionals. As such an orientation was not
typical for marketers other than nursing homes, the failure to test
its effects did not detract from any desire to advance marketing
science. Although the testing of such an orientation's effects
would have contained meaning for the study of nursing home satis-
faction, so would H4A_B(which could contribute to marketing science
as well). Therefore, the author thought this compromise acceptable.

This decision was based upon the premise that findings

supporting H4A-B would support H which would (in turn) point to a

4
rather important conclusion--that each time a nursing home "chooses
sides" in need conflicts involving patients and sponsors, one side

would become more satisfied and the other less so. Therefore, some

70

dissatisfaction resulted from any resolution of such dilemmas, and
this dissatisfaction extended to the care provided by the nursing
homes involved. In addition to answering some interesting theoreti-
cal questions regarding surrogate market behavior, such findings
would support the HI (Guiding) hypothesis. This would provide the
nursing home industry with a new argument against those muck-raking
critics who used dissatisfaction emanating from it to "demonstrate
that"all nursing home operators are bad.” Furthermore, if the
universal presence of such dissatisfaction was demonstrated, nursing
home operators might better understand it and work at developing
strategies for dealing with it.77
Because the above goals were so important (and this
chapter indicated they were attainable) the author next directed

his attention to development of a methodology which would evaluate

the factors to which they related.

 

77For an illustrative description of such strategies, see
Bertram H. Raven and Ariel W. Kruglanski's I‘Conflict and Power" in
Paul Swingle's The Structure of Conflict (New York: Academic Press,
l970), pp. 69-l04.

 

CHAPTER II
METHODOLOGY

The research structure suggested by chapter one was synthe-
sized and presented as Figure 2.l. As shown by this exhibit, a
number of methodological requirements stemmed from the author's
interests. Among these were the following:

-The separation of homes guilty of callous neglect from
the research sample.

-The development of a means of identifying individual
nursing homes' orientation (patient oriented, sponsor
oriented, etc.).

-The creation and application of a technique that would
relate nursing homes' choice of orientation to their
organizational need structures.

-The creation and application of instruments capable of
testing and comparing patient/sponsor perception of
nursing home orientation.

-The creation and application of tools capable of testing
and comparing patient/sponsor satisfaction with care
provided by nursing homes.

Although the preceding represented the major task confronting
the author, he recognized that other ancillary problems existed
which would also have to be resolved. This chapter will detail the
methods developed to deal with the project's major and ancillary
problems. Once this methodology has been presented in its entirety

the final section shall discuss the limitations imposed by the chosen

techniques.

71

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Figure 2.l--Continued

Research Hypotheses

 

A nursing home confronted
with conflicting needs of
patients and sponsors will
tend to satisfy the group
whose satisfaction will
best serve the nursing
home's need structure

2A-1

2A-2

28

Operational Hypotheses

 

Proprietary homes will be
more sponsor oriented when
dealing with private-pay
patient/sponsor conflicts
than non-profit homes are
in similar conflict situa-
tions involving Medicaid
patients.

01"

Proprietary homes run by
administrators totally
committed to the profit
motive will be more sponsor
oriented when dealing with
private-pay patient/sponsor
conflicts than homes run by
administrators less moti-
vated by profits are in
dealing with similar con-
flicts involving Medicaid
patients.

Proprietary homes run by
administrators totally
committed to their role as
a health care professional
will be more oriented to a
behavior associated with
this role when it conflicts
with the needs of Medicaid
patients and/or sponsors
than will homes run by ad-
ministrators with lesser
commitments to this role
when faced with similar
private-pay patient and/or
sponsor conflicts.

74

Figure 2.l--Continued

Research Hypotheses

3A

Nursing home orientation
consistently favoring the

needs of patients or

sponsors in situations
involving need conflicts
between these two groups H

is eventually perceived 38
by both groups indigenous
to the situation.

H4A

Marketers of long term

nursing care faced with
conflicting needs of

patients and sponsors

create dissatisfaction

on the part of one of H
these groups when the

needs of the other are

favored as this favoritism

is perceived as unfair.

48

Operational Hypotheses

Patients in patient-oriented
homes will perceive more
attention to their needs (vs.
those of their sponsors) than
will patients in sponsor—
oriented homes.

Sponsors of patients in spon-
sor—oriented homes will per-
ceive more attention to

their needs (vs. those of
their patients) than will
sponsors of patients in
patient-oriented homes.

Patients in sponsor-oriented
homes are more dissatisfied
with the nursing care pro-
vided than are patients in
patient—oriented homes.

Sponsors of patients in
patient-oriented homes are
more dissatisfied with the
nursing care provided than
are sponsors of patients in
sponsor-oriented homes.

75

The sample

 

As previously discussed, the author limited his study to
nursing homes within the state of Michigan. However, because he-
was interested in researching dissatisfaction with nursing homes
that did not arise out of callous neglect, he wanted to go beyond
this broad constraint to eliminate from his sample as many homes
guilty of such neglect as possible. Making such a distinction did
not appear easy since no uniformly accepted index of nursing home
quality existed.

In addition to the preceding dilemma the author expected
to encounter another problem with any sample he chose, that of
sample non-response. In his interviews with nursing home adminis-
trators, he sensed a reluctance to participate in any study of the
industry. The prevailing attitude seemed to be that every time the
nursing homes cooperated with a researcher, that researcher then
did his best to exploit any negative findings he encountered by pub-
lishing "exposés'I of the industry. Given the prior analysis of the
"popular press'l treatment of nursing homes, the above apprehensions
appeared well founded.

An analysis of scholarly research into nursing homes indi—
cated that such distrust of researchers apparently manifested itself
in a low response rate to research inquiry. Miller's study of
Florida nursing homes achieved only a thirty-six per cent response

to a mail questionnaire,1 and in Trainor's Washington State study

\

lMiller, p. 18.

¥

76

even worse results were produced by a mail contact soliciting later
interviews.2 Because the author anticipated using a mail question—
naire as one of his research instruments, he was very troubled by
such low response rates. A similarly low response rate when
coupled to the small number of nursing homes within Michigan could
cripple the project.

The author's response to the above problems was to choose
as his sample the nursing home membership of the Health Care
Association of Michigan (HCAM). This trade association for nursing
home administrators represented 257 member nursing homes at the
time of this study.3

When apprised of the author's interest, this association
proved eager to cooperate. Its education committee provided a $400
grant and agreed to assist in whatever other ways it could. Although
HCAM was obviously attracted by the positive stance taken by the
proposed research, it imposed no ”strings” in return for its parti-
cipation, and granted the total freedom needed to maintain objectivity.
This was fortunate, for subsequent experience would show that the
choice of this association's membership as a research sample was
invaluable to achieving the research objectives of this project.

With regard to eliminating callous neglect from his sample,

the author believed that many of the least desirable nursing homes

 

2Trainor, p. 10.

3This organization has within its membership both nursing
homes and homes for the aged. Because of the definitional considera—
tions already discussed, homes for the aged were excluded from the
sample.

77

probably would eliminate themselves by not investing the time and
money necessary for membership in a trade association. Further-
more, the vast majority of HCAM members had faced other, more
tangible mechanisms likely to screen out the worst offenders.

Unfortunately, because of historical factors, the
barriers to membership in HCAM had not been entirely uniform. The
Health Care Association of Michigan was formed during the initial
phases of this research from what had formerly been the Michigan
Nursing Home Association (approximately 190 members) and the
Michigan Health Facilities Association (approximately 70 members)
which was the Michigan chapter of the prestigious national American
Nursing Home Association.

All former Michigan Nursing Home Association (MNHA) mem-
bers had to undergo rather careful scrutiny prior to their
acceptance as full fledged members, and had agreed to adhere to a
rigid code of ethics as a condition of membership.4 One relevant
provision of the MNHA code was that members be subject to the
scrutiny of an ethics and standards committee that investigated
all complaints about member conduct and did have the power to revoke
membership if conditions warranted. Although the author assumed

that these procedures probably did not eliminate all undesirable

 

4See MNHA, Application for Membership (Lansing: Michigan
Nursing Home Association, l974), and MNHA, Michigan Nursing Home
Association Operational Code (Lansing: Michigan Nursing Home
Association, l972).

 

 

 

78

members, he felt they were about as effective a screening device
as he was likely to find.

Unfortunately, identical procedures were not operative
for the Health Facilities Association members, so the author was
faced with the decision of whether or not to include them in his
sample. Ultimately, he did decide to include them. Talks with
MNHA members indicated that the Health Facilities Association
members were thought to be as ethical as the MNHA nursing homes
(or else the two organizations would not have merged). Further-
more, the Health Facilities Association members were a part of a
larger prestigious nursing home trade association (the American
Nursing Home Association) which was well thought of nationally,
but had never attained any size in Michigan. Taken altogether, the
author felt his choice of sample did meet his objective of screen-
ing out as many undesirable homes as possible, so he next turned
his attention to the development of a research instrument to be
applied to this sample.

Identification of nursing_homes'
orientations and need structures

 

The task of developing a technique for assessing what
orientation (patient, sponsor, etc.) a nursing home took in patient/
sponsor conflicts was a difficult one. Any long—run direct observa-
tion was likely to be extremely difficult and subject to many

methodological drawbacks.

79

Furthermore, second hand assessments of homes' orienta-
tion by outside ”experts” seemed likely to be fraught with error.
The obvious need was for some instrument which would honestly re-
flect whose side the nursing homes took when dealing with actual

conflict situations.

To this end the ”Administrator Questionnaire” presented
as Appendix ”B“ was constructed. The relationships between its
component parts and the hypotheses already proposed was synthesized
in Figure 2.2.

As can be seen from Figure 2.2, there were two groupings
of interest to this research project; (1) a set of simple questions
related Uinursing homes' needs structures, and (2) a series of cases
intended to determine nursing homes' orientations in various con-
flict settings.

All the cases and questions were derived from interviews
with the aforementioned governing board of the American College of
Nursing Home Administrators. They represented actual conflict
situations these administrators had encountered in the nursing
homes they managed. Cases “one,“ ”three,” and “five” represented
situations in which the needs of the patient were in conflict with
those of the sponsor and the nursing home administrator had to
choose which set to favor. Cases “two,” "four,” and I'six" pre—
sented similar dilemmas in which the needs of patients and/or
sponsors conflicted with the administrator's prerogatives as a

health care professional.

8O

 

Research Hypothesis Administrator
(From Figure 2.l) _Questionnaire

 

Cases Questions

 

HZA-l Proprietary homes will be more sponsor 1,3,5 3
oriented when dealing with private-pay
patient/sponsor conflicts than non profit
homes are in similar conflict situations
involving Medicaid patients/sponsors.

H2A-2 Proprietary homes run by administrators 1,3,5 3,5a
totally committed to the profit motive will
be more sponsor oriented when dealing with
private-pay patient/sponsor conflicts than
homes less motivated by profits are in
dealing with similar conflicts involving
Medicaid patients.

HZB Proprietary homes run by administrators 2,4,6 3,5e
totally committed to their role as a health
care professional will be more oriented to
behavior associated with this role when it
conflicts with the needs of Medicaid patients
and/or sponsors than will homes run by adminis-
trators with lesser commitments to this role
when faced with similar private-pay patient
and/or sponsor conflicts.

Figure 2.2. Research structure and administrator
questionnaire development

The cases and questions referred to took the following format:
Case One

Sara M. is a 68-year-old resident of the X nursing home. She is
mentally alert and in good physical condition for her age. Lately,
James L., a 7l-year-old widower who was admitted to the home as a
private pay patient after a mild stroke which left him only minimally
impaired physically has developed an interest in Sara. Sara and
James have been visiting each other's rooms and holding hands. Mr.
L's sponsor observed this and became very upset. He has repeatedly
demanded that the home “break-up” this budding romance, and your
attempt to dissuade him has failed.

Definitely Yes Definitely No
l 2 3 4 5

la. Would you ”passively“ try to keep Sara and James apart by
arranging activities for them at different times and/or places.

lb. Would you "actively“ try to break up this romance by instruct-
ing your staff not to allow Sara and James to hold hands or
be alone together, etc.

lc. Would you have been more likely to do either a_or p had Mr.
L's sponsor threatened to withdraw James from your home if
you did not ”do something”?

 

81

Desiring to gather as much information as possible, the
author offered three alternative (although sometimes related)
courses of action for the respondents to select in each case. This
step enabled him to keep the instrument's length manageable while
trebling the inputs available for analysis. In order to determine
the nursing home's orientations, the responding administrators
were asked to indicate (on a five point semantic scale) whether or
not they would take each of the actions suggested. Hoping to test
the apparent validity of the questionnaire, two different versions
were used, one identifying the patients as "private pay" and another
identical in content except the patients were described as “Medicaid“
recipients. This was an attempt to circumvent the problem
associated with asking nursing homes to indicate that they treat
patients/sponsors differently depending upon the source of revenue
supporting them. Because the author doubted that any questionnaire
(no matter how well designed) could get individual administrators
to admit to such a distinction, he decided to see if he could get
the industry as a whole to indicate any differential treatment by
unknowingly responding to different questionnaires. However, if
the instrument was functioning properly, nursing homes answering a
“private—pay“ questionnaire should be more sponsor oriented (in
patient vs. sponsor conflicts) than those responding to the ”Medicaid”
instrument, etc.

As is obvious from studying the various response alterna-

tives, all questions except those associated with case "one" arrange

82

the choices in such a way that the polar semantic choices reflect
parallel “side-taking” action. That is, a response of ”definitely
yes" to question ”3a“ would clearly indicate action more favorable
to the patient's side than the sponsor's. Careful analysis shows
similar results for all the odd-numbered response alternatives
except for those associated with case ”one” (where they are all
reversed). Similarly, an answer of “definitely no” to question
”2a” manifests behavior placing the prerogatives of the adminis-
trator superior to the expressed needs of patients and sponsors.
Again, this indication of administrative side-taking is similar
for all even numbered responses.

In order to simplify analysis, a decision was made to
reverse all indicated responses to the questions of case ”one”

(a response of ”five” would become a response of ”one,” etc.).

Once this was accomplished and all responses ”ran the same direction,”
it was possible to develop a simple decision rule for assessing the
orientation of individual nursing homes.

Clearly, in assessing patient/sponsor orientation, a
response of ”3” to any of the odd-numbered responses would indicate
a situation in which the administrator was undecided about the
correct course of action to follow. (In fact, this response was
included to keep normally uncooperative administrators from ”giving
up” on a questionnaire which undoubtedly would present them with

many difficult choices). However, it was felt that any response on

either side of this neutral position did indicate side taking.

83

Therefore, the author defined any response of “four or more" or
"two or less" as indicating "sponsor" and "patient“ orientation
(respectively) when made in response to odd numbered questions.

Likewise, he defined any response of "four or more“ or “two or

 

less" as representing_”patient/sponsor" and "administrator"
orientation (respectively) to the patient andlor sponsor vs.
administrator conflicts posed oy even numbered guestions. But,
this side-taking was not expected to be one hundred per cent uni-
form for all questions. The situations described and the individuals
responding were too heterogeneous to create much likelihood of
that happening. Therefore, very strong orientations could be dis-
played by response patterns in which all answers were not of
identical intensity. Any decision rule chosen would have to re-
flect this fact. The only question was, “where to draw the line.“

Since each of the two conflict types offered nine possible
responses, the author recognized that the number "five“ represented
a logical breaking point of just over half of the total possible
response alternatives. Because he felt nursing home administrators
might be timid about expressing their choices, he elected to use
this point to differentiate between the various nursing home
orientations. Coupling this decision with the preceding produced
the following operational definitions:

—A patient—oriented home is one in which the administrator

responds "four or more” to “five or more“ of the nine
responses to odd numbered cases.

 

-A sponsor—oriented home is one in which the administrator
responds "two or less" to ”five or more” of the nine
responses to odd numbered cases.

84

-A patient/sponsor-oriented home is one in which the
administrator responds “two or less" to "five or more“
of the nine responses to even numbered cases.

-An administrator-oriented home is one in which the
administrator responds "four or more" to "five or more”
of the nine responses to even numbered cases.

-Homes which fit none of the above definitions are con-
sidered to be indeterminate in their orientation.

 

Once the preceding decisions were made, the questionnaire
was pretested by a panel of nursing home administrators attending
a summer training seminar conducted by the Michigan Nursing Home
Association. In order to keep from ”spoiling” a large portion of
the total potential sample, the size of this panel was purposely
kept small. Ultimately, nine nursing home administrators responded
to "Medicaid“ questionnaires and nine others responded to ”private-
pay“ questionnaires. Applying the above decision produced the
results shown in Table 5.

The author was quite encouraged by the preceding results.
Intuitively, the hospital/medical overtones associated with nursing
homes would seem to dictate that the majority of homes responding
be patient oriented for patient vs. sponsor conflicts and adminis-
trator oriented for administrator vs. patient and/or sponsor conflicts.
For the most part, the above data conformed to these expectations and
lent some face validity to the research instrument. Equally promising-
was the indication of a small group of homes taking the “other side'l
of the proposed choice dilemmas. As shall be shown later, this factor
was vital to the comparisons necessary for a thorough testing of the

proposed hypotheses.

85
TABLE 5
RESULTS OF ADMINISTRATOR QUESTIONNAIRE PRE-TEST

 

 

 

Orientation Patient/Sponsor
Exhibited Identified as . . .
by Home Medicaid Private-pay

 

Patient vs. Sponsor Conflicts (Cases 1, 3, 5)

 

Patient 7 3
Indeterminate l 5
Sponsor l l

 

Administrator vs. Patient and/or Sponsor Conflicts (Cases 2, 4, 6)

 

Administrator
Indeterminate
Patient/Sponsor

 

Finally, although the sample was judged too small for
further statistical analysis, the directional emphasis of the data
did conform to the already proposed relationships. To the extent
that less patient orientation indicated greater sponsor orientation
the homes were more sponsor oriented for private—pay patients than
they were for Medicaid patients. Likewise, the degree of adminis-
trator orientation was (weakly) greater for Medicaid patients than
for private-pay patients (as the author had conjectured it would be).

In light of these results the author decided to adopt the
proposed questionnaire as one of his research instruments. However,
in consultation with the individual who supervised the pre-test, he

added some clarifying instructions, slightly reworded some choice

86

alternatives, and minimally revised the wording of a few of the
cases. As can be seen by examining Appendices ”C" and ”D," the
revised questionnaires, no substantial changes were made. Once
these were revised, the questionnaires were reviewed by the
executive director of the nursing home association who attested
to their apparent validity and ease of interpretation.

