“It’s important, but…”: Perceived Barriers and Situational Dependencies to Social Contact Preferences of Nursing Home Residents

Abstract

Background and Objectives

U.S. Nursing homes (NH) are shifting toward a person-centered philosophy of care, where staff understand each residents preferences, goals and values, and seek to honor them throughout the care delivery process. Social interactions are a major component of life and while low rates of social interactions are typically found among NH residents, little research has examined resident preferences for specific types of social interactions. The purpose of this study is to explore, from the perspective of the NH resident, barriers to social contact preferences and situations when social preferences change.

Research Design and Methods

Two interviews were conducted with 255 NH residents 3 months apart, recruited from 32 NHs using 13 social-contact items from the Preferences for Everyday Living Inventory-NH.

Results

Content analysis of 1,461 spontaneous comments identified perceived barriers to preference fulfillment along with reasons why residents would change their mind about the importance of a preference (situational dependencies). Nearly 50% of social preferences for choosing a roommate, having regular contact with friends, giving gifts, and volunteering were associated with barriers. Social preferences were likely to change based upon the quality of the social interaction and the resident’s level of interest.

Discussion and Implications

Knowledge of barriers regarding social preferences can inform care efforts vital to advancing the delivery of person-centered care. In addition, understanding the reasons why NH resident preferences change based upon context can help providers with staff training leading to individualized care and develop meaningful social programs that are in line with resident preferences.

Social relationships are crucial to health and well-being throughout the life span. Levels of social integration have a significant and direct impact on physical and mental health (Berkman, Glass, Brissette, & Seeman, 2000; Umberson & Montez, 2010). Among older adults, higher levels of social integration are associated with longer survival rates, greater perceived quality of life, successful aging, and psychological well-being (Guse & Masesar, 1999; Kiely & Flacker, 2003; Powers, 1991; Retsinas & Garrity, 1985; Yeung, Kwok, & Chung, 2012). Within the residential care setting, nursing home (NH) residents’ social contact preferences are of particular importance because patterns of social interactions change when an older adult shifts from a community-living environment to residential care (Abbott, Bettger, Hanlon, & Hirschman, 2012). The NH is a socially unique setting for many reasons. Hubbard, Tester, and Downs (2003) identified three aspects of residential care that impacts social interactions. First, personal characteristics of residents, such as cognitive, sensory, and functional limitations were found to influence social interactions. For example, the presence of cognitive impairment may prevent an individual from initiating a conversation. Similarly, hearing loss hinders the ability for individuals to have conversations. Second, the cultural attributes of the organization, such as the philosophy of care and the making of shared meaning between staff and residents, influences social interactions among residents. Third, the built environment, such as the floorplan of the building or gates on doors influenced social interactions as residents seek public and private areas to either engage with or avoid engaging with others (Hubbard et al., 2003).

Similarly, Bonifas, Simons, Biel, and Kramer (2014) found four themes that influence social interactions among NH residents. First, living in a NH restricts the context for a resident’s social interactions including when, where, and how the interaction occurs. For example, family and friends must adhere to facility regulations for visiting a loved one in a NH, and may feel unsure about when and how to interact with a loved one after he or she moves into a NH. Second, social interactions in the NH were mostly superficial, except when family/friends visited, because of few shared interests and the desire not to be faced with the cognitive or functional limitations of other residents on a daily basis. Indeed, other studies have found that NH social opportunities do not align with residents’ expectations of friendship (Casey, Low, Jeon, & Brodaty, 2016). Third, personal characteristics were a barrier to social interactions due to being busy with self-care, having sensory losses (i.e., hearing) and functional limitations that contributed to people disconnecting from others due to the pain of anticipatory loss. Behavioral and psychological symptoms of dementia were also barriers to social interactions among NH residents. Finally, barriers to social interactions in the NH were created by the organizations design or floorplan, such as small rooms that were not conducive to hosting guests and a lack of privacy. In addition, residents felt that stigma around living in a NH decreased interactions with family and friends (Bonifas et al., 2014).

A small, but compelling body of research finds NH residents spending a relatively small proportion of their time, between 10% and 16%, interacting with other people on a daily basis (Abbott, Sefcik, & Van Haitsma, in press). Similar findings have been reported by others, (Burgio et al., 2001; Van Haitsma, Lawton, Kleban, Klapper, & Corn, 1997) indicating a long-standing struggle to provide the optimal environment, activities, and match to resident preferences for social contact. In order to ensure that NHs are equipped to provide meaningful social activities and enhance social relationships, more research is needed to understand the specificities of NH residents’ preferences for meaningful social interactions.

The life-span theory of socioemotional selectivity (SST; Carstensen, 1995) suggests that individual preferences related to the amount and mode of social interaction may change over the life course based upon differing time horizons (Löckenhoff & Carstensen, 2004). Younger individuals perceive that they have more time in which to develop connections and seek information. Therefore, their social contact goals are motivated by seeking out new contacts and investing in relationships that may provide some future benefit. Conversely, older adults have less desire for new information, but seek to regulate their emotions. Seeing a shorter time horizon, older adults are less likely to invest in new connections. Instead, they prefer to spend time with a smaller number of familiar connections (Fredrickson & Carstensen, 1990) that are emotionally meaningful and less taxing (Scheibe & Carstensen, 2010). When viewing NH social interactions through the lens of SST, NH residents may find it challenging to establish social ties, it is therefore increasingly important to identify ways in which residents can establish meaningful connections. The present study seeks to contribute to this knowledge through two aims. First, we explore barriers to social contact preferences, from the perspective of the NH resident. In other words, we looked for personal, social, or environmental factors that functioned as barriers to fulfilling important social contact preferences. Second, we examine the ways in which NH residents explain how their social preferences are situationally dependent. For example, we wanted to understand what personal, social, or environmental factors were related to NH residents changing the importance rating of a social contact preference over time.