The reason for any unusual caution indicated by the
preceding was that the author found himself working with a rela-
tively untried methodological technique. The concept of presenting
conflict cases and deducing the nursing home's orientation from
their handling of them was developed jointly by the author and his
dissertation committee. The author knew of no other such studies,
and he was unable to find any within the marketing literature. So,
he looked to other disciplines for similar methodological approaches.

The findings in these other areas were equally sparse.
The only similar methodology that was uncovered had been utilized

in the study of risk taking. In their Risk Taking, A Study in

 

Cognition and Personality, Kogan and Wallach described what they
called a "choice dilemma procedure.”5 This technique, which was
borrowed from an earlier work,6 tried to determine whether an

individual was a risk taker or a risk avoider by assessing his

 

5Nathan Kogan and Michael Wallach, Risk Taking, A Study
in Cognition and Personality_(New York: Holt Rinehart and Winston,
1964).

 

6See Wallach, et al., “Group Influence on Risk Taking,”
gournal of Abnormal and Social Psychology_LXV, No. 2 (1962), 75-86.

87

responses to a number of dilemmas indicating varying degrees of
risk. Although conceptually similar, these studies were quite
different from the author's in terms of the actual techniques
employed. Because of this fact (and the paucity of other similar
studies), the author was reasonably sure that the case dilemmas
component of his methodology represented unusual (perhaps pioneer—
ing) research. Insights gained from his utilization of this
technique will be presented in chapter four.

Once judged to be satisfactory, the questionnaires were
numerically coded and mailed to the nursing home administrators
who comprised the membership of the Health Care Association of
Michigan. In order to further test the questionnaires' apparent
validity (as well as to increase the expected size of any orienta—
tion differences manifested) a decision was made to retain the
two-sided (private—pay vs. Medicaid) feature of the pre-test
instrument. Accordingly, the respondents received instruments
that were identical in content except for the description of the
patients/sponsors involved. One half of the sample received
questionnaires identifying the patients/sponsors as “private-pay”
and the other half received questionnaires which described the
same subjects as ”Medicaid" patients/sponsors. In order to imple-
ment these actions, an alphabetical listing of the association's
members was numbered. All odd numbers were sent a “Medicaid”
questionnaire and all even numbers a ”private-pay" questionnaire.

To help keep the records ”straight“ these two different questionnaires

88

were color-keyed (“Medicaid“ questionnaires were white and "private-
pay" questionnaires were buff).

In an attempt to increase the response rate, the question-
naires were mailed out under the cover letter of the executive
director of HCAM. As can be seen from examining this letter
(presented in Appendix “E”), the questionnaire was presented as a
project of the education committee of the association into how
administrators "perceive the best ways to do their jobs.ll The
accompanying return envelope was addressed to the executive office
of the association (which then forwarded them to the author). All
of these actions were taken to minimize any apprehensions the
sample respondents might have had about participating in the study.

After a month had elapsed the reminder letter presented
as Appendix “F” was mailed out to the sample non-respondents. With
it went another numerically coded questionnaire (of the same type
as before) and another return envelope addressed to the association.

As shall be discussed in chapter three, the response to
the mailed questionnaire was most gratifying. This was fortunate,
for a large sample of respondents was absolutely necessary for re-
solution of the last major dilemma confronting the author, that of
comparing the reactions (in regard to perception and satisfaction)

of patients to different nursing home orientations.

89

The testing and comparing of
patient/sponsor reactions to
different nursing_home
orientations

In order to test/compare reactions to different nursing
home orientations, four tasks must be undertaken: (l) a sample of
nursing homes manifesting the different orientations must be identi-
fied and chosen, (2) a sample of patients and sponsors within each
of the identified homes must be secured, (3) some instrument cap—
able of measuring both perception of nursing orientation and
satisfaction with nursing care must be developed, and (4) this
instrument must be applied to the sample of patients/sponsors. The
ensuing section of this chapter shall relate how the above tasks
were accomplished.

Choosing a sample of_patient/
sponsor-oriented nursing homes

 

 

The task of identifying a sample of nursing homes with the
desired orientation was accomplished with the aid of the Western
Michigan University Computer Center. Four print-outs (two for
"Medicaid” and two for ”private—pay“ respondents) were created. Each
of these print-outs grouped the respondents according to which
questionnaire they answered (”private-pay” or ”Medicaid”), and then
rank ordered them on the basis of their manifestation of the subject
behavior. That is, one group who responded to "Medicaid” question—
naires and qualified as ”sponsor oriented homes” was ranked from

least extreme to most extreme according to this variable. Homes who

 

 

90

responded ”four or more“ to ijg_of the nine odd numbered questions
were ranked first. Homes who responded ”four or more" to £15 of the
nine odd numbered questions were ranked next, etc. The same pro-
cedure was utilized with the other groupings as well. Once this

was done two lists of sixteen of the most patient-oriented and
sponsor-oriented homes (respectively) were drawn up. Because these
two lists represented the polar extremes in nursing home orienta-
tion, the author wanted to test and compare the reactions of patients
and sponsors to the care provided by them.

As shall be discussed later, he saw interviewing techni-
ques as being the best way of accomplishing this end. However, the
cost of interviewing was known to be sizable and this factor man-
dated that patients/sponsors in a maximum of twelve homes could be
interviewed. Therefore, the above sample had to be distilled still
further.

In order to ensure a reasonable population of lucid
patients and cooperative sponsors to sample from, all small (under
40 beds) homes were eliminated from the lists of ”possibles.“ Simi-
lar thinking prompted the removal from the lists of as many ”private-
pay” respondent homes as possible. Because the subject homes had
identified their orientation by responding to questionnaires identify-
ing the patients/sponsors as either ”private-pay” or “Medicaid,“
the author felt any patients or sponsors later drawn from these homes
for interviews would have to be of the same type (for he didn't
know if individual homes treated the two categories of patients/

sponsors differently). For homes responding to a ”private-pay“

91

questionnaire this situation posed a potential problem as the rela-
tive number of such patients/sponsors was small, and drawing from
them a reasonable sample to interview might prove impossible. In
order to avoid this difficulty the majority of homes who had
responded to ”private-pay“ questionnaires were eliminated from
further consideration.7 Ultimately, this left two lists of eight
homes apiece: one list of eight patient-oriented homes (all
”Medicaid” respondents), and one list of eight sponsor-oriented
homes (six ”Medicaid” and two ”private-pay” respondents).

From the above two groupings the executive director chose
two final lists of six patient oriented and seven sponsor oriented
homes. These final lists were based upon his judgment as to which
homes would be most likely to cooperate with a study requiring the
interviewing of the homes' patients and sponsors. (The reason
seven sponsor oriented homes were chosen was that he was not sure
all of them would cooperate). The six patient-oriented homes were
all ”Medicaid” respondents while the seven sponsor-oriented homes
contained one ”private-pay“ respondent. It was from these homes
that samples of patients and sponsors would be drawn for future

study.

 

7The reason all_such homes were not eliminated was due to
the disparity in numbers between patient-oriented and sponsor-
oriented homes. Patient-oriented homes were so numerous that elim-
inating all private-pay respondents still left an adequate number
of such homes to study. However, sponsor-oriented homes were so
small in numbers that the biggest of the I'private—pay" sponsor-
oriented homes had to be retained in order to achieve a reasonable
sample size.

92

Developing a sample of
patients and sponsors

HCAM assumed the responsibility of securing the coopera-
tion of each of the chosen homes. As shall be explored more
thoroughly in the following chapter, this task proved much more
difficult than anticipated. Eventually, all of the patient—
oriented homes and five of the sponsor—oriented homes agreed to
participate in this project. Each of these homes was asked to send
the association a list of six mentally competent patients (who
could be interviewed) and ten co-operative interested sponsors
(from which a total of six sponsor interviews would be secured).
The only condition imposed upon the homes' choices was that the
patients/sponsors be of the desired (private-pay or Medicaid) type.
These lists were then forwarded to the author and served as the
sample against which his measures of patient/sponsor response to
nursing home orientation would be applied.

An instrument for assessing

patient response to nursing
home orientation

 

 

It was anticipated that assessing patient response to
nursing home orientation might represent a difficult task. Because
older people frequently have failing eyesight and may be functionally
illiterate, any form of mailed questionnaire was deemed inappropriate.
Similar problems with hearing and lack of access to telephones pretty
well precluded telephone interviews. Therefore, the only viable

alternative appeared to be personal interviews. Because the interviews

93

were to be utilized for comparison purposes, their content had to

be structured so as to ensure uniformity. Given the two preceding
factors, the only remaining question for the author to decide was

“what shall the interview contain?”

Because the author knew the people being interviewed
would be fairly old, he wanted to limit the length and complexity
of any instrument chosen in order to minimize respondent fatigue.
Despite this limitation, the interview's content would have to
probe two diverse issues, the perceived quality of the nursing
care provided and the comparative orientation of the nursing home
to the patient's needs (vs. those of his sponsor).

In determining the quality of the nursing home as per-
ceived by patients, the author did not wish to probe too deeply
all of the finite facets of nursing home care (food, service, etc.).
He felt that doing this with patients might take inordinately long
to discuss and evaluate. He also didn't want to "make waves” about
these issues by discussing them with nursing home residents who
might not previously have thought about them. Given the apprehensions
of nursing homes about researchers, such questions might have caused
the homes to bar all interviewers.

Similar concerns plagued the issue of determining patient
perception of nursing home orientation. There was no way the author
wanted to ask the patients, ”does this nursing home favor the needs
of your sponsor over yours?" Once again this was thought to be a
potential cause of trouble for the nursing homes (whose patients might

not have thought about it before).

94

Reflection upon these problems (and an active literature
search) culminated in the Patient Interview Format presented as
Appendix ”G.” All but questions “five" and “ten” were intended to
rate the patient's satisfaction with his nursing home. "Five" and
"ten” were included to test the patient's perception of the orienta—
tion of the nursing home toward patient/sponsor needs.

The satisfaction related questions were part of a
“Gratification From the Home Environment (GH)“ instrument developed
by Pincus.8 The interviewer using the GH instrument was to distill
the responses to questions l-4, 6-9, and ll-l2 down into one single
satisfaction rating arrived at from a careful study of the ”Rating
Scale for Gratification From the Home Environment” developed by
Pincus and presented as Appendix ”H.“ Although this instrument was
intended to study homes-for-the-aged residents, the author decided
that it also could be utilized to study nursing home residents if
they were in good enough condition to be able to understand it.

According to Pincus, the satisfaction rating obtained from
the "GH” instrument was intended to be independent of a number of
other environmental factors (i.e., the patients' health, how they
felt about being placed in an institution, etc.) that might surround
their residence. When Pincus compared patients' GH rating with
various measures of these factors he found no significant correlation.

The only factor which he did find to have any effect on GH was the

 

8Aiien Pincus, pp. 81-86.

95

length of time the individual had been in the institution, and even
the impact of this element was not profound.9 Finally, in testing
the actual application of the GH rating scale, Pincus found no

variation between evaluators (albeit from a small sample).10

In light of these findings the author felt confident of
his decision to use the Pincus instrument for the purpose of evaluating
patient satisfaction with the nursing homes in his sample. This
left assessment of patient perception of nursing home orientation
the only remaining dilemma to be resolved.

In order to assess patient perception of nursing home
orientation, questions "5” and ”l0“ were added to the patient inter-
view format. These questions were reviewed with the executive
director of HCAM prior to their inclusion and were adjudged suffi-
cient. With the patient issues resolved, the focus next turned to
the similar problems associated with sponsors.

Assessing sponsor response to
nursingnhome orientation

 

 

It was the author's judgment that measuring sponsor response
to nursing home orientation should present fewer problems than the
already discussed assessment of patient response. Presumably, the
sponsors would be in good physical condition with adequate hearing
and eyesight. These factors indicated that any of a number of techni-

ques might be applicable.

 

10

9Pincus, p. 86. Pincus, p. 82.

96

However, because of a desire to obtain a quick reply and
keep the response rate high, a decision was made to utilize an
interview format. But, in order to conserve resources, these
interviews were to be done via telephone.

Turning to the issue of what to include in the interview,
an assessment of the patient interview format indicated that there
was no way it could be "bent'l to assess sponsor response. Further-
more, because sponsors were physically removed from the nursing
home setting they could be probed more intensively about detailed
aspects of the nursing homes' services.

After studying the few instruments available, the author
decided to use a “Relative Interview Questionnaire” that had been
prepared for the Institute of Gerontology by Barbara Tomlinson.H
Because it appeared so appropriate to the needs at hand, the
Tomlinson questionnaire served as the basis for the Sponsor Tele-
phone Interview presented as Appendix “I.” The first two questions
of the Sponsor Telephone Interview were of a demographic nature
and were intended to see whether the respondent met the definitional
requirements discussed in the beginning of this paper.

All of the remaining questions except I'4" and I'll" were

from the Tomlinson questionnaire and were intended to measure sponsor

 

HSee Barbara Tomlinson, ”The Nursing Home Research Project
and Ehe Relative Sub-Study” (unpublished paper, Institute of Gerontology,
l97l .

 

97

satisfaction with a number of quality related variables. The
Tomlinson questions had been pre-tested by a small panel of nurs-

12 Because of

ing home administrators and directors of nursing.
this pre-test and their apparent validity, they were used without
modification to evaluate sponsor satisfaction with the nursing
homes' services.

Questions ”4“ and “ll were included to test sponsor per-
ception of nursing home orientation. Because they used the same
format as the Tomlinson questions (and were reviewed by the
executive director of HCAM) no further pre-test was felt to be
necessary.

Because he was concerned that sponsors might be reluctant
to respond to a ”blind” telephone interview, the author constructed
the letter presented as Appendix “J." The “patron" letter was to
be signed by the home housing his patient and mailed to the sponsor
prior to his actual telephone contact. This was intended to re—
assure the sponsor as to the motives and use of interview.

With the completion of the patron letter the only remain-
ing dilemma was how to apply all the patient/sponsor measures to the
sample selected. Because the author knew how the responses should
"come out,‘I he did not wish to risk injecting bias by applying the

instruments himself. Therefore, he sought some other means to do it.

 

12Tomlinson, pp. ll-l3.

98

Application of patient/sponsor
measures to the research sample

In order to apply his patient/sponsor measures the author
secured the services of Michigan Interviews, a Lansing based pro-
fessional market research agency with trained interviewers all
over the state of Michigan. Because these services were relatively
expensive, a small ($250) research grant was secured from Michigan
State University to help defray their cost.

Because of these interviewers' professional backgrounds,13
no attempt at further training was made. However, each of the
interviewers was provided with a carefully prepared packet of all
the items they would need for each home. In addition to adequate
supplies of all the instruments already discussed, this packet in-
cluded envelopes addressed to the patron-letter recipients, a list
of the patients and sponsors to be interviewed, the instruction
sheet presented as Appendix ”K“ and the letter of introduction from
HCAM presented as Appendix ”L.”

As can be seen from the instruction sheet, the interviewers
were to make phone contact with the nursing home administrator prior
to their visit. Upon arrival, they were to show the letter of intro-
duction if they encountered any difficulties caused by an administra—

tor who had forgetten about his pledge to cooperate, was absent, etc.

 

13Three were former Gallup pollsters, one was a supervisor
for Audits and Surveys, Inc., and one was a professor of sociology at
a community college.

99

Once admitted the interviewers were to verify that the
patients/sponsors to be interviewed fit the desired private-pay/
Medicaid category. Then, they were to ask the nursing home adminis-
trator to sign the patron letters and lead them around to the chosen
patients.

Upon completion of the patient interviews, the inter-
viewers were to mail the patron letters and wait a few days before
initiating the sponsor telephone interviews.

The author reviewed all of the packet materials with a
panel of research experts and the director of Michigan Interviews
prior to their dissemination. These individuals judged them to be
entirely adequate. However, in order to prevent any unforeseen
complications, he also discussed the project with each of the
interviewers by telephone prior to their interviews.

These preparations completed the creative phase of the
project's methodology development. Of course, the eventual analysis
of the instruments utilized had always been an important parameter
of their construction. However, when they were finalized it became
much easier to discuss appropriate statistical techniques for the

analysis phase of this research.

Analytical techniques employed

As discussed earlier, this study constituted exploratory
research into the origins of dissatisfaction with nursing homes. This

emphasis greatly complicated the choice of appropriate statistical

100

techniques with which to analyze the findings. As should be evident
by now, the research design concentrated upon studying those groups
judged most likely to display the behaviors of interest to the author.14
The general methodological limitations of such a choice mechanism are
explored more fully in the following section. But, from an analytical
point of view, the groups chosen for study all have one common short-
coming, none of them constitute a random sample. Therefore, any
statistical technique utilized could not be considered a conclusive
measure of the power of the findings. Rather, the tests employed should
be understood to represent a relative indicator of the importance of the
behavioral differentials manifested. Strongly "significant" findings
would indicate whether or not the author's hypothesized sources of
dissatisfaction with nursing homes seemed justified. If so, subsequent
research under more ideal conditions could determine whether or not his
findings were true for nursing homes in general. Accordingly, the
author was not troubled by his decision to choose an appropriate statis-
tical test and employ it as though his data met the assumptions of the
test (even though it most assuredly did not).

The test decided upon for all of the comparisons of interest
to this research was the Mann-Whitney U test. This non-parametric test
was indicated due to the ordinal nature of the data and the fact that

14i.e., the Administrator questionnaire was administered only

to HCAM members because they were thought less likely to include homes
guilty of callous neglect. Furthermore, the patients and sponsors
interviewed were chosen by administrators in homes identified to rep-
resent the extremes in orientation.

101

it could analyze very small cell sizes (a property not available from
its closest equivalent, the chi-square test).

The procedure for applying the Mann~Whitney test (which is
demonstrated and explained in Appendix "M”) was, of course, the same
for each application. And, the same confidence level of .10 was utilized
each time the test was applied. However, the mechanics of preparing the
data for the test was different each time.

In order to test the hypotheses (HZA-B) linking orientation
to need structure, data fitting the dimensions of the research hypoth-
eses first had to be broken out of the assembled raw totals. For HZA-Z
and H2B this involved arriving at a definition hinted at by these
hypotheses. For HZA-Z administrators ”totally committed to the profit
motive" were defined as those who answered ”l" to question 5a, and the
opposite extreme was assigned those who answered "2 or more" to the same
question. Likewise, the administrators of H28 who were "totally com-
mitted to the profit motive” were defined as those who answered "l” to
question 5e, while their less extreme counterparts were defined to be
those who answered "2 or more” to the identical query. These breaking
points were chosen because it was felt that most of the responses to
these questions would cluster around the first two response choices,
and any differences would have to be determined from within their ranks.
Once this decision was made there was no problem in sorting out the
various information sources that fit the hypothesis to be tested. But,
this still left unresolved the question of what individual inputs should

be analyzed.

102

Originally, the author had considered analyzing the various
categories on the basis of the relative number of "sponsor-oriented,”
"patient-oriented," indeterminate, etc. homes they contained. However,
this approach was rejected because the decision rules that defined
these groups could mask the comparative intensity of responses to
individual items (i.e., according to the definition, a response of "4”
was considered to be same as a response of ”5," etc.).

A better approach was thought to consist of applying a Mann—
Whitney test to the relative response patterns to each of the questions
that defined the dimension under consideration. However, this neces-
sitated the development of an appropriate decision rule to utilize once
the tests had been performed on each of the questions. Relying upon
the same logic that produced his earlier definitions, the author decided
to accept the research hypothesis under consideration if five or more
of the nine relevant items were in the presumed direction at the .10
confidence level.

The testing of H3A and H38 concerning patient/sponsor percep-
tion of nursing home orientation presented rather more of a problem.
Though both the patient and sponsor instruments each had two questions
("5 and 10” and ”4 and ll” respectively) evaluating this issue, the
question was how to compare them.

The patient dimensions of this dilemma were resolved in the
following manner:

(1) The response to questions five and ten were coded on a

four point scale ("1" for strongly agree, ”4" for
strongly disagree, etc.)

103

(2) For each respondent the difference between question five
and question ten was recoded in the following manner.

Response Difference
Category -3 -2 -l 0 +l +2 +3

New Code Relatively more 1 2 3 4 5 6 7 Relatively more
attention to attention to

sponsor needs patient needs

(3) The newly coded response differences were compared via a
Mann-Whitney test at the .10 level of confidence.

As can be deduced from the above, if patients in patient-
oriented homes displayed significantly more responses in the direction
of "7" than did patients in sponsor—oriented homes, the null hypothesis
would be rejected and H3A would be supported.

Sponsor perception of nursing home orientation was assessed in

an identical fashion:

(l) The response to questions four and eleven were coded on

a four point scale (”l'I for very satisfied, “4" for very
dissatisfied)

(2) For each respondent the difference between question eleven
and question four was recoded as shown:

Response Difference

Category -3 -2 -l O +l +2 +3

New Code Relatively more l 2 3 4 5 6 7 Relatively more
attention to attention to
sponsor needs patient needs

(3) The newly coded response differences were compared via a
Mann-Whitney test at the .10 level of confidence.

This time, if sponsors of patients in sponsor-oriented homes
displayed significantly more responses in the direction of "1" than

sponsors of patients in patient-oriented homes support would be indi-

cated for H3B°

104

Analyzing the data related to patient/sponsor satisfaction
with nursing care proved much more straightforward. In order to compare
patient satisfaction with the nursing care provided all that had to be
done was to array the two groups' responses to the "overall satisfaction
with the home rating" and run the Mann-Whitney test.

The evaluation of sponsor satisfaction with the nursing care
provided was done in a somewhat similar manner. The responses to each
of the sponsor interview questions numbers ”three” through "ten" (except
for "four") were coded and a Mann-Whitney comparison was run. However,
because of the large number of different response sets to be compared,
this approach raised the question of how to evaluate all comparisons in
order to support or reject H4B‘ The decision rule created in response
to this issue was that the author would accept H4B if four or more of
the seven comparisons to be made assumed the expected directions at the
.10 confidence level. With this decision the author's methodology was
complete, and he was now able to assess the limitations contained

within it.

Methodological limitations

 

This study, like any other done with a limited sample, could
be considered constrained by the ”classic" general limitation, that its
respondents might not be representative of the population outside of
Michigan. However, the author is not convinced how valid this particular
argument is in regard to this project.

The main issue of interest, dissatisfaction with nursing homes,

appeared to be a nation-wide phenomenon. Although the official

105

definition of what constitutes a nursing home varies from state to
state, the author doubted that the people dissatisfied with nursing
homes knew (or cared) about these distinctions. And, the criticism of
Michigan nursing homes seemed no different than that produced by other
areas. Further, the hypothesized source of dissatisfaction-without-
neglect (conflict between patients and sponsors) appeared likely to be
more or less universal. Apparently, about the only strong argument for
this geographical limitation was that the patients and sponsors drawn
for analysis might somehow be "different” from their non-Michigan coun-
terparts. Because of the dynamics introduced by varying state Medicaid
programs, this difference was thought possible. Just how great its
impact might be was felt to be debatable, but the possibility of differ—
entials between Michigan and other areas indicated additional research
to prove (or disprove) their existence might be useful if this research
pinpointed potentially fruitful areas for further scrutiny.

A more troublesome general limitation was an inability to
indicate how much dissatisfaction with nursing homes was due to inherent
patient/sponsor conflicts (even supposing strong support of the author's
research hypotheses). The cause of this deficiency was the apparent
lack of prior research into patient/sponsor conflict within nursing
homes. As was discernible from chapter one, the author had ample indi-
cation that such conflicts existed, but had no way of assessing their
exact source (i.e., specific patient needs vs. specific sponsor needs)
or relative importance. Instead the existence of these conflicts was
simply accepted and further research structure development proceeded

from there. To have done otherwise would have constituted an entire

106

research project in itself. Such an excursion into medical sociology
would not have lent any insights to the surrogate/consumer dimensions
of marketing science. Furthermore, preliminary research into patient
and sponsor needs might eventually prove needless if subsequent study
into their "proven" impact on nursing home satisfaction netted no posi-
tive results. Given the exploratory nature of this study, a better
approach was thought to consist of accepting these conflicts as givens
and concentrating upon whether or not they seemed to affect patient/
sponsor satisfaction with nursing homes. If such a relationship was
shown to exist, subsequent research into the specifics of patient/
sponsor conflicts could evaluate its relative magnitude and importance.

Moving from the general to the specific, the author saw
several other criticisms that could be leveled at his methodology.
First among these was the possibility that the administrator question-
naire might not be a valid indicator of nursing homes' orientation.
Basically, this possibility revolved around three potential areas of
concern: (l) the questionnaire might not really reflect administrators'
orientations; (2) the administrators might not answer it truthfully;
and (3) the administrators might not really be the ones to decide what
was to be done in conflict situations.

With regard to the inherent validity of the questionnaire,
every step possible had been taken to ensure its efficacy. Its origin
(ACNHA board members' experiences), its pre-test, and its approval by
the executive director of MNHA all seemed to indicate that the instru-

ment did perform its function. Lacking the ability to compare indicated

107

responses with actual action (over a long period of time in many
different homes), there were few choices other than to accept it.

Even if the instrument was an accurate indicator, the argument
could be made that the administrators might not answer it truthfully.
With this danger in mind, the conflict situations portrayed had been
kept as free from apparent morality considerations as possible. Further-
more, in asking MNHA members to respond to a supposedly in-house project
(in which individual anonymity was assured), individual responses could
be expected to be more truthful than they would be if some independent
or governmental researcher was involved. Beyond these considerations,
there was no reason to assume that any other falsification might not be
uniformly distributed (and therefore cancel itself out).

A more vexing argument could be found in an assertion that
administrators are not the ones who actually implement the action to be
taken in conflict situations and so their responses might not really
reflect the nursing homes' ”true" orientation. Those who held this view
would argue that members of the nursing staff are more likely to be the
ones who actually adjudicate conflicts on a day-to-day basis. Because
the actions they take might (or might not) parallel administrator policy,
the nurses should be the ones contacted to determine orientation.

The author saw determination of whether or not nurses' actions
reflected administrators' policies as being beyond the scope of this
study. Still, he was concerned enough about this issue that he talked
individually with various heads of nursing and their respective admin-
istrators. These groups exhibited no strong differences in orientation

and the nursing staff did seem to look to the administrator for direction

108

in policy-related issues. This factor was made particularly clear when
the author suggested to both administrators and nurses that he was
considering mailing his questionnaire to heads of nursing. The response
to this suggestion was that (in addition to lowering the probable number
of respondents) many of the heads of nursing would "clear" their re-
sponses with their administrator before they sent them in. In light of
these factors, the original decision to contact administrators was felt
to be justified.

The author was not as concerned about the content validity of
his patient and sponsor interview instruments. Because most of the items
contained in these instruments had been developed and tested by other
researchers, they were accepted without much further scrutiny. He did
realize that patients and sponsors could, conceivably, be afraid to
answer them truthfully. However, patient satisfaction was being rated
one time from a number of different interviewing probes. Presumably,
the subtle nature of the evaluative device when coupled with assurances
of anonymity should have screened out most of this type of bias.

As sponsors were further removed from the influence of the
home, the only source of bias in their answers should have been some
emotional considerations (already discussed in chapter one) and fear of
reprisals against their patient. Assurances of anonymity should have
calmed most of these fears and the patron letter from the home, itself,
should have erased the remainder of them. With these factors dismissed,
the only remaining validity issue was the amount of subjectivity involved

in applying the instrument.

109

The main concerns here centered on two separate issues: (1)
whether the interviewers would be capable of judging the subtle dis-
tinctions implied by the instruments, and (2) the possibility that one
"bad“ interviewer might unduly bias an admittedly small sample. The
potential for judgmental error was much greater for the Pincus instru-
ment than for the telephone interviews. The only offsetting factors
were the assumed professionality of the interviewers and the Pincus
finding (earlier introduced) indicating no variation in application
among pjs_interviewers. The author found these assurances less than
satisfactory, but the apparent desirability of the Pincus instrument
led him to utilize it despite its limitations.

The author's apprehensions about one "bad" interviewer biasing
his findings were easier to dismiss. The interviews were almost uni-
formly distributed among the five interviewers (i.e., in most cases,
the interviewers had almost equal numbers of patient—oriented and sponsor-
oriented homes to contact). Only one interviewer had a concentration
of homes all on "one side” of the orientation conflicts being studied.

In general, the author believed the validity of all of his
instruments was as satisfactory as circumstances permitted. He felt
the individual inadequacies that might surface in his findings would
not be totally undesirable. The fact of their existence would serve
as a guide to future researchers who might follow.

The author entertained similar feelings about the reliability
of the samples to which these instruments were applied. Besides the
statistical limitations already introduced, his chief concerns in this

area centered around two broad issues: whether the nursing homes

110

chosen for interview activity were not ”typical” of the total population
of nursing homes, and whether the patients and sponsors chosen by the
homes for interviewing were not ”typical" of all the patients within

the home.

To begin with, the list of homes typifying patient orientation
and sponsor orientation most certainly were not "typical." By definition
they were the most extreme homes the author could find.

Still, it must be remembered that this study was interested
in studying dissatisfaction with nursing homes that resulted from
resolution of patient/sponsor conflicts. In theory, such dissatisfaction
should arise any time patient/sponsor needs conflict and the conflict is
resolved (by definition to someone's dismay). Discerning a causal
effect between such conflict management and patient dissatisfaction
would be impossible in a home which did not consistently take one side
or the other (i.e., at some time everybody would be unhappy and the
dissatisfaction would be equal for both sides).

In light of these considerations, the only hope for relating
conflict and dissatisfaction was to be found in comparing the relative
satisfaction of patients/sponsors in homes who consistently took one
side or the other. If a causal relationship was discerned in these
extreme cases, generalization to the dissatisfaction produced every
time a nursing home faced a conflict resolution setting would be possible.
Therefore, the choice of these extreme homes was not only justified, but
absolutely essential.

However, even within the two categorical extremes, there could

be no doubt that the nursing homes chosen by HCAM were not a random

 

111

sample. The already discussed nursing home size limitations mandated
the culling of all small homes from the list of "possibles." The sub-
sequent reduction of these lists by HCAM further detracted from any
random nature they might have had. But, the direction assumed by HCAM
choice was not easy to predict.

Admittedly, HCAM could have chosen only sterling examples for
the author's interviewing activities. However, such a choice would not
seem logical as it would imply that all patients and sponsors interviewed
would have a uniformly high estimate of their nursing homes' quality.
Such findings would not have supported the author's guiding hypothesis
that dissatisfaction with nursing homes was not always related to
callous neglect, and such an action would not have been in the best
interests of the nursing home association.

On the other hand, an argument could be made that the associa-
tion would conspire to choose homes that would, because of some combina-
tion of good and bad, produce interviews that would support the author's
hypotheses. Careful scrutiny of this project's research structure
showed that such manipulation of findings would be theoretically impos-
sible (even if HCAM was sophisticated and interested enough to attempt
it). At any rate, the easy access to patients and sponsors facilitated
by HCAM participation more than compensated for any accompanying
sacrifices in sample reliability.

The only element that really troubled the author about HCAM
choice was whether or not the supposedly "unco-operative" homes might
have provided stronger demonstrations of the behavior he wanted to test.

However, if HCAM could not get the homes to co-operate, it was doubtful

112

that anyone could. Therefore, the chosen sample of homes was judged
as adequate as possible.

In the author's opinion the likelihood of working from an
unrepresentative sample was even greater for the patients/sponsors to
be interviewed than it had been for the homes from which they were
chosen. He suspected that administrators might choose from their ranks
those patients and sponsors whom they expected to reflect most favorably
upon the services offered by their home. There seemed to be no way to
stop such a choice, for even if the interviewers had been allowed to
choose their own ”random" sample from a list of the "competent" patients
and "co-operative" sponsors, a skilled administrator could still bias
the sample by whom he chose to submit for consideration. Furthermore,
administrator resistance to such a complicated plan might have been
gaining entry to the homes impossible.

However, even assuming that administrators could (and did)
choose their patients/sponsors according to expected responses, this
practice, if uniformly distributed, would not necessarily harm this

research. The research hypotheses called for a comparison of the

 

relative satisfaction of patients/sponsors within the different homes.
Unless all patients and sponsors rated all aspects of their homes at
the very top end of all evaluative scales, the required comparisons
should still be available (albeit at the high end of the scale). Feeln
ing such uniform polarization to be unlikely, acceptance of the non-
random nature of patients and sponsors samples chosen by the nursing

homes seemed reasonable.

113

In summary, the author thought his methodology was sound.
Any inherent flaws were either unavoidable compromises or calculated
risks that appeared justifiable at the time. Secure in this knowledge,
the focus of attention was next shifted to the findings produced by

this methodology.

CHAPTER III
FINDINGS AND ANALYSIS

Introduction

As is evident from Chapters I and II, this project proceeded
by first developing a number of general guiding hypotheses which (after
a careful analysis of the situation involved) resulted in the formula-
tion of more specific research hypotheses. In turn these research
hypotheses were exploded into still more specific operational hypotheses
which were to be tested with the elements developed in the proceding
chapter.

This chapter shall be devoted to the operational hypotheses
and the elements used to test them only. Once these findings have been
analyzed their implications for broader levels of abstraction will be
discussed in the "conclusions” section of the final chapter. For the
sake of convenience, a summary of the relevant findings shall first be
introduced. The detailed analysis used to produce these findings will

then be examined in subsequent sections of this chapter.

Summary of findings
An extensive analysis of the research findings resulted in the
following:

-Response to the author's questionnaire was so high (76%) as
to be judged exceptional for the industry.

114

115

-The findings indicated the questionnaire gas a valid
indicator of orientation choice for patient/sponsor con-
flicts. But, the data pointed to a conclusion that the
questionnaire mi ht not be a valid indicator of orienta-
tion choice for administrator vs. patient and/or sponsor
conflicts. It only weakly reflected administrator commit-
ment to the health care professional role and unexpectedly
manifested more_patient[sponsor orientation for Medicaid
patients than for private-pay patients (albeit at a low
level of statistical significance).

 

-As suspected earlier, inadequate data was available to
test H2A_] comparing orientation choice for proprietary
and non-profit homes. Accordingly, H2A-2 was tested.

 

-Of all the hypotheses tested, the strongest support gas
found for HZA-Zo Proprietary homes run by administrators
totally committed to the profit motive were more sponsor-
oriented when dealing with private-pay patient7sponsor
conflicts than homes run by administrators less motivated
by profits were in dealing with similar conflicts involving
Medicaid patients.

—Support was not found for H23. Proprietary homes run by
administrators totally committed to their role as a health
care professional were not more oriented to behavior
associated with this role when it conflicted with the
needs of Medicaid patients and/or sponsors than were homes
run by administrators with lesser commitments to this role
when faced with similar private-pay patient and/or sponsor
conflicts. In fact, the opposite was weakly indicated.
However, the importance of this finding was felt to be
diminished by the low level of statistical significance
manifested as well as the validity considerations already
mentioned.

-A strong finding consisted of demonstrated variation in the
"side-taking" of nursing home marketers. This was true
despite strong social considerations that seemed to mandate
otherwise.

-An unexpected finding consisted of an indication that
sponsor-oriented homes were much more reluctant to co-
operate with nursing home research than were their patient-
oriented counterparts.

-Hypotheses H3A and H33 assessing patient/sponsor perception
of nursing home orientation were not conclusively supported.
The data hinted at a finding that patients in patient—
oriented homes and sponsors of patients in sponsor-oriented

116

homes did perceive relatively more attention to their
own respective needs. However, the differences found
were not statistically significant.

~H4A could not be conclusively supported. Although

patients in sponsor-oriented homes did manifest slightly
more dissatisfaction with the nursing care provided than
patients in patient-oriented homes,as the differences
displayed were not statistically significant.

-Equally frustrating results attended the data relevant

to H43 which could not be supported. Even though six of
the seven variables tested displayed slightly more sponsor
dissatisfaction with the nursing care provided by patient-
oriented homes than was the case for the sponsor-oriented
equivalents, only two of the differences were statistically
significant. This fell far short of the four required by
the acceptance decision rule discussed in Chapter II.

The remainder of this chapter shall detail the findings which

resulted in the above.

Questionnaire response
Response to the author's questionnaire was extremely high.
Once all parties with prior knowledge of the study were culled from

1 a total of 246 questionnaires were mailed, and 188 of these

the sample,
were returned (resulting in a gross response rate of 76 percent). How-
ever, 23 of these were judged unusable due to extensive (more than

two items) omissions and 9 others were not analyzed as they were
received after the author's data cut-off date. Only 6 questionnaires
were received from non-profit homes and these responses (along with

the hypotheses they were to test) were also deleted as this was thought

to be too small a sample for adequate analysis. Subtracting all these

 

1These included ACNHA/HCAM officers as well as pre-test
respondents.

117

from the total response left 150 questionnaires and a net response rate
of 61 percent. Considering the response rates of other researchers into
nursing homes, this was considered to be exceptional and no further
sampling of non-respondents was thought necessary.

Although this quantitative response was most encouraging, the
qualitative reply was equally gratifying. Despite the fact that no
space on the questionnaire had been provided for open-ended response,
several respondents attached personal notes to their questionnaires.
Without exception these were uniformly positive. The following was
typical:

I really enjoyed completing the questionnaire. I found the

questions were the type we face quite frequently and hope that

we always make the proper decisions. These would be good to

use in conjunction with the state exam and PES test for

licensure. Reasons for specific answers would be given after-

wards in oral form. Thank you.
The author would like to think that the positive feelings expressed by
such gratuitous comments were in some small part responsible for the
unexpectedly high response rate (although the factor of HCAM involvement
was probably more important). At any rate, heartened by the encouraging
response to his questionnaire, the author next set about assessing its
apparent validity.

Assessment of question-
naire validity

 

The first step in assessing questionnaire validity was the
creation of Table 6 which displayed the responses by orientation and
patient identification. As can be seen from Table 6, the raw data

conformed to the expectations demanded of the trial questionnaire in

118

TABLE 6

ADMINISTRATOR QUESTIONNAIRE RESPONSE BY ORIENTATION
AND PATIENT IDENTIFICATION

 

 

Orientation Exhibited Patient/Sponsor identified as:
by Home Medicaid Private-Pay

Patient vs. Sponsor Conflicts (Cases 1, 3, 5)

 

Patient 54 (76%) 54 (68%)
Indeterminate 8 (11%) 17 (22%)
Sponsor 9 (13%) 8 (10%)

 

Administrator vs. Patient and/or Sponsor Conflicts
(Cases 2, 4, 6)

 

Administrator 37 (52%) 46 (58%)
Indetenninate 16 (23%) 16 (20%)
Patient/Sponsor 18 (25%) 17 (22%)

 

Chapter II. The majority of the homes were patient-oriented (for patient/
sponsor conflicts) and administrator-oriented (for administrator vs.
patient and/or sponsor conflicts). These findings about the "normal'I
orientation taken lent face validity to the instrument. But, the author
was interested in going beyond them to determine whether the orientations
shown reflected the behavioral manifestations expected to stem from the
identified source (private pay/Medicaid) of patient revenue.

Clearly, when defined only by the orientation parameters of

Table 6, the findings were so similar as to defy revenue source

119

comparison. However, as discussed earlier, very real differences could
be masked by the macro nature of the definitions concerned.

Reflection upon this point resulted in Tables 7 and 8 which
displayed the response totals to individual items according to patient
identification (private-pay/Medicaid) only. Because the response patterns
were frequently very similar, a simple arithmetic mean was included to
assist the reader in identifying the relative direction (or orientation)
indicated by the paired response patterns as well as the differentials
compared via the Mann-Whitney.

As can be seen from examining Table 7, seven out of the nine
patient/sponsor conflict comparisons took the assumed direction of
greater sponsor orientation for private-pay patients. Two of the dif-
ferences displayed were statistically significant enough to reject the
null hypothesis of ”no difference.” The author felt this supported the
apparent validity of his instrument, and he decided to test it no
further. When the data of Table 7 was refined still further on the
basis of administrator emphasis on profit, he expected to find (and
found) even greater behavioral differentials which would conform to the
directions already hypothesized.

However, an examination of Table 8 produced a different story.
Here the comparative response patterns for administrator vs. patient
and/or sponsor conflicts indicated eight out of nine comparisons that
were in the "wrong” direction of greater sponsor/patient orientation
for Medicaid patients. This unexpected finding indicated that something
was probably wrong. But, determining the exact source of the problem

was difficult as Table 8 displayed response totals that contained two

 

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124

different variables, patient identification and administrators'
commitments to their roles as health care professionals. Conceivably,
either the "private pay” or "Medicaid“ respondents could be comprised
of inordinate numbers of individuals expressing polar extremes of the
health-care-professional variable. The concomitant behaviors could be
masking the differences manifested by varying the identified source of
patient revenue.

Accordingly, Table 9 was constructed which held constant the
administrator commitment to the health care professional role (as
identified by question ”5e”) while varying the identified source of
patient revenue. Table 9 indicated that respondents were manifesting
orientation choices that were in direct opposition to those assumed to
stem from patient revenue distinctions. Fifteen out of eighteen com-
parisons indicated the ”wrong“ direction and three of these were
statistically significant. This finding pointed to a conclusion that
either the assumptions about patient revenue distinctions were incorrect
for this administrator perogative conflict variable, or the question-
naire was not a valid indicator of the orientations chosen for such
conflicts.

The author hoped to determine which of the above was the
apparent difficulty by constructing Table 10. Table 10 held the iden-
tified source of patient revenue constant while comparing the responses
of those who indicated commitment to the administrator's role as a
health care professional as being most important (5e = l) with those
who indicated somewhat less commitment to this role (5e >1). If the

questionnaire was at all valid in reflecting orientations chosen for

125

 

 

 

 

 

 

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126

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129

administrator role conflicts, it should indicate relatively greater
orientation to administrator perogatives for ''totally committed" admin-
istrators than for those “less committed." As can be seen, Table 10

did indicate the assumed orientation for thirteen out of the eighteen
comparisons made. This suggested the problem was with the assumptions,
not the validity of the instrument. Unfortunately, the statistical
significance of the ”correct” comparisons was so small that the author
fully expected the ”right” differentials provided by administrator role
commitment to be more than offset by the ”wrong" differentials of patient
identification when combined in the comparisons suggested by HZB'

The author was able to determine only a few clues as to why
the questionnaire produced the preceding results with administrator
perogative conflicts. Interviews with various administrators indicated
that the question (5e) used to define relative administrator commitment
to the health care professional role may not have been well phrased.
Stating that "being professionally satisfied by all actions taken by
myself or my staff" was "very important" may have been the kind of l'God,
motherhood, and the flag” response that almost everyone (regardless of
their true feelings) would automatically choose. The fact that 75 per-
cent did indicate being ”professionally satisfied" was "very important”
added strength to this suspicion that the indicated commitment to the
health care professional role may be so trite as to be a poor item to
use in assessing questionnaire validity.

The administrators interviewed were totally at a loss to
explain why greater patient/sponsor orientation was manifested for

Medicaid situations than their private-pay counterparts. The only

 

 

130

possible explanation seen by the author was that pressing administrator
perogatives too far with Medicaid patients might result in complaints to
the state Medicaid authorities which, in turn, might result in greater
scrutiny being paid to the home by the various licensing authorities.
Such a motivation would be operative for administrator vs. patient and/or
sponsor conflicts and not for patient vs. sponsor situations. In the
first instance the home would be taking actions possibly repugnant to
both patient and sponsor-~clearly a possible "flag" for further scrutiny.
In the case of patient vs. sponsor conflicts the whole issue would be a
"family matter”--presumably of less general interest. These differences
could be responsible for the apparently conflicting findings. Of course,
this was only conjecture which would have to be investigated by later
research (that would seem to face more than a few methodological diffi-
culties).

In the author's opinion this total analysis indicated that his
questionnaire apparently was a valid indicator of the orientations chosen
for patient vs. sponsor conflicts. However, enough unanswered questions
emanated from the data regarding administrator vs. patient and/or sponsor
conflicts to make generalizing from this data to any other issue under
consideration highly suspect. Therefore, he decided to discount any
subsequent findings stemming from administrator perogative conflicts.

The fact that the most positive findings were in the patient vs. sponsor
area lent further support to an earlier decision to investigate the
perceptions/satisfactions resulting from orientation choices available
to patient vs. sponsor conflicts (and not their administrator perogative

counterparts). With these thoughts about his instrument's validity in

131

mind the author next focused his analysis upon the data needed to

evaluate the hypotheses linking orientation choice and need structure.

The existence of variation in
marketer-orientation choice

 

 

Implicit to both the preceding discussion and the author's
operational hypotheses was an assumption that some variation in marketer
orientation choice did exist. Otherwise, the comparisons necessary to
hypothesis testing could not be undertaken. The presence of such vari-
ation was not clear prior to this study. Because of ”moral" considera-
tions, nursing home marketers might be expected to always favor the
hapless patient in patient vs. sponsor conflicts. Similarly, adminis-
trators (in light of their “almost doctor" self-images) might be
expected to always favor their administrative perogatives in administrator
vs. patient and/or sponsor conflicts.

As is obvious from Tables 6-10, such uniform orientation
choice was clearly np£_the case. Considerable variation was shown to
exist for individual response items and extremes in orientation strong
enough to permit identifying patient-oriented, sponsor-oriented, (etc.)
homes were shown to be present. The author felt these findings were
significant by themselves in addition to their importance for the
remainder of his research.

Detailed findings relative

to—H2A_1

HZA-l Proprietary homes will be more sponsor oriented
when dealing with private-pay patient/sponsor
conflicts than non-profit homes are in similar
conflict situations involving Medicaid patients.

132

As discussed earlier, the author's fear that inadequate
numbers of non-profit respondents would be available to test HZA-l were
realized. Accordingly, he turned to its conceptual equivalent, H2A-2'

Detailed findings relative

to‘HZAm2

 

H2A-2 Proprietary homes run by administrators totally
committed to the profit motive will be more sponsor
oriented when dealing with private-pay patient/
sponsor conflicts than homes run by administrators
less motivated by profits are in dealing with
similar conflicts involving Medicaid patients.

Table 11 detailed the information pertinent to H2A-2 in a
format similar to that utilized for Tables 7 and 8. The only new
factor, the administrator's relative commitment to profit, was deter-
mined from the response to question ”5a" in the manner discussed in
Chapter II.

As the author had expected, when the profit orientation para-
meters were combined with patient revenue distinctions so as to portray
the most extreme cases, the response patterns assumed the hypothesized
directions even more positively than they had in Table 7. Seven out of
the nine comparisons assumed the hypothesized directions and five of
these were statistically significant. In light of the decision rules
developed in Chapter II, this indicated support for H2A-l' As the
author had predicted earlier in this chapter, similar findings were not
to be found for HZB'

Detailed findings relative

to H265

 

 

H28 Proprietary homes run by administrators totally com-
mitted to their role as a health care professional

133

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134

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135

will be more oriented to behavior associated with

this role when it conflicts with the needs of Medicaid

patients and/or sponsors than will homes run by admin-

istrators with lesser commitments to this role when

faced with similar private-pay patient and/or sponsor

conflicts.

The findings pertaining to H28 were presented in Table 12.

This table confirmed the author's earlier apprehensions about combining
administrative commitments to the health care professional role with
patient revenue distinctions to produce the (supposedly) most extreme
cases. Seven out of the nine comparisons were in the "wrong'I direction

and one of these was statistically significant. Accordingly, H was

2B
not supported.

As discussed in the section evaluating questionnaire validity,
the author did not put a great deal of faith in these findings. He did
find it interesting that the unexpected (opposite) reactions to
private-pay/Medicaid distinctions were so strong as to apparently
"over-power" the responses paralleling administrative commitment to
the health care professional role. (i.e., combining these two vari-
ables, one of which assumed the ”right" direction, resulted in compari-
sons that were §Ejll_in the ”wrong" direction.) Although the author
did think the unexpected reactions to private-pay/Medicaid distinctions
were worth further study, discussion of his perceptions of their poten-
tial importance shall be delayed until the final chapter.

With these choice-mechanism issues disposed of, the next
issue was assessing the apparent results of the orientation alternatives

available to patient/sponsor conflicts. As discussed in Chapter II,

the perceptions/satisfactions emanating from patient/sponsor orientations

136

 

 

 

 

 

 

 

 

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137

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138

were to be evaluated by conducting interviews with patients and sponsors
involved with homes representing the extremes of patient or sponsor
orientation. Identifying homes belonging to the two categories was not
difficult, but obtaining cooperation from the two types of homes chosen
was so markedly different from one type to the other as to constitute

an unexpected finding.

Comparative co-operation of

patient—oriented and'sponsor—
oriented homes

 

 

Table 13 portrayed the comparative response of patient oriented
and sponsor oriented homes to the HCAM request for co-operation in this
research project. Remembering that the homes were asked to send HCAM
a list of six lucid patients and ten co-operative sponsors, the two

groups of homes actually co-operating appeared about equal in their

 

compliance with the requests made. For the most part patient-oriented
homes forwarded more than the requisite number of patient names while
sponsor-oriented homes only provided the six requested. However, the
sponsor-oriented homes provided more than the ten sponsor names requested,
while such over-compliance was less uniform for the patient-oriented
homes.

The real differences were to be found in both the proportion
of homes within the two categories who submitted lists at all, as well
as the degree of co-operation actually extended once the subject homes
agreed to participate. As can be seen, all of the patient-oriented
homes co-operated fully, while only five of the seven sponsor-oriented

homes actually participated. Furthermore, of the sponsor-oriented homes

139

 

 

 

 

 

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140

who agreed to participate, only three of the homes actually forwarded
the requested material in the manner desired the first time.

To the author these differences hinted at an unexpected
behavior differential which was manifested along orientation choice
lines. Seemingly, the sponsor—oriented homes were much less anxious
to admit outside researchers than were the patient-oriented homes.

As shall be discussed in Chapter IV, the author does believe these
indications of behavioral differentials should be investigated further.
Given their apparent intensity (and the attendant reluctance of some
homes to participate at all), he was grateful that enough homes were
secured to enable him to test his hypotheses regarding the perceptions/
satisfactions produced by varying orientations.

Detailed findings regarding

patient/sponsor_perception

of_nursing_home orientation
H3A and H33

 

The author's evaluation of the perception of nursing home

orientation was meant to test the following:

H3A Patients in patient-oriented homes will perceive more
attention to their needs (vs. those of their sponsors)
than patients in sponsor-oriented homes.

H3B Sponsors of patients in sponsor-oriented homes will

perceive more attention to their needs (vs. those of
their patients) than will sponsors of patients in
patient-oriented homes.

The findings reflecting patient/sponsor perception of nursing
home orientation were included in Table 14. As might have been expected,
the majority of both the patients and sponsors perceived no difference

between the nursing homes' attention to their needs and those of their

 

 

 

 

141

 

 

 

 

 

 

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142

counterparts. However, the differences that were manifested (though

not statistically significant) were in conformity with the directions
proposed by H3A and H38“ Patients in patient-oriented homes did indicate
that they perceived slightly more attention to patient needs (vs. sponsor
needs) than did patients in sponsor-oriented homes. Likewise, sponsors
of patients in sponsor-oriented homes did indicate perception of slightly
more attention to Sponsor needs (vs. those of patients) than did sponsors
of patients in patient-oriented homes.

Because the Mann-Whitney test pertaining to the above two com-
parisons did not reject the null hypothesis of "no difference" at the
chosen level of .10, the best the author could claim for H3A and H38 was
that the findings were promising, but inconclusive. He thought part of
the problem keeping his findings from statistical significance might be
some sort of response set to the perception questions (which were, after
all, related in meaning and wording). Such a set could keep the majority
of respondents from indicating any difference at all in their replies to
the paired questions producing the data tested. Accordingly, he hoped
for somewhat better results in analyzing the satisfaction related find-
ings which were the product of many inputs of a varied nature.

Detailed findings regarding

patient satisfaction produced
by nurSing_home orientation

E14.
H4A proposed the following:
H4A Patients in sponsor-oriented homes are more dis-

satisfied with the nursing care provided than are
patients in patient-oriented homes.

143

Table 15 arrayed the data gathered to test H4A‘ Table 15
strengthened the author's earlier suspicions that nursing home adminis-
trators had probably chosen the most favorable patients for interviewing
purposes as most of the ratings assigned were in the favorable portion
of the rating scale. Still, some ratings were at the bottom end of
satisfaction and, promisingly enough, these were only to be found among
patients in sponsor-oriented homes. However, these were counterbalanced
by a large number of other sponsor-oriented homes at the top end of the
scale which produced averages indicating only very slight directional
conformity with H4A' Because the Mann-Whitney does not evaluate com-
parative means (which were included only to assist the reader in deter-
mining direction), but rather rankings, the author thought it might
indicate greater significance than would otherwise be expected. As can
be seen, such was the case, but the level of significance still did not
meet the .10 confidence level proposed. Therefore, once again the best
that could be said was that the findings relative to H4A were promising
but inconclusive.

The author thought the problem with H4A might be conceptually
similar to that of H3A and H38 in that the Pincus rating scale used to
test H4A produced just one solitary variable. Though based on many
inputs, this variable could assume only one of five values. Because
the sample was probably skewed toward the favorable end of the scale to
begin with, the differentials needed to support the author's hypotheses
could be present, but not indicated due to the limited sensitivity of

the single application of the Pincus rating. Accordingly, he thought

144

 

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145

better results might be available from the multi-faceted approach used

to measure sponsor satisfaction with nursing home care.

Detailed findings regarding
sponsor satisfaction pro-
dUced by nursing home
orientation (H48)

 

 

 

 

H4B Sponsors of patients in patient-oriented homes are

more dissatisfied with the nursing care provided
than are sponsors of patients in sponsor-oriented
homes.

An examination of the data relevant to H4B (Table 16) indicated
that probing several issues related to nursing care did produce more
striking differentials in the perceived quality/satisfaction attendant
to that care. This time all but one of the comparisons manifested the
hypothesized directions of greater sponsor dissatisfaction with the
nursing care provided by patient oriented homes. Furthermore, two of
the six "correct" differentials were statistically significant.
Unfortunately, this was not enough to meet the decision rule (requiring
four out of six "correct” comparisons) that was developed in Chapter II
to assess H4B° Disappointingly, the same "promising, but inconclusive”
adjectives were appropriate for the data pertaining to H4B°

As shall be discussed in the final chapter, this recurring
theme of ”promising, but inconclusive” results need not indicate that
this study was a total failure. Rather, it may hint at the existence of

a very real phenomenon (both inside and outside of nursing homes) that

could be worthy of further research.

7

146

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CHAPTER IV

CONCLUSIONS, INSIGHTS, AND RECOMMENDATIONS

Introduction

 

Because of its exploratory nature, this research was intended
to produce insights in three different areas. Its primary objective
was to probe the suspected origins of dissatisfaction with nursing
homes. However, the parallels between such homes and other surrogate
situations suggested a potential for attaining a second objective
by generalizing the findings of this project to those other surrogate
relationships. Finally, in the process of conducting such an explora-
tory study, the author sought to test a number of different research
techniques and so provide guidance for subsequent research (and
researchers). This chapter shall discuss the implications of the
findings (already detailed in chapter III) to each of these three
topics. For the reader's convenience a verbal summary and graphic
depiction (Figure 4.1) of the most relevant conclusions will first
be introduced. This will be followed by a detailed presentation of
the analysis that produced these conclusions. The limitations of
these conclusions will also be introduced where appropriate. The
final section shall detail the directions the author believes sub-

sequent research should take.

147

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149

Summary of conclusions

 

The strong indications of ”side—taking” (on both sides of
surrogate disputes) evidenced by this study pointed to a
good likelihood of even greater variation in orientation
choice for less emotion laden situations.

 

The author's most positive conclusion was that H2 relating
nursing home orientation and nursing home need structures
was tenable. In spite of some contradictory indications
(of suspect validity) the evidence supporting this finding
was powerful enough to warrant acceptance of H2. Moreover,
there was at least some indication that further research
might permit generalization of the hypothesis.

No conclusion indicating patient/sponsor perception of
nursing home orientation (H3) could be reached. However,
the directional emphasis of the data (which did take the
hypothesized directions without attaining statistical
significance) argued for a position that such perception
might be present in other surrogate situations, and
research in these areas might be fruitful.

It was not possible to conclude that nursing home orienta—
tion choice was linked to patient/sponsor dissatisfaction
(H4). The directional emphasis of the data (which sup-
ported H4 without attaining statistical significance),
indicated further analysis of the general relationship
between marketer orientation and surrogate/consumer satis-
faction might be promising. However, the complexity of
surrogate/consumer relationships external to nursing homes
made predictions about such research very difficult to
formulate.

The failure of H3 and H4 mandated that HI be rejected.

The findings indicated that nursing home orientation in
patient vs. sponsor conflicts was not a major source of
dissatisfaction with nursing homes. However, the over-all
directional emphasis of the author's data (which conformed
to the predictions of the conflict model) pointed to other
non-neglect related variables which could be the source of
dissatisfaction with nursing homes, and should be studied
further.

With regard to research techniques the author felt the
surprisingly high response to his questionnaire indicated
that securing association assistance was a good way to
research the otherwise antagonistic individuals involved
with nursing homes. He found the case approach to be a
good mechanism for research orientation choice. The Pincus
interview format was judged to be too subjective in appli-
cation to provide a sensitive indicator of variation in

150

the perceived quality of nursing homes. Similar (though
less intense) feelings were produced by usage of the
Tomlinson interview instrument.

Variation in nursing_home
orientation Choice

 

 

As discussed in Chapter III, before reaching any conclusions
about nursing home/surrogate market behavior, the author first had to
assume that variations in orientation choice existed. Given the
environment facing the nursing home industry, such differences could
have been lacking, but were shown to be present. The fact that side-
taking was shown not to be uniform for nursing homes has powerful
ramifications for marketing science.

Orientation variation in non-
nursing home surrogate situations

 

If orientation choice can vary for nursing homes (despite
apparently strong social pressures to the contrary), the amount of
variation in other surrogate situations seems likely to be still greater,
and worthy of further research. In the author's opinion, the best
potential for further studies of similar orientation variation would
probably be found in the industrial arena. In this lucrative market
studies of whether or not industrial marketers faced with surrogate
conflict situations also varied in their orientation seem likely to
produce intriguing findings. This is doubly true in light of the

author's conclusions linking orientation choice and need structure.

151

Conclusions about orientation
choice and nursing home
need structure

 

 

 

Originally, the author proposed the following hypothesis
linking orientation choice and nursing home need structure:

H A nursing home confronted with conflicting needs of
patients and sponsors will tend to satisfy the group
whose satisfactions will best serve the nursing
home's need structure.

The strongest findings of this research were produced by
the author's exploration of the relationship proposed by H2. The
power of his findings linking strong commitment to the profit motive
to greater sponsor orientation (in patient vs. sponsor conflicts)
for private-pay (vs. Medicaid) patients produced a conclusion that
H2 was tenable. This position was taken despite unexpected indica-
tions that administrators were not similarly more oriented to
patient/sponsor concerns (in administrator vs. patient and/or sponsor
conflicts) when private-pay patients were involved (vs. Medicaid
patients). The importance of the administrator vs. patient and/or
sponsor findings was thought to be diminished by the somewhat shaky
validity of the questionnaire on this point and the possibility that
the original assumptions about Medicaid/private-pay behavioral dis—
tinctions might actually be opposite to those proposed for such
conflicts.

The author realized that the power of his conclusion regarding
H2 was severely limited by the single operational hypothesis utilized
to produce it. He felt much additional research would be necessary

before it could ever be considered very powerful. Subsequent studies

of this issue in nursing homes would need to determine whether

152

duplications of this project with other nursing home samples chosen on
a more random basis would evidence similar results. Further, before
much confidence could be placed in H2 the factors producing the con-
tradictory findings in the area of administrator vs. patient and/or
sponsor conflicts would have to be explored. Studies in this area
would have to conclusively determine whether the problem was with the
author's instrument or his assumptions about private-pay vs. Medicaid
revenue distinctions in such cases. An equal number of unanswered
questions were felt to be present in non-nursing home areas.

Orientation choice in non-nursing
home surrogate situations

 

By testing H2, the author hoped to gain insights about the
following:
HII Guiding A marketer confronted with a surrogate
purchase situation containing conflicting
needs of consumers and surrogates will
formulate actions that best satisfy the
need structure of the marketing organization.
In general, the author saw no reason why the conclusions of
H2 could not be extended to non-nursing home areas. This position
clearly indicated that further research into the relationship between
orientation choice and marketer need structure could be very promising.
Once again, the author felt the industrial area offered a
particularly interesting area for such research. If variations in
industrial marketer orientation were shown to be present by the research
already recommended, linking that orientation to marketer need structure

could have powerful strategic implications. In the author's opinion,

some of the main problems facing such research would be the definition

153

and classification of marketer need structures, as well as determina-
tion of the impact produced by ”outside” variables (the state of the
economy, the competitive nature of the market, etc.). Similar dif-
ficulties with outside variables might attend the study of orientation
choice in consumer settings.

Duplicating the author's study of orientation choice in
the consumer surrogate situations proposed by Hollander might pro-
duce interesting findings. But, before these could ever be considered
very conclusive, research into external imposition of orientation
choice would be in order. (i.e., in situations, such as the doctor-
patient relationship where one party is known to be all powerful,
do marketer need structures cause any differences in the degree of

side-taking, or is it uniform?)

Conclusions about patient/
pponsor perception of
orientation choice

 

 

 

In regard to the perception of nursing home orientation
choice, the author had proposed the following:
H3 Nursing home orientation consistently favoring the
needs of patients or sponsors in situations involving
need conflicts between these two groups is eventually
perceived by both groups indigenous to the situation.
Because neither sponsors nor patients indicated the perception
of nursing home orientation at statistically significant levels, H3

could not be supported. However, the directional emphasis of the

author's data (which had been in conformity with his operational

154

hypotheses) hinted that such perception just might be present in other

surrogate settings, as discussed in the following section.

Perception of orientation choice
in non-nurSing_home settings

 

HIII Guiding Market orientation favoring the needs of
either consumers or surrogates in a
surrogate market situation is eventually
perceived by both groups indigenous to
that situation.

Although the failure to find definitive support for H3
within nursing homes precluded the possibility of acceptance of HIII
Guiding, the author felt his findings might possibly indicate that
such perception of marketer orientation could very well be present
in other "typical" surrogate situations. Whether or not such perceptions
of marketer orientation might be present at levels sufficient to support
HIII Guiding could depend upon the surrogate situation involved.

Certainly, for the interior decorators or "professional shop-
pers” studied by Hollander the whole issue of perceived marketer
orientation appears to be a moot point. Because such surrogate rela-
tions would be entered into (and maintained) at the sole discretion of
the consumer, the author is unable to imagine any reason why such a
consumer would long tolerate any situation distinctly unfavorable to
him. Therefore, for such ”shoppers" all of the related consumer/surro-
gate conflict issues would seem to be irrelevant. Similar conclusions
can be reached for most other surrogate situations (even those involving

recommenders and diagnosticians). Presumably, if a consumer knew so

little about an area that he had to rely upon a professional, the

155

chances of his perceiving marketer orientation to surrogate needs he
did not understand seems somewhat unlikely.

However, for the industrial surrogate situations discussed
by Kotler, e§_al,, just the opposite would appear to be true. Industrial
surrogate situations are distinguished by the fact that they are some-
what non-voluntary and comparatively continuing in nature. Under such
conditions the likelihood of industrial perception of marketer orienta-
tion appears good. Whether or not the chances of orientation perception
would be greater for industrial surrogate situations than for nursing
homes is certainly debatable. Although industrial and nursing home
surrogate situations are analogous, a strong argument was made in the
first chapter for a position that the concentrated nature of the nurs-
ing home purchase (i.e., all elements are present within the nursing
home at one time) would lead to a relatively greater likelihood of
nursing home orientation perception. However, an equally convincing
argument in the opposite direction does exist. As already discussed,
sponsors were expected to (at least consciously) place patient needs
somewhat superior to their own. This could lead to suppression of
indications that nursing homes were paying more attention to their own
needs than those of patients (although, in retrospect, the author found
little to indicate this was true). Furthermore, patients and sponsors
would have relatively little knowledge about "typical" nursing home
operations and so would have no comparative basis to use in assessing
orientation. Such would not be the case for industrial surrogate situ~
ations. The greater market knowledge available to industrial surro-

gates and consumers, the continuing nature of the industrial market

156

(with its attendant "grape vines," etc.). and the presumed sophistication
of those involved could all mandate a greater likelihood of industrial
marketer orientation being perceived than was the case for nursing homes.
The author was in no position to determine which of the pre-
ceding arguments might be true. He did feel that the encouraging results
of his own experiment did argue for research into these issues. However,
as shall be discussed in the following section, the likelihood (and
importance) of industrial perception of marketer orientation could be
submerged or amplified by a number of other variables related to satis-
faction. Accordingly, suggestions for research into the perception of
industrial marketer orientation will not be discussed here until after
the complete research problem has been outlined.
Conclusions regarding_patienp1sponsor

satisfaction resulting from
orientation choice

 

 

The author had proposed the following hypothesis relating
patient/sponsor satisfaction to orientation choice:

H4 Marketers of long term nursing care faced
with conflicting needs of patients and
sponsors create dissatisfaction on the
part of one of these groups when the needs
of the other are favored as this favoritism
is perceived as unfair.

As was the case with perception, the satisfaction related
data assumed directional emphasis that would have supported H4 but
statistical significance was lacking, so the results were, at best,
inconclusive. Nevertheless extension of the findings to broader

areas might be possible.

157

Satisfaction emanating from orientation
choice in non—nursing home settings

 

 

Hoping to be able to generalize from the findings of his
research, the author had proposed the following:

HIV Guiding In a surrogate purchase situation containing
conflicting needs, the group not favored by
marketer orientation will express greater
dissatisfaction with the purchase involved
than the favored groups if the favoritism is
perceived as unfair.

The failure to obtain clear support for H4 does not necessarily
mean that HIV Guiding should be totally rejected. As discussed earlier,
the relative insensitivity of the Pincus instrument could have been
responsible for the failure to attain statistical significance with the
patient dimensions considered. Furthermore, depending upon the surro-
gate situations involved, the promising nature of the directional dif-
ferences that were exhibited could hint at stronger satisfaction related
findings that might be available in other surrogate areas.

Any future attempt to research satisfaction related dimensions
of conflict in surrogate market situations might properly exclude the
Hollander surrogates for the reasons already discussed. Whether or not
the promising indications contributed by nursing homes would likely be
duplicated by more powerful findings in industrial surrogate situations
would probably depend upon three issues-~perception of orientation,
the importance of the orientation manifested to those involved, and
the alternatives available to those affected by the orientation chosen.

Though not previously researched, a 10gical assumption would

be that clearly perceived marketer orientations would be more powerful

 

158

in influencing satisfaction than those which were not. If industrial
surrogates and consumers perceived marketer orientation more clearly
than those involved with nursing homes, more powerful results could be
expected from industrial surrogate situations than had been the case
for nursing homes. Thus, the further research suggested by the previous
section appears doubly important.

Should industrial surrogate ”actors“ be found to perceive
marketer orientation more distinctly, the satisfaction related effects
of such perception might hinge upon how important the identified orienta-
tion was to those who were affected by it. Nursing homes constitute
virtually the entire life of the residents they serve. Therefore the
importance of their actions to the patient-consumers involved must be
considered at least as great or greater than the significance of the
gifts/entertainment/etc. produced by industrial marketer orientation
are to the purchasing agents and the firms they represent. Accordingly,
whether or not the satisfaction opinions influenced by industrial
marketer orientation would be more intense than those encountered within
nursing homes could depend upon the combination of these perceptions
and importance-of-orientation variables. But, even if the indications
of dissatisfaction produced by unfavorable industrial marketer orienta-
tion were found to be less intense, their importance to industrial

markets might conceivably be greater than was the case for the marketers

 

of long term nursing care. This seemingly inconsistent premise is based
upon the responses available to the surrogates/consumers involved.
Within broad limitations the patients and sponsors affected

by nursing home orientation have little alternative but to disparage

159

the home serving them when it doesn't cater to their needs. True, in
unbearable situations the patient could switch homes or complaints be
made to the health authorities, but the nursing homes contacted indi-
cated that the former action was seldom taken and the latter occurred
only in extreme cases.1 The options available to industrial situations
are much more numerous and (from the marketer's viewpoint) more powerful.

Because industrial surrogates choose from apparent equals,
even small differences in their personal feelings toward a supplier
could produce large differences in the relative amount of business
allocated. Of course, the ability of the surrogate to exercise this
power to force orientation favorable to himself would be constrained
by his relationship with the consuming firm he represents. Unlike the
Patient/sponsor situation, industrial consumers can terminate their
attachment to any unsatisfactory surrogate with relatively little dif-
fiCUI ty. On the other hand, they might be reluctant to do so because
0f the time and expense involved with training a replacement (who might
do the same thing).

Just how all of the preceding influences might ”sort out” is
not Clear. In the author's opinion, the findings of his operational

hypotheses (though not statistically powerful enough to support his

research hypotheses) suggest that further research into the dynamics
\

1It is virtually impossible for a patient to check himself
Out 4nd sponsors are reluctant to make such a move as it involves
C0051 derable effort on their part. In regard to complaints, the
aUthor wonders how effective patients (who are often considered to
e a senile lot, anyway) would be in effecting action from the proper
€1quhorities. Furthermore, both patients and sponsors could be con-
S13E31 ned from registering formal complaints for fear of retaliation.

160

of’ “industrial surrogate behavior might be rewarding. Such research

w0L11cifmve to investigate the various combinations and permutations of

the following:

—00 industrial surrogates and industrial consumers perceive
marketer orientation? (And, if so, how strongly?)

-If perceived, how important is this orientation to the
consumers/surrogates involved. (Is it resented, con-

sidered a fact of life, etc.)

-What consumer/surrogate actions stem from orientation

choice? (i.e., sale implications, policy restrictions, etc.)

Hopefully, research into these issues might produce more
<13n<21usive evidence than the author could obtain about the origins of

dissatisfaction with nursing homes.

Eoncflusions about the true source of
_j§gseatisfaction with nursing care

In the beginning the author hypothesized the following:

HI Guiding Marketers of long term nursing care seeking
to provide services to patients who have
interested sponsors are faced with a surro-
gate purchase situation containing conflicting
sets of needs. Among these needs are those of
the sponsor, those of the patient, and those of
the marketing organization. Conflicts result-
ing in the failure to serve the needs of the
patient, his sponsor, or both are a major con-
tributor of dissatisfaction among patients and
sponsors that is more or less inevitable.

In light of the failure to support the hypotheses leading up
to til Guiding, this hypothesis was rejected. Although the long term
'"Jrsllig care market did appear to represent a surrogate situation with
conf"l‘icting needs, the available evidence, though in conformity with
the Sqairit of HI Guiding, did not indicate that patient vs. sponsor

conf1‘ict was ”. . . a major contributor of dissatisfaction among

PAtients and sponsors. . . .” The author's feelings about this

161

coric:1usion (and the facts used to reach it) were somewhat mixed. Because
the: directional emphasis of his data was in accordance with the hypoth-
esis; (even though not at a level of statistical validity), he examined
se\/earal simple explanations for the failure to attain statistical
significance.

The author thought one methodological explanation for his
disaippointing results in the area of satisfaction might rest on the
relaaizively small size of his sample of patients and sponsors. Possibly,
hacl nuore patients and sponsors been contacted, they would have responded
in t11€ same proportions as his smaller sample and produced stronger
finciiiqgs. However, the indicated significance of his findings was so
low tzhat an extremely large sample (reSponding in approximately the
sanme r3roportions) would be required before the data could be regarded
as conclusive at the .10 level.

The author believed that the problems introduced by the small
size? crf'his sample of patients and sponsors were probably compounded by
the ilfisstruments he used. As discussed in earlier chapters, the author
had l"EB-ail apprehensions about utilizing the Pincus instrument with a
sm91‘1 sanmle that was probably skewed towards the favorable side from
the beginning. Apparently, these fears were well founded. Though the
non“\r‘andom nature of the sample was unavoidable, the subjective nature
0f tr“? Pincus instrument made fine distinctions in satisfaction diffi-
CUIIZ tn) obtain. The fact that this instrument produced such disappoint—
ing YTEsults, even when applied by professional interviewers, argues for

a poSVition that any subsequent researchers might well view its use with

caution. This position is strengthened by the fact that some

162

disirinctions of the type posited by the author were produced by the
somewhat less subjective Tomlinson interview. However, the author was
not 'totally pleased even with the Tomlinson instrument. It, too,
reQLiired very subjective opinions and observations. Doubtless, it could
be iinproved by tying evaluations to more quantitative measurements of
the :same variables (e.g., what percent of the patients you have inter-
acted with would probably rate the food as satisfactory, etc.).

If this research project were duplicated with a random sample
(in ‘itself a real problem due to illness of patients, etc.) and more
sensi tive instruments, the author believes that support for his initial
guidi rig hypothesis might possibly be found. However, in comparing the
experise involved to the honest probability of success, it appears that
furttner research effort would better be directed at some associated
areas;. Because of this project, a number of insights into what shape
such ssubsequent research should take are apparent.
In'51ghts/recornmendations
f2? ‘Further research

The insights generated which would be of interest to subsequent
research were centered in two main areas, research techniques, and
promissing indications for further research. In regard to research tech-
niques’ the author thought his case-centered questionnaire approach
"ePY‘ESented a useful contribution to anyone researching the area of
su""COSJate market orientation. The author's experience suggested that
the truarniest problem associated with such an instrument was the assessm
ment 0f its validity. His only advice to others who might wish to use

Slmflar‘ techniques would be to make sure the case materials chosen are

 

163

as true to life as possible. Not only does this contribute to the face
validity of the instrument, but also it probably increases the response
rate.

The favorable quantitative and qualitative response to the
author's questionnaire by a population difficult to research (at best)
impl ied that the interest generated by "real-life" problems could be an
effective motivator to combat sample non-response. Of course, as pre-
viously discussed, evaluating the power of this interest factor was
compl icated by the presence of another contributor to questionnaire
response, the assistance of HCAM.

In the author's opinion anyone wishing to research the nursing
home industry should seriously consider first securing the cooperation
of the local professional associations. Because of the pressures
threatening the industry such associations appear to have become partic-
ularly powerful. These same pressures seem to contribute to the
industry's antagonism to outside research. So, the best way to research
issues requiring a reasonably representative sample of homes would
probably be to involve the relevant associations. In the author's case,
the Mi chigan associations proved most cooperative (even before the
1551198 to be researched were fully formulated). The only precondition
inSTSted upon was a genuinely unbiased approach to the issues being
anEStigated. For most scientific research such a requirement should
”01" be much of a problem. (If it is, the researcher should probably

question his motives for doing the research.)2

164

As discussed in the preceding section, the author was less
than pleased with the Pincus and Tomlinson instruments. Their sub-
jectrive nature makes determination of finite distinctions difficult.
Giveri the lack of prior research into nursing homes, expediency may
dictatte using these available tools instead of developing new ones.
Howe\/er, future researchers should be forewarned of their deficiencies.

Beyond development of the tools necessary for conducting
reseaicch, the next issue becomes what direction such research should
take. The findings of this project suggested further research into
two cfi‘fferent areas might be promising. The most general of these
was iri the area of industrial surrogate market dynamics. As discussed
more f’ully in the preceding sections, the following areas appear
promi 3 ing:

-Study of whether variation in marketer orientation is

2:?EEQE in industrial surrogate/consumer conflict situ-

-Further analysis of the relationship between industrial
marketer orientation and organizational need structure,

—Research into whether or not industrial marketer orien-
tation is perceived by the consumers and surrogates
involved,

-Further study of the market implications of industrial
marketer orientation choice.

Turning the focus back toward nursing homes, the author
believens the reason greater patient/sponsor orientation (for adminis-
trator“vs. patient and/or sponsor conflicts) was unexpectedly indicated
for Medicaid patients should be probed further. The problem could have
been the validity of the questionnaire on these issues, but the author

is “0t Certain that such was the case. Had validity been the problem,

165

he would have expected a more indeterminate pattern to emerge. The
fact that the pattern indicated administrators were more willing to
give up their perogatives with Medicaid patients could have ominous
impl ications. Because administrator perogatives could be equated with
medical imperatives, the findings generated could imply that Medicaid
patients actually receive care that is worse for them in a medical
sense (despite the fact that it probably keeps them and their families
happy) than private-pay patients. The possibility that one of the
factors responsible for this strange situation could be over-zealous
scrutiny of the industry is ironic. At any rate, the true reasons for
this unexpected behavior should be studied.

Another unexpected finding apparently worthy of further
research was that obtained from comparing the cooperation extended by
Patient-oriented and sponsor-oriented homes. The sponsor—oriented
homes seemed so defensive as to cause the author to wonder whether their
aCthi ties should be monitored further.

The author did believe that one element (the satisfaction
related dynamics of conflict) leading to his original guiding hypoth-
esis could and should be studied further. Although the satisfaction
dilclrerences manifested by this project were not statistically sig-
nilCl'Cant, their directions were in accordance with those hypothesized
by the Miller analysis of conflict. During the course of this project,
the aUthor has come to suspect that patient vs. sponsor and administrator
VS- patient and/or sponsor conflicts may not be the most powerful ones
present within the nursing home. In his opinion, the most troublesome

CONTHCt within nursing homes may be that involving the servicing of

166

patients (and their attendant sponsors) who really didn't want to come
therwa in the first place. Certainly, the negative implications of aged
instritutionalization (discussed in Chapter 1) indicate that most
patitants would prefer not to be admitted. Furthermore, the power of
sponsor guilt produced by placing a patient in a home would support a
strorig argument that sponsor involvement with nursing homes is

invol untary.

As such, the foundation for a powerful patient/sponsor con-
flict: regarding nursing homes appears to be laid. This conflict is not
between patients and sponsors or even patients/sponsors against the
home. The real conflict is between the patients/sponsors and the cir-
cumstéinces that forced the admission to this I'dreaded“ institution.
Becausse of the powerful emotions involved, striking out at the only
availeable target, the nursing home, appears logical (particularly when
criticzism of nursing homes seems so socially acceptable). In light of
these (:onsiderations the author is convinced that a study comparing the
relatiive satisfactions of patient/sponsors who wanted to come to the
home vrith those of patients/sponsors who didn't want to should be made.
AlthOLugh such a study would have more than a few methodological problems
(patienits who didn't want to come would probably be more sickly, etc.),
the irujications are that it would be feasible. The fact that approxi-
matel), one-third of the patients admit themselves indicates that enough
0f the: ”wanted to come” (or at least "didn't not want to come”) variety
wouhd be available to conduct an experiment. The fact that two-thirds
Of the [Natients were admitted by others (and so might belong to the

"didn't want to come” category) indicates that enough situations to

167

test: the other side would be available. It also implies that this source
of ciissatisfaction, if shown to be present, could be a non-neglect
related variable powerful enough to be responsible for much of the
dissatisfaction with nursing homes.

Should this ”conflict effect” be shown to be present in
nurS'ing homes, investigation of its impact could be shifted to other
areas; of marketing where consumers are overruled by circumstances they
cannCJt control. Indeed, this variable might be found to explain some
of true dissatisfaction seemingly inherent to such non-consumer con-
trol'leed markets as hospitals, utilities, the oil companies, and (biggest
of al 1) government services. If so, such a finding would make a real
contrvibution not only to the marketing literature, but also to other
socia l sciences which have been borrowed from (without return exchange)

for WHJCh too long. As such it is certainly worth pursuing.

APPENDIX A

I NTERVIENS WITH OFFICERS OF MICHIGAN CHAPTER OF AMERICAN
COLLEGE OF NURSING HOME ADMINISTRATORS (ACNHA)

 

APPENDIX A

INTERVIEWS WITH OFFICERS OF MICHIGAN CHAPTER OF AMERICAN
COLLEGE OF NURSING HOME ADMINISTRATORS (ACNHA)

Date of

Interv i ew Location Name Title (ACNHA)

March 13, l974 Grandville, MI Mr. Robert Dreyer President
Feb. 5, 1974 Coldwater, MI Mr. Harold Creal President-elect
March 1 4, l975 Benton Harbor, MI Mrs. Ranee Clayton Vice President

March 7, 1975 Grand Blanc, MI Mr. Dale Pelton Treasurer

168

 

APPENDIX B

PRETEST ADMINISTRATOR QUESTIONNAIRE

 

ADMINISTRATOR QUESTIONNAIRE

NOTICE: All information which would permit identification of the
individual or his place of employment will be held in strict
confidence, will be used only by persons engaged in and for the
purposes of this survey, and will not be disclosed or related to
others for any purposes.

-------—-——-—------—---—--——_-—--——-—--—~---—------—-——-~--—----.

The Health Care Association of Michigan is conducting a state—
wide survey of its members to develop information about how
administrators perceive the best ways to do their job. Your
answers will be given confidential treatment, the information
will be used for statistical purposes only, and will be presented
in such a manner that no individual person or establishment can
be identified.

Thank you for your cooperation

1. How long have you been the administrator:
a. in this facility? (no. of years)

b. in other nursing homes, homes for the aged, or similar
facilities? (no. bf years)

c. in hOSpitals? (no. of years) -

2. Which of the following professional degrees, licenses, or
association registrations do you have? (Mark all that apply)

Physician (M.D.)

Physician (D.O.)

Bachelor's or master's in business administration
(BS/BBA/WBA)

Registered Nurse (R.N.)

Licensed Practical or Vocational Nurse (L.P.N. or L.V.N.)
Registered Physical Therapist (R.P.T.)

Registered Occupational Therapist (O.T.R.)

Other professional degree, license, or association
registration (specify)
None of the above _

 

3. What type of facility are you now managing: (check the appropriate
box)

Proprietary
Non-profit/charitable
County health care facility

H. If you are administering a proprietary nursing home, are you the
full or partial owner? (check one)

Yes No

”*0 ———-

169

Administrator Opinions:

Instructions: The following questions are based on a scale
of (l) to (5). These numbers match a semantic scale Spanning
two extreme opinions, such as "Very Important" and "Very
Unimportant." Assume that a question were to ask:

 

How important is being well liked by local businessmen
to your activities as an administrator?

Very Important Very Unimportant
l 2 3 H 5

Referring to the above scale you would place a "l" in
the blank if you thought this factor very important,

"5" if you thought it very unimportant, "3" if you

felt neutral about it, "2" if you thought it somewhat
important, and "H" if you thought it almost unimportant.

S. In the operation of your nursing home, how important are the
following goals? Very Important Very Unimportant
. l 2 3 H 5

a. The generation of profit (or financial solvency for non—
profit homes). ” T I

b. Being well liked by patients.

0. Being thought of as an able health care professional by
colleagues.

d. Being well liked by staff.

e. Being professionally satisfied by all actions taken by
myself or my staff.

Administrative Dilemmas:

Introduction:

 

Frequently, nursing home administrators may be faced with
situations in which their actions are bound to diSplease someone
no matter what they do. As our industry is relatively new, there
often seem to be no clear—cut guidelines as to what actions should
be taken. A number of such dilemmas are described below, and we
are interested in how you would resolve them.

Although these may or may not be situations which you have

personally encountered, please lend us your expertise by reporting
your feelings about the various solutions posed.

170

-_ _3_

Instructions: A number of administrative dilemmas are briefly
outlined in the remainder of this questionnaire. After each
dilemma a number of alternative actions which an administrator
might take are suggested. You are to report whether or not
you think you would take the action suggested by utilizing a
semantic scale of Definitely Yes/Definitely No in much the same
fashion as the previous questions.

 

EXAMPLE:

Myrna L. iszn181 year old private pay patient of the "B"
nursing home. She is white, and spent most of her life in
Alabama. Recently Becky W., a black 85 year old from
Chicago,became Myrna's new roommate. The two did not get
along from the start and Myrna has demanded that she be
assigned a new room herself, or be given a new roommate.

Definitely Yes Definitely No
l 2 3 H S

 

3. Would you try to "stall" Myrna, hoping time might
resolve the differences?
b. Would you move Myrna into a new room?
0. Would you move Becky into another room and get
Myrna a new roommate?
Referring to the above scale, you would place a "l" in the blank
opposite the question if you definitely would, "5" if you definitely
would not, "3" if you were undecided, "2" if you probably would,
and "H" if you probably would not.

PLEASE RESPOND TO THE FOLLOWING CASES IN THE SAME MANNER AS THE
PRECEDING.

Memo: For many of the following cases, both sponsors and patients
are mentioned. For the purposes of this questionnaire, sponsors
are those responsible parties who negotiate a patient's admittance
and are designated as the first to be called should an emergency
arise. For all the situations mentioned below it is to be assumed
that the Sponsor is interested enough that he calls on the patient
at least twice a month. All patients discussed are to be assumed
to be long-term residents who will stay in the home until their
condition becomes terminal. Any additional information needed is
contained in the body of the cases.

171

One

Case

Sara M. is a 68-year-old resident of the X nursing home. She is
mentally alert and in good physical condition for her age. Lately,
James L. a 71—year-old widower who was admitted to the home as a
private pay patient after a mild stroke which left him only minimally
impaired physically, has developed an interest in Sara. Sara and James
have been seen visiting each other's rooms and holding hands. Mr.

L's sponsor observed this and became very upset. He has repeatedly
demanded that the home "break-up" this budding romance, and your
attempt to disuade him has failed.

Definitely Yes Definitely No
l 2 3 4 5

 

la. Would you ”passively” try to keep Sara and James apart
by arranging activities for them at different times and/or
places.

lb. Would you ”actively" try to break up this romance by
instructing your staff not to allow Sara and James to hold
hands or be alone together, etc.

1c. If Mr. L. threatened to withdraw James from your home if
you did not "do something," would your answers to either
of the above change?

Two

Case

Jenny P. was admitted to the home as a private pay patient after a
mild stroke which left her unable to live in her old apartment. Her
sponsor (who is her daughter) is extremely guilty about her inability
to take Jenny into her own home. Jenny, who has some mild tremor in
her hands, has decided that she cannot feed herself (and, in fact,
usually does spill some food on her clothes when she tries). However,
she can get the job done with some prodding.

Jenny's sponsor has demanded that you hand feed Jenny even though in
your opinion she does not need it. You have explained this to Jenny
and her sponsor, but both remain adamant.

Definitely Yes Definitely No
l 2 3 4 5

2a. Would you be willing to propose a compromise in which
Jenny was hand fed one of her meals (perhaps evening)
so that she would look better for visitors?

2b. Would you be willing to propose a compromise in which
Jenny was hand fed by her sponsor whenever she had the
time and had to go it her own at all other times?

2c. If none of the above were acceptable, would you go ahead
and hand feed Jenny?

~—

~—

172

Case Three

 

Case

Georgia X is a widow who was admitted to the nursing home as a private
pay patient when it was found she could no longer live by herself. Her
physical condition is not bad for her age (seventy-nine), and her

mental condition is fairly alert. Her sponsor is her eldest son (one

of two) who resides in an adjoining town. Her sponsor detests his
younger brother, Tom, who is a merchant seaman and is only infrequently
in the area. For whatever reasons (no good ones you know of) Georgia's
sponsor has left explicit orders that she is not to leave the nursing
home with anyone other than himself. He has explicitly stated that

under no circumstances is she to be allowed to go out with Tom. Suddenly,
Tom shows up and wants to take his mother out for an ice cream cone. She
states that she would like to go with him.

Definitely Yes Definitely No
l 2 3 4 S

 

33. Would you call Georgia's sponsor and try to get him to
let Georgia go?

3b. If you did call and you could not reach the sponsor, would
you let Georgia go?

3c. If you did call, did reach the sponsor, and he still refused
to allow her to go, would you let Georgia go (assuming you
saw no reasons not to let her)? ' "‘

Four

Ed L. is an eighty-one-year-old private pay patient who was admitted
to,the home after a hip fracture. The operation to repair this fracture
left his walking somewhat shaky unless he uses a cane (which he detests).
His mental condition is sometimes confused, but the one thing he is

always sure of is that he does not want to use that cane. The nursing
home staff is able to make Ed use his cane during the day, but at night

he will frequently get up to go to the bathroom and ”forget” it. He has
been told to either use his cane or call for assistance, but he frequently
does not do this. The staff has tried raising the rails on his bed, but
he just climbs over them. Twice he has fallen at night and not been

hurt. Finally, it is decided to put a restraint on him at night to keep
him in bed. He objects violently to this and his sponsors demand that you
not leave it on him even though its purpose has been made clear to them.

- Doctor's orders are to use restraints as required.

Definitely Yes _ Definitely No
l 2 3 4 S

 

4a. Would you be willing to propose a compromise in which Ed was
allowed to remain without restraints following any night in
which he used his cane or asked assistance?

4b. Would you be willing to agree to one short trial period without
the restraint to give Ed ”one last chance” (if he ever failed
to use the cane, he would have to be restrained for good)?

173

4c. If Ed's sponsors were willing to sign a document
absolving the nursing home of all responsibility for any
injury arising from his not being restrained, would you
agree to not restrain him?

Case Five

Case

Vicky M. is a seventy-six-year-old private pay patient of the "Y"
nursing home. Her physical and mental condition are generally good.
She receives a small allowance from her sponsor to pay for personal
items. The "Y" nursing home has just secured the seryices of a
professional beautician who comes in once a week to serye the patients.
Her fees, though modest, are not included in the patients' normal rates
and must be charged to them or their sponsors as additional. Vicky's
rommate has her hair done by the beautician and now Vicky wants it, too.
She has asked her sponsor (her nephew) for the additional money, but he
has steadfastly refused to give it to her. Vicky has asked the
administrator of the ”Y" home to try to "force” her sponsor to give her
this extra money.

Definitely Yes Definitely No
l 2 3 4 S

 

Sa. Would you talk to Vicky's sponsor in an attempt to persuade
him to let Vicky have the extra money to see the beautician
once a week?

Sb. If the above were tried and failed, would you try to work
out a compromise with her sponsor in which Vicky got enough
extra money from him to see the beautician at least once
every other week?

Sc. If none of the above worked, and Vicky thought this issue
important enough to be very unhappy about it, would you be
willing to ”force" Vicky's sponsor by telling him to either
give her the money or remove her from your institution?

Six

Shirley O. was admitted to the ”Z” nursing home as a private pay

patient after an operation to repair a hip fracture (her second). Her
mental condition is borderline senile. After her second operation

Shirley decided she could not get around without a wheel chair even

though her doctor says that she probably could (and should) walk with a
walker. The ”Z" nursing home has two dining rooms. In the main dining
area no wheel chairs are ever allowed, as this is where the ablest patients
dine. Upon her arrival Shirley wheeled herself to this area (where her
friends were) and was told she could not go in except with her walker. She
then demanded to be fed in her room, but was told she did not need this and
it was the main area or nothing. She then got out of the wheel chair and
sat on the door to the main area crying piteously. Her sponsors came in

at this very moment and were enraged. Even after they were told the reasons
behind the nursing home's actions they demanded that Shirley be allowed

to eat in the main area with her wheel chair or be fed in her room.

174

 

Definitely Yes Definitely No
l 2 3 4 5

6a. Would you be willing to propose a compromise that would
allow Shirley to eat in her room if she had used her
walker at some other times during the day?

6b. Would you be willing to propose a compromise that would
allow Shirley to take her wheel chair into the main
dining room if she had used her walker at some other times
during the day?

6c. If for some reason the above were unacceptable to Shirley,

her sponsors, or yourself, would you agree to allow Shirley
to take her wheel chair into the main dining area?

175

APPENDIX D

FINAL ADMINISTRATOR QUESTIONNAIRE
(Private-Pay Version)

ADMINISTRATOR QUESTIONNAIRE

NOTICE: All information which would permit identification of the individual or his place of employment
will be held in strict confidence, will be used only by persons engaged in and for the purposes of this
survey, and will not be disclosed or related to others for any purposes.

 

The Health Care Association of Michigan is conducting a statewide survey of its members to develop
information about how administrators perceive the best ways to do their job. Your answers will be
given confidential treatment; the information will be used for statistical purposes only and will be
presented in such a manner that no individual person or establishment can be identified.

Thank you for your cooperation.

 

1. How long have you been the administrator:

a. in this facility? (no. of years)
b. in other nursing homes, homes for the aged, or similar facilities? (no. of years)

c. in hospitals? (no. of years)

2. Which of the following professional degrees, licenses, or association registrations do you have?
(Mark all that apply)

Physician (M.D.)

Physician (D.O.)

Bachelor's or Master's in business administration
(BS/BBA/MBA)

Registered Nurse (R.N.)

Licensed Practical or Vocational Nurse (L.P.N. or L.V.N.)
Registered Physical Therapist (R.P.T.)

Registered Occupational Therapist (O.T.R.)

Other professional degree, license, or association registration
(Specify)

 

None of the above
3. What type of facility are you now managing? (Check the appropriate box)

Proprietary
Non—profit/charitable
County health care facility

4. If you are administering a proprietary nursing home, are you the full or partial owner?
(Check one)

Yes No

Administrator Opinions:

Instructions: The following questions are based on a scale of (l) to (5). These numbers match
a semantic scale spanning two extreme opinions, such as "Very Important" and "Very Unimportant."
Assume that a question were to ask:

How important is being well liked by local businessmen to your activities as an administrator?

Very Important Very Unimportant
1 2 3 4 5

Referring to the above scale you would place a "1" in the blank if you thought this
factor very important, "5" if you thought it very unimportant, "3" if you felt neutral
about it, "2" if you thought it somewhat important, and "4" if you thought it almost
unimportant.

180

-2-

    
   
   
 
   
    
  
  
 
   
  
   
   
  
   
 
 
  
 
  
  
  
    
 
  
   
  

In the operation of your nursing home, how important are the following goals?
very Important Very Unimportant
1 2 3 4 S

a. The generation of profit (or financial solvency for non-profit homes).
b. Being well liked by patients.

c. Being thought of as an able health care professional by colleagues.

d. Being well liked by staff.

e. Being professionally satisfied by all actions taken by myself or my staff.

Administrative Dilemmas:
Introduction:

Frequently, nursing home administrators may be faced with situations in which their actions are
bound to displease someone no matter what they do. As our industry is relatively new, there often
seen to be no clear-cut guidelines as to what actions should be taken. A number of such dilemmas are
described below, and we are interested in how you would resolve them.

Although these may or may not be situations which you have personally encountered, please lend us
your expertise by reporting your feelings about the various solutions posed.

Instructions: A number of administrative dilemmas are briefly outlined in the remainder of this
questionnaire. After each dilemma a number of alternative actions which an administrator might
take are suggested. You are to report whether or not you think you would take each action sug—
gested by utilizing a semantic scale of Definitely Yes/Definitely No in much the same fashion as
the previous questions.

EXAMPLE:

Myrna L. is an 81 year old private pay patient of the "B" nursing home. She is white, and
spent most of her life in Alabama. Recently Becky W., a black 85 year old from Chicago,
became Myrna's new roommate. The two did not get along from the start and Myrna has demanded
that she be assigned a new room herself or be given a new roommate.

Definitely Yes Definitely No
l 2 3 A 5

a. Would you try to "stall" Myrna, hoping time might resolve the differences?
b. Would you move Myrna into a new room?

c. Would you move Becky into another room and get Myrna a new roommate?

Referring to the above scale, you would place a "1" in the blank opposite the question if you definitely
would, "5" if you definitely would not, ”3" if you were undecided, "2" if you probably would, and "4" if
you probably would not. Although you would probably need more facts to reach an actual decision than those

PLEASE RESPOND TO THE FOLLOWING CASES IN THE SAME MANNER AS THE PRECEDING, BEING SURE TO RESPOND TO EACH
ALTERNATIVE ACTION PRESENTED.

Memo: For many of the following cases, both sponsors and patients are mentioned. For the purposes of
this questionnaire, sponsors are those responsible parties who negotiate a patient's admittance and are
designated as the first to be called should an emergency arise. For all the situations mentioned below
it is to be assumed that the sponsor is interested enough that he calls on the patient at least twice a
month. All patients discussed are to be assumed to be long-term residents who will stay in the home
until their condition becomes terminal. Any additional information needed is contained in the body of
the cases.

Case One

Sara M. is a 68-year-old resident of the X nursing home. She is mentally alert and in good physical
condition for her age. Lately, James L., a 71—year-old widower who was admitted to the home as a
private pay patient after a mild stroke which left him only minimally impaired physically, has

181

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-3-

developed an interest in Sara. Sara and James have been seen visiting each other's rooms and
holding hands. Mr. L's sponsor observed this and became very upset. He has repeatedly demanded
that the home "break-up” this budding romance, and your attempt to dissuade him has failed.

Definitely Yes Definitely No
l 2 3 4 5

la. Would you ”passively” try to keep Sara and James apart by arranging activities for
them at different times and/or places?

lb. Would you ”actively” try to break up this romance by instructing your staff not to
allow Sara and James to hold hands or be alone together, etc?

lc. Would you have been more likely to do either a_or b_had Mr. L's sponsor threatened
to withdraw James from your home if you did not ”do something"?

Case Two

Jenny P. was admitted to the home as a Medicaid patient after a mild stroke which left her
unable to live in her old apartment. Her sponsor (who is her daughter) is extremely guilty
about her inability to take Jenny into her own home. Jenny, who has some mild tremor in her
hands, has decided that she cannot feed herself (and, in fact, usually does spill some food
on her clothes when she tries). However, she can get the job done with some prodding.

Jenny's sponsor has demanded that you have Jenny hand fed even though in your opinion she
does not need it. You have explained this to Jenny and her sponsor, but both remain adamant.

Definitely Yes Definitely No
l 3 5

 

ix)
L\

2a. Would you be willing to agree to a compromise in which Jenny was hand fed one of
her meals (perhaps evening) so that she would look better for visitors?

2b. Would you be willing to agree to a compromise in which Jenny was hand fed by her
sponsor whenever she had the time and had to go it her own at all other times?

2c. If none of the above were acceptable, would you go ahead and have Jenny hand fed?

Case Three

Case

Georgia X is a widow who was admitted to the nursing home as a Medicaid patient when it was
found she could no longer live by herself. Her physical condition is not bad for her age
(seventy-nine), and her mental condition is fairly alert. Her sponsor is her eldest son (one
of two) who resides in an adjoining town. Her sponsor detests his younger brother, Tom, who
is a merchant seaman and is only infrequently in the area. For whatever reasons (no good ones
you know of) Georgia's sponsor has left explicit orders that she is not to leave the nursing
home with anyone other than himself. He has explicitly stated that under no circumstances is
she to be allowed to go out with Tom and has indicated he does not wish to discuss the matter

further. Suddenly, Tom shows up and wants to take his mother out for an ice cream cone. She
States that she would like to go with him.

Definitely Yes Definitely No
l 2 3 A 5

3a. Would you be willing to call Georgia's sponsor in an attempt to get him to let
Georgia go even if you thought this might be highly irritating to him?
3b. If you did call and you could not reach the sponsor, would you let Georgia go?

3c. If you did call, did reach the sponsor, and he still refused to allow her to go,
would you let Georgia go (assuming you saw no reasons not to let her)?

Four

Ed L. is an eighty-one-year—old Medicaid patient who was admitted to the home after a hip
fracture. The operation to repair this fracture left his walking somewhat shaky unless he
uses a cane (which he detests). His mental condition is sometimes confused, but the one
thing he is always sure of is that he does not want to use that cane. The nursing home staff
is able to make Ed use his cane during the day, but at night he will frequently get up to go

to the bathroom and "forget" it. He has been told to either use his cane or call for assistance,

178

  
   
   
 
 
 
 
   
  
   
    
 
   
  
   

-4-

Definitely Yes Definitely No
l 2 3 4 5

4a. Would you be willing to agree to a compromise in which Ed was allowed to remain without
restraints following any night in which he used his cane or asked assistance?

4b. Would you be willing to agree to one short trial period without the restraint to give
Ed "one last chance" (if he ever failed to use the cane, he would have to be restrained
for good)?

6c. Would you be more inclined to agree to either of the preceding if you thought failure
to do so would result in Ed's sponsors moving him to another nursing home?

Case rive

Vicky H. is a seventy~six-year-old private pay patient of the "Y" nursing home. Her physical and
mental condition are generally good. She receives a small allowance from her sponsor to pay for
personal items. The "Y" nursing home has just secured the services of a professional beautician
who comes in once a week to serve the patients. Her fees, though modest, are not included in the
patients' normal rates and must be charged to them or their sponsors as additional. Vicky's room—
mate has her hair done by the beautician and now Vicky wants it, too. She has asked her sponsor
(her nephew) for the additional money, but he has steadfastly refused to give it to her, and he
seems to be becoming very hostile to the entire issue. Vicky has asked the administrator of the
"Y" home to try to "force" her sponsor to give her this extra money.

 

Definitely Yes Definitely No
1 2 3 4 5

58. Would you be willing to risk irritating Vicky's sponsor by attempting to persuade him
to let Vicky have the extra money to see the beautician once a week?

Sb. If the above were tried and failed, would you be willing to try to work out a compromise
with her sponsor in which Vicky got enough extra money from him to see the beautician
at least once every other week?

5c. If none of the above worked, and Vicky thought this issue important enough to be very
unhappy about it, would you be willing to try still stronger measures ("shaming" the
sponsor, etc.) to ”force" him to give Vicky the money?

Case

Six

Shirley 0. was admitted to the "Z" nursing home as a private pay patient after an operation to
repair a hip fracture (her second). Her mental condition is borderline senile. After her second
operation Shirley decided she could not get around without a wheel chair even though her doctor
says that she probably could (and should) walk with a walker. The "Z" nursing home has two dining
rooms. In the main dining area no wheel chairs are ever allowed, as this is where the ablest
patients dine. Upon her arrival Shirley wheeled herself to this area (where her friends were) and
was told she could not go in except with her walker. She then demanded to be fed in her room but
was told she did not need this; it was the main area or nothing. She then got out of the wheel
chair and sat at the door to the main area crying piteously. Her sponsors came in at this very
moment and were enraged. Even after they were told the reasons behind the nursing home's actions
they demanded that Shirley be allowed to eat in the main area with her wheel chair or be fed in her
room.

Definitely Yes Definitely No
1 2 3 4 5

6a. Would you be willing to agree to a compromise that would allow Shirley to eat in her
room if she had used her walker at some other times during the day?

6b. Would you be willing to agree to a compromise that would allow Shirley to take her
wheel chair into the main dining room if she had used her walker at some other times
during the day?

6c. If for some reason the above were unacceptable to Shirley, her sponsors, or yourself,
would you agree to allow Shirley to take her wheel chair into the main dining area?

183

 

APPENDIX E

INITIAL COVER LETTER

 

 

FOUNDED I948

HEALTH CARE ASSOCIATION OF MICHIGAN

1320 Commerce Center Burldmg " 300 South Capitol Avenue’ Lansrng, Michigan 48933 ' Phone (5173 371-1700

August 22, I974

Dear H CAM Member:

The Health Care Association of Michigan, through its Education Committee,
is cooperating in a statewide member survey to develop information about
how administrators perceive the best ways to do their iob.

Administrators are urged to complete the enclosed questionnaire and return
it in the envelope provided for that purpose. It will take only a few minutes
of your time. Please complete it and return it now.

We emphasize that this is an association sponsored project. Its success is up
to you .

Sincerely,

@mé‘ilaw

Charles E. Harmon,
Executive Director

CEHzlb

Enclosure

184

(Dedicated to d‘liqlitif stanJa/zds

 

 

APPENDIX F

REMINDER LETTER

 

 

Founoeo I948
I:I_ALTH CARE ASSOCIATION OF MICHIGAN

1320‘Ccmmetce Center Building / 300 South Capitol Avenue / Lansing, Michigan 48933 / Phone (517) 371-1700

September 20, I974

 

Dear HCAM Member:
On August 22, I974, we'liorwarded to you a questionnaire designed to
develop information about how administrators perceive the best wgys_ to

do their job.

Many members have already responded to this Association sponsored survey.
We regret that we have not heard from you.

Would you please take the few minutes required to complete the questionnaire
and return it to us? Your participation is vital to the success of the project.

Thank you for your consideration.

Sincerely,

Quinskkm

Charles E. Harmon,
Executive Director

CEHzlb

Encl .

185

mil/innltrl I‘n Alf/Inn's} ,'<‘AHJAIIJA

 

APPENDIX G

PATIENT INTERVIEW FORMAT*

*Questions 1-4, 6-9, 11—12 by Allen Pincus, Ph.D., University of

Wisconsin.

 

—>.—___——“ "F"— '
Nursing Home '

 

PATIENT INTERVIEW FORMAT

Intaoduce youaoeifi and expiain what you ate doing.

Name Age
To be anoweaed by nnating home peasonnei:

Is patient receiving any public funds to help defray the costs of his stay
at this nursing home? Yes No

To be anoweaed by patient (aead it to him):

1. .If I were planning to come into Home, what would you say
to me? (Get R to ”piay a game” with you saying oomething iihe: "Make
beiieve I'm youa age and am thinking 05 coming to Home
and I come to you 50a advice. Heip me decide." Act as ig’gpu aae
taking notes.)

 

2. What would I need to know to do OK here? (Continue with note piaying
game, at i6 you aae theia age and they aae aduioing you.)

 

3. In what ways did you have to change in order to adjust to the Home?
(Paobe: things have to do dififieaentiy, getting up, going to Aieep,
eating pat/tun, being atone, etc.) - - ~-

4. What were some things you had to learn in order to adjust?

5. How would you reSpond to this statement?

"Within reason, the staff at this nursing home usually tries to do what
I want."

Would you
(Check one) Strongly Agree Agree Disagree Strongly Disagree

 

 

 

6. What kind of person your own age would you advise to come to

Home? (Paobe: taaito 05 peaoon, iiineoo, etc.)

 

7. In what ways is life the same for you as it was before you came into the
Home?

8. In what ways is it different?

9. If you were being asked to advise a government inspector about how a
Home like this should be changed to make it a better place, what would
you tell him?

186

lo.

11.

12.

How would you reSpond to this statement?

"Within reason, the staff at this nursing home usually tries to do what
the relatives of residents want."

Would you ','
(Check one) Strongly Agree Agree Disagree Strongly Disagree

 

 

If )pu had to do it all over again, would you apply to
Home? (Paobe why)

 

Are you glad you came to' Home?

 

Thank the patient

Overall satisfaction with the home rating
(See accompanying hating Acate.l

I87

 

 

 

 

 

 

 

APPENDIX H

RATING SCALE FOR GRATIFICATION FROM THE HOME ENVIRONMENT (GH)*

*By Allen Pincus, Ph.D., University of Wisconsin, 1968.

 

RATING SCALE FOR GRATIFICATION FROM THE IDME ENVIRONMENT (GH)
(Questions 1—4, 6—9, and ll-12)

S is sorry he came to the Home. If he had to do it over again he would
try to find some alternative to his current living arrangements. The
Home is no good and has nothing to offer 8. Life is miserable there and
he would like to get out.

S would come again, but only as a last resort, if there were no place
else to go. He is resigned to living in the Home and at best "enduring"
the environment, but sees it as more tolerable than someone with a
rating of l. 8 might mention some positive things about the Home but
might also frequently refer to the fact that if a person has money or
children he shouldn't be in the Home. "Nobody comes here for pleasure,"
is a frequently expressed sentiment.

S would probably come again as a last resort, but is ambivalent about
whether he is glad he came. S may enjoy the security or sustaining
services the Home offers, but feels he is getting this at the expense
of his privacy and/or freedom which is important to him. S may be
satisfied with the Home, but not really happy there. It will never
be "home" for S.

S is glad he came and would come again. He seems to be generally satis-
fied with the Home, but makes some statements which would place him a
step below those with a rating of 5. For example, S might mention

that he is glad he came to the Home because he is no longer a burden on
the family, as opposed to saying that he is glad he came because of some
positive aspect of the Home itself. Or perhaps there are some aspects
of the Home which mar S's enjoyment of it,.but not to the extent of
someone with a rating of 3.

S is definitely glad he came and would definitely come again. The
emphasis is on "this is the best place for me" rather than on "this

is a last resort." The environment meets most of S's needs. There

may be some aspect of the environment which S does not like, but he has"
learned to accommodate himself to them and it does not bother him very
much. The institution is a satisfactory and satisfying home for S.

I88

 

 

APPENDIX I

SPONSOR TELEPHONE INTERVIEW

 

Nursing Home

 

SPONSOR TELEPHONE INTERVIEW
Intaoduce youabefifi and expiain what you aae doing.

Name Age

 

1. How long has your relative been in nursing home?

 

 

(16 aefiatéve LA no Zongea in home, aecoad how Kong he wad theaeT'

2. How frequently do you visit (did you visit) your relative in the home?
/month (15 fieaa Ihan once pea month, continue Lnteaview, but do
not necoad data and be bane to do an addftzonafi phone inzeavfew in
oadea to achieve youa quota 05 six inzeaULewb.)

Please indicate how satisfied you have been with each of the following
aspects of the nursing home. (Check one)

 

Very Very

 

 

Satis. Satis. Dissat. Dissat.
3. adequate number of staff
'4. co-Operation of staff with you

5. outside groups frequently coming in
to entertain the residents

6. general cleanliness of resident
maintained

7. good food
8. cheerful atmosphere
9. kindly treatment of relative
10. diversionary activities, i.e., TV,
crafts, library, hobby center, music
room, discussion groups, Bible study,

games available, movies

11. co-Operation of staff with resident

Thank the nebpondent.

I89

 

APPENDIX J

PATRON LETTER

Dear Patron:

Our nursing home is participating in a research project being
conducted jointly by the education committee of the Health Care
Association of Michigan and Michigan State University. This

study is attempting to determine some of the factors which produce
satisfaction with nursing homes.

Within the next few days you may be contacted over the phone by
an interviewer involved with this project. We feel that this
study represents needed research into an important area, and urge
your co-Operation. Please be assured that your answers will be
held in strictest confidence and no individual reSponses will
ever be identified or divulged (even to us).

Thank You for Your Co—Operation. -.

190

 

APPENDIX K

INTERVIENER INSTRUCTIONS

 

Before
Hand

The Day
of the
Interview

IMPORTANT
NOTE

Name of nursing home

 

INTERVIEWER INSTRUCTIONS

NOTE: Please read all materials prior to initiating any contacts. Should
you have any questions call me (Richard Buchanan) at 616-664-4627 or
616-383-1925.

Introduction

 

This project involves two research instruments which are to be applied

to two populations associated with nursing homes. One population,
patients, are to be personally interviewed while the other, the rela—
tives or "responsible parties,” are to be interviewed over the telephone.
Because nursing homes are generally wary of participating in research

of any kind (they have been badly misused in the past) EXTRA CARE SHOULD
BE USED IN DEALING WITH THEM. However, your objectives will be easy

to accomplish if the fcli wing steps are taken.

Upon receipt of these materials call the nursing home listed on the
cover of this packet and make arrangements (usually with the admin-
istrator) to come into his home and interview patients- Be sure to
identify yourself as part of the project being conducted by the Health
Care Association of Michigan. The administrator has already agreed

to participate with this project, but may need reminding. Should
there be any problems or questions suggest the home re—contact the
Health Care Association. Ask for enough time for you to conduct six
interviews and do a few additional jobs (to be explained later).
Familiarize yourself with all materials prior to the interview.

On the agreed-upon date go to the home and identify yourself via the
letter from the Health Care Association provided in the packet. Also
in the packet are ten letters and envelopes addressed to the relatives
you will be contacting later. These are to reassure the relatives
that it is all right to participate in the study. Have the letters
signed by the nursing home in the Space provided (a rubber stamp would
do nicely) and take these with you to be mailed later. Return
addresses may be affixed by the nursing home if desired.

The sample respondents to be interviewed by this project have to be
very carefully chosen. Each nursing home serves two different kinds
of patients/relatives, private-pay and Medicaid. It is very important
that the patients/sponsors chosen from this home be of the

type. Supposedly, this has already been taken care of in the list of
respondents provided. However, it is so important that you should
double check this information anyway. If your list of reSpondents
does not conform to the desired characteristics, ask for others.
Should the home be unable to come up with enough patients/sponsors

of the desired type, it is permissible to fill in with the other type
(but be sure to identify their reSponses as such).

I91

 

 

The Let the nursing home personnel steer you around to the proper patients.

Patient Should any of the patients on your list be unwilling or unable to

Interview participate on the date of your visit it is permissible to substitute
(try to get six interviews). Just be certain that the patient inter-
viewed is of the desired type (private pay vs. Medicaid), has been at
the home long enough to judge it, and is mentally competent to inter-
view (some may be a trifle on the senile side, but that is all right).
Use the ”patient interview format” with the patients. It should be
read to them and you should act according to any instructions supplied
with each question. Only questions ”5” and'UIV'require you to mark
down a Specific reSponse. The reSponSes to all the others are to be
aggregated in one single ”Satisfaction with the home" rating. Use
the rating scale provided to reach this rating.

iNext Mail the letters to the relatives. Allow enough time for them to be
delivered.
Relative The relative interviews are to be conducted over the phone. Where

 

Interview possible the telephone numbers have been provided for you. If you
do not have the telephone numbers, you might request them from the
nursing home or just call information. Be sure to remind the relative
of the letter he received. If he is very reluctant to participate
you could refer him back to the nursing home (or just go on to the
next). Read him the Sponsor telephone interview and fill in the
desired information. Once you have six interviews with the desired
(private-pay vs. Medicaid) orientation who visit their relative at
least once per month your job is complete.

Etiscelr If anyone wants to know what this information is for, you may explain
lxnneous that it is part of a research project tryihg to uncover what is the
best way for a nursing home to satisfy the peOple it serves.

GOOD LUCK

192

 

 

APPENDIX L

LETTER OF INTRODUCTION

+

K‘ / /' g/z , ' . . //’ //. /.
. Mix/[4 V ///’I . Ann/:f/ré/x/ // .. AWN/MyK/l/
/
f' /' '; . .
11,210 i M/ux/r 111-1 6 r1/% /' .///////(/(////

K‘ . /. /.
/////M/I‘/’, . ”hp/guy ,’«l.’/.,’.,’

. 72/1/1543 / J/l/ ‘ / 2‘00

January l3, I975

To Whom lt May Concern:

This will identify the interviewer for the research proiect sponsored by'
Health Care Association of Michigan and Michigan State University.
Ralph Schmuckal of our staff discussed it with you recently.

If you have any questions, please call us. Thanks as always for your
cooperation.

Sincerely,

8W8 OW

Charles E. Harmon,
Executive Vice President

CEHdb

 

 

.o'.

 

 

 

APPENDIX M

STATISTICAL TECHNIQUES EMPLOYED

 

STATISTICAL TECHNIQUES EMPLOYED

Introduction

 

The purpose of this section shall be to illustrate one
example of the Mann-Whitney test employed for research purposes. The
majority of the techniques contained herein were drawn from Nonpara-
metric Statistics for the Behavioral Sciences (McGraw-Hill, New York,
I956) by Sidney Siegel. The interested reader is referred to this work

for greater detail.

Assumptions of test

 

The Mann-Whitney U test assumes at least ordinal data obtained
from independent random samples. As discussed in the "Analytical tech-
niques employed” section, the data definitely did 393 constitute a
random sample. Therefore, the "significance" of any application of the
test should be understood to represent only an indicator of the relative

importance of the findings.

Subject of test

 

The items chosen for demonstration purposes were the total
responses to the questionnaire alternative "la." As shown in Table 7,
these were as follows:
DY l 2 3 4 5 DN
Private 13 28 ll 9 l8
Medicaid 9 21 ll 23 18

I94

 

 

 

 

 

 

 

 

 

 

 

Test procedure
The above response patterns were analyzed via the following
procedural steps from Siegel.

1. "Determine the values of n1 and n2. n1 = the number of cases
in the smaller group; n2 = the number of cases in the larger
group."

n1 = 71 n2 = 79

2. "Rank together the scores for both groups assigning the rank
of 1 to the score which is algebraically lowest. Ranks range
from 1 to N = n1 + n2. Assign tied observations the average

of the tied ranks.”

 

 

Private Medicaid
Average No. x No. x
Value Value Rank Ng;_ Value Rank Value Rank N9; Value Rank

1 11.5 13 149.5 11.5 9 103.5
2 47 28 1316 47 21 987
3 82.5 11 907.5 82.5 11 907.5
4 104 9 936 104 12 1248
5 132.5 18 2385 132.5 18 2385

3. "Determine the value of U. . .

R2 = sum of the assigned ranks for n2”

R2 = I49.5 + I,3I6 + 907.5 + 936 + 2385
R2 = 5694

I95

 

C
II

(79) (71 - 5694

 

2

C
II

3075

”The method for determining the significance of the observed
value of U depends on the size of n2:

If n is larger than 20, the probability associated with
a vaiue as extreme as the observed value of U may be
determined by computing the value of 2 as given by
formula and testing this value by referring to Table A.

 

 

 

 

 

 

 

Z = U - n1 n2
2
///7(n1) (n2) (n1 + n2 +1)
12
z = 3075 - (79)2 7l)
/(791(7u (151)
12
z = 1.02

The observed value of Z is .1539

"If the observed value of U has an associated probability
equal to or less than a reject H0 in favor of h].”
Since the associated probability of .1539 is greater
than the chosen a of .10, the null hypothesis of no

difference cannot be rejected.

I96

 

 

 

 

 

 

 

 

 

Correction for ties
As noted by Siegel:

The Mann-Whitney test assumes that the scores represent a
distribution which has underlying continuity. With very precise
measurements of a variable which has underlying continuity, the
probability of a tie is zero. However, with the relatively
crude measures which we typically employ in behavioral scien-
tific research, ties may well occur . . .

The effect of tied ranks is to change the variability of
the set of ranks. Thus the correction for ties must be applied
to the standard deviation of the sampling distribution of U.
Corrected for ties, the standard deviation becomes:

 

   

where N = n1

- t (where t is the number of observations tied
12 for a given rank)

T is found by summing the T's over all groups of tied

observations. With the correction for ties we find 2 by

 

 

 

/1 “2 N3 ‘ N H
N(N-l) 12 ' ET

The Western Michigan University Computer Center which was used
to process the author's data employed a program which did not include
a correction for ties. The author was assured that the effect of ties
was nominal, but for his own edification he ran one test of his data
through with a correction for ties in order to see what effect might be

produced. Accordingly, he made the following calculations: 1

I97

 

       

. .. . .... - ... .. ..... ~. ..«.. . . .. - . a .—
v
.. .
x .
. .. ,_ .,... , .
l

' . ..'. ,.. . . £-

.-
l .
. n
- .. v
' . . u v
. ' v u. .
t .
a

   

 

 

 

 

 

 

 

 

z = (22)3 - 22 + (49)3 - 49 + (22)3 - 22 + (21)3 - 21 + (35)3 - 36

T 12 12 12 12 1T?
2T = 16226

2 = 3075 - (792(71)

3
//(i9 71) (150) - 150 _ 16,226
156ll4§i 12
z = 1.05

The probability associated with a value of 2 as extreme as
1.95 is .1469.

Because the difference between the probability of z with the
correction factor and the probability of 2 without the correction factor
was so small (.007), the author decided that the advantages of utilizing
the existing program far outweighed the possible disadvantages, espe-
cially in light of the fact (as noted by Siegel) that " . . . when we
do not correct for ties our test is 'conservative' in that the value of

p will be slightly inflated."

I98

 

BIBLIOGRAPHY

BIBLIOGRAPHY

Books

Alexander, George and Lewin, Travis. The Aged and the Need for Surrogate
Management. Syracuse, N.Y.: Syracuse University, 1972.

 

Barney, Jane. Patients in Michigan's Nursigg_Homes. Ann Arbor: Insti-
tute of Gerontology, I973°

 

Baumgarten, Harold. Concepts of Nursing Home Administration. New York:
Macmillan, T965.

 

 

Braverman, Jordan. Nursing Home Standards . . . A Tragic Dilemma in
American Health. Washington, D.C.: American Pharmaceutical
Association, 1970.

 

Brotman, Herman B. Who Are the Aged: A Demographic View. Ann Arbor:
Institute of Gerontology, 1968.

Kogan, Nathan, and Wallach, Michael. Risk Taking, A Study in ngnition
and Personality. New York: Holt Rinehart and Winston, I964.

 

Kotler, Philip. Marketing_Management. Englewood Cliffs: Prentice-
Hall, 1972.

 

Margolis, Sidney. "The Older Consumer as a Force in the Marketplace,"
The Aging Consumer. Papers from the 22nd Annual Conference
on Aging. Ann Arbor: Institute of Gerontology, 1969.

 

Mendelson, Mary. Tender Loving_Greed. New York: Alfred A. Knopf, 1974.

 

Meyers, Robert J. Medicare. Homewood, 111.: Richard D. Irwin, 1970.

Miller, Gerald, and Steinberg, Mark. Between People: A New Analysis
of Interpersonal Communication. Palo Alto: Science Research
Associates,‘1975.

 

Rewoldt, Stewart H., et al. Introduction to Marketing Management.
Homewood: Richard D. Irwin, Inc., 1969.

Rokeach, Milton. The Nature of Human Values. New York: The Free
Press, 1973.

 

I99

200

Siegel. Sidney. Non-Parametric Statistics for the Behavioral Sciences.
New York: *McGraw-Hill, 1956.

Stanton, William J. Fundamentals of Marketing. New York: McGraw-Hill,
1971.

 

Townsend, Claire. Old Age: The Last Segregation,_Ralph Nader's Study
Group Report on Nursing Homes. New Yofk: Grossman PUbTishers,
1971.

Webster's Seventh Collegiate Dictionary. Springfield, Mass.: S. and C.
Merriam Company,TT963.

 

Periodicals, Journals, and Articles

Busse, Ewald. "The Modern Challenge of Threescore and Ten.“ Journal
of the American Geriatrics Society, XVII (September, I969l,
887-93.

 

Fenelon, Stephani. ”Patients' Families Need Information." Modern
Nursing Home, January, 1974, pp. 8-9.

 

Gallagher, Jim. ”Family Faces Guilt Feelings-~Easing Parent's Move to
Nursing Home.“ Detroit Free Press, November 10, 1974,
pp. 1C, 9C.

 

Hollander, Stanley. ”Buyer Helping Businesses . . . and Some Not-So-
Helpful Ones.“ MSU Business Topics, Summer, 1974, pp. 52-68.

 

Hollander, Stanley C. "She Shops for You or with You." New Essays in
Marketing Theory. Edited by George Fisk. Boston: Allyn
and Bacon, Inc., 1971, pp. 218-40.

 

 

Hyatt, Jim. ”Medicare Woes, Nursing Home Benefits Grow Harder to
Collect.” The Wall Street Journal, April 8, 1970, pp. 1, 28.

 

Jacoby, Susan. "Waiting for the End: On Nursing Homes.‘I New York
Iimgg, March 31, 1974, p. 13. '“‘"“““

Kotler, Philip. "Behavioral Models for Analyzing Buyers." Journal of
Marketing, XXIX (October, 1965), pp. 37-45.

 

Lieberman, Morton A., and Lakin, Martin. ”0n Becoming an Institutionm
alized Aged Person." Processes of Aging, Edited by Richard
A. Williams. New York: Atherton Press, 1963, pp. 475~503.

 

Loehwing, David A. "Recovery in Nursing Homes.” Barron's, March 26,
1973, p. 3.

20I

Luck, David J. "Broadening the Concept of Marketing--Too Far."
Journal of Marketing, XXXIII (July, 1969), 53-55.

 

Raven, Bertram H., and Kruglanski, Ariel W. "Conflict and Power," Ih§_
Structure of Conflict. Edited by Paul Swingle. New York:
Academic Press, 1970, pp. 69-109.

 

Sheldon, Henry. "The Changing Demographic Profile." Handbook of Social
Gerontology. Edited by Clark Tibbitts. Chicago: University
of Chicago Press, 1960, pp. 27-61.

 

Simos, Bertha. "Adult Children and Their Aging Parents." Social Work,
XVIII (May, 1973), 78-85.

 

Spivak, Jonathan. ”HEW Plans to Issue Regulations to Improve Safety
and Medical Care at Nursing Homes.“ Wall Street Journal,
January 14, 1974, p. 7.

Wallach, Michael, et a1. ”Group Influence on Risk Taking." Journal of
Abnormal and Social Psycholqu, LXV, No. 2 (1962), pp. 75—86.

 

Yawney, B. A., and Slover, D. L. "Relocation of the Elderly." Social
Work (May, 1973), pp. 87—95.

Association Materials

 

American College of Nursing Home Administrators. Membership Information.
Silver Springs, Md.: ACNHA, 1974.

American Nursing Home Association. Facts in Brief. Washington, D.C.:
ANHA, 1972.

 

American Nursing Home Association. ”Proposed Position Paper," ANHA
Governing Council Report. Chicago: ANHA, August 19, I973.

 

Michigan Nursing Home Association. Application for Membership.
Lansing: MNHA, 1974.

Michigan Nursing Home Association. Michigan Nursing Home Association
Operational Code. Lansing:__MNHA, 1972.

 

Government Publications--Federal

Brotman, Herman. The Older Popglation: Some Facts We Should Know.
Washington, D.C.: Government Printing Office, 1970.

 

 

 

 

 

 

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U.S.

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U.S.

202

Bureau of the Census. Current Population Raports. Series P-23,
No. 43, "Some DemographiE'Aspects of Aging in the United
States." Washington, D.C.: Government Printing Office, 1973.

Bureau of the Census. We the American Elderly. Washington, D.C.:
Government Printing Office, 1973.

Comptroller General of the United States. Report to the Congress,
Continuing Problems in Providing Nursing Home Care and Pre-
scribedTDrugs Under the Medicaid Program in California.
Washington, D.C.: Government Printing Office, 1970.

Department of Health, Education, and Welfare. Characteristics of
Residents in Nursing and Personal Care Homes. Rockville, Md.:
National Center for Health StatiStics, 1973.

Department of Health, Education, and Welfare. Charges for Care
and Sources of Payment for Residents in NursingTHomes.
Rockville, Md.: National Center for Health Statistics, 1973.

Department of Health, Education, and Welfare. Chronic Conditions
and Impairments of Nursinngome Residents. TROCkvilTe, Md.:
National Center for Health Statistics, 1973.

Department of Health, Education, and Welfare. Health Resources
Statistics,_1972-73. Rockville, Md.: Natibnal Center for
Health StatiSticszl973.

 

Department of Health, Education, and Welfare. Nursing Home Care,
Consumer Information Series #2. Washington, D.C.: Govern-
ment Printing Office, 1972.

Congress. Senate. Committee on Finance and U.S., House of
Representatives, Committee on Ways and Means. Summary of
Social Security Amendments of 1972, Public Law 92-603.
Washington, D.C.: Government Printing Office, 1972.

Congress. Senate. Special Committee on Aging. Hearings Before
the Subcommittee on Long Term Care of the Special Committee
on Aging, parts 1415. Washington, D.C.: Government Printing
Office, 1971.

 

Office of Human Development. Administration on Aging. New Facts
About Older Americans. Washington, D.C.: DHEW, 1973.

 

 

203

Government Publications—-State

 

Michigan. Bureau of Health Facilities. February 1974 Directory of
Hospitals, Nursing Care Facilities, and Homes for the Aged.
Lansing: Michigan Department of Public Health, 1974.

Michigan. Division of Health Facilities Standards and Licensing.
Rules and Regulations for Nursinngomes and Homes for the
Aged. Lansing: Department of’PublicTHealth, 1974}

Michigan. Medical Assistance Program Bulletin No. B—3 (Revised Reim-
bursement RatesT. Lansing: Department of Social Services,
I974.

 

Unpublished Works

 

Bair, L. A. ”The Effect of the Introduction of Medical Assistance and
Medicare on the Structure of the Michigan Nursing Home
Industry.” Unpublished Ph.D. dissertation, Michigan State
University, 1973.

Henry, L. H. ”The Effect of Medicare and Medicaid on the Supply and
Demand Conditions of Nursing Homes.‘I Unpublished Ph.D.
dissertation, Notre Dame, 1970.

Miller, Frederick. "An Analysis of the Marketing Strategy of Florida
Nursing Homes." Unpublished Ph.D. dissertation, Louisiana
State University, 1970.

Pincus, Allen. ”Toward a Conceptual Framework for Studying Institu-
tional Environments in Homes for the Aged.“ Unpublished
Ph.D. dissertation, University of Wisconsin, 1968.

Saul, Sidney. ”A Study of Family Factors Relating to Application to
a Home for the Aged.” Unpublished Ed.D. dissertation,
Columbia University, 1968.

Silverstone, B. M. ”Expert vs. Consumer VieWpoints: An Organizational
Analysis of the Contrast in Descriptions of Homes for the
Aged by Administrators and Indigenous Residents." Unpublished
Ph.D. dissertation, Columbia University, 1973.

Tomlinson, Barbara. "The Nursing Home Research Project and the Relative
Sub-Study.” Unpublished paper, Institute of Gerontology, 1971.

Trainor, John. "The Nursing Home Industry in Washington State." Unpubu
lished Ph.D. dissertation, Washington State University, 1970.

 

 

204

Miscellaneous

 

Baumgarten, Harold. Letter to R. W. Buchanan, March 18, 1974.

Baumgarten, Harold. The First Kuttnauer Seminar on Nursing Homes and
Extended Care Facilities (DecemberTBI9,’l967) as related by
Harold’Creal, Past President of the Michigan Nursing Home
Association in a personal interview February 5, 1973.

 

 

 

 

 

 

 

 

 

 

 

 

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