Design and Methods

The Preferences for Everyday Living Inventory (PELI; Van Haitsma et al., 2013; Van Haitsma et al., 2014) is a comprehensive, reliable assessment instrument that examines the content, meaning, and importance of 72 psychosocial preferences for social contact, growth activities, leisure activities, self-dominion, and enlisting others in care (Carpenter, Van Haitsma, Ruckdeschel, & Lawton, 2000). The PELI asks respondents to rate these items using the stem “How important is it to you to… [Insert preference]” with response options on a 4-point likert scale from 1 (very important) to 4 (not important at all). The PELI-NH was administered via face-to-face interviews with n = 255 NH residents with an Mini-Mental State Examination (MMSE) ≥ 13 (MMSE; Folstein, Folstein, & McHugh, 1975) at baseline (T1) and 3 months later (T2). Residents were recruited from NH facilities in the greater Philadelphia, PA area in an effort to meet targeted enrollment goals based on gender, ethnicity, and race. A convenience sample of 35 NHs agreed to participate in this study. We were unable to recruit participants from three locations; therefore, our final sample consisted of 32 NHs. The participating 32 NHs included 12 for-profit NH sites (37.5%), 19 nonprofit NH sites (59.3%), and one government NH site (3.2%). Number of beds ranged from 61 to 396 with an average of 178 beds.

The facility contact person from each NH identified residents who would enjoy participating in an interview about their likes and dislikes, who were up to moderately cognitively capable (MMSE ≥ 13), English speaking, and had a length of stay of at least 1 week and an expected stay of 3 months. The recruitment process was expanded to allow for the attending physician and/or director of nursing to sign off on each resident’s medical status. Once residents were identified, the attending physician and/or director of nursing verified that the resident was medically stable and had the capacity to consent for themselves or had a family member that could consent for the resident. The attending physician and/or director of nursing deemed 575 of the 581 residents identified by facility contact staff as medically stable.

For residents that could self-consent, the facility contact person approached residents to gain their assent to be contacted by the research team and informed the residents’ responsible parties about the study. For residents that required family consent in order to participate, the facility contact person was asked to approach the family to seek agreement to provide their contact details to the research study team to inform them of the study. A phone script was provided to the facility contact person to facilitate this connection. The research team followed institutional review board guidelines for seeking consent for this vulnerable sample.

A total of 581 residents were referred by organizations to participate in the study and 147 declined participation in the study. An additional 92 individuals were not enrolled due to responsible party/family refusal or being deemed medically unstable. Of the 342 individuals enrolled, n = 255 completed both interviews. Attrition between the first and second interviews was primarily due to death, discharge from facility, or withdrawing from the study at the time of the second interview.

Informed consent for participation in the study was established in-person and was repeated before the follow-up interview three months later. Throughout both interviews, if a resident offered clarifications for their answers, their responses were recorded verbatim. Overall, 7,893 comments were recorded from the 72 PELI-NH questions. The present study focuses on 1,461 responses provided to 13 social preference questions from the PELI-NH (Table 1).

Table 1.

Social Contact Questions From the PELI-NH

How important is it to you to….
Have regular contact with family?
Have regular contact with friends?
Be involved in choosing your roommate?
Spend time one-on-one with someone?
Give gifts?
Meet new people?
Spend time by yourself?
Volunteer your time?
aDo things with groups of people?
Be a member of a club?
aParticipate in religious services or practices?
Reminisce about the past?
Be around children?

Note: ^aMDS 3.0 Questions from Section F. Preferences for Customary Routine and Activities (Saliba & Buchanan, 2009).

Data Analysis

To examine the barriers and dependencies of social preferences, resident responses were transcribed verbatim and content analysis strategies of Graneheim and Lundman (2004) were used to identify explicit content (barriers and situational dependencies). We applied a previously developed coding scheme developed to classify barriers and situational dependencies associated with NH resident preferences (Heid et al., 2016). The coding scheme includes four major domains: within person (e.g., functional ability, personal schedule), facility environment (e.g., facility schedule, facility policy), social environment (e.g., quality and type of interactions), and global environment (e.g., weather, current events, and special occasions). Within the four domains, there are 27 themes identified that could affect resident preferences in two ways. First, it could act as a barrier that prevents fulfillment of the stated preference. Second, it could act as a situational dependency, whereby one’s level of importance changed based on the situation. A comment was coded as both a dependency and a barrier if it made reference to both a situation that would change the preference importance and a situation that would restrict preference fulfillment (Heid et al., 2016). Four research team members were assigned to code one fourth of the comments in the total data set (roughly 1,973 lines each). Through weekly team meetings, issues with coding were reconciled through conversation and consensus. Upon completion of coding, each team member was randomly assigned to review 25% of another team member’s coding; discrepancies among these double-coded responses were discussed and reconciled to consensus through team meetings.

Results

NH residents were mostly widowed (44%) White (77%) females (67.8%) with a mean age of 81 and a high school education (48%). Residents had an average length of stay of 924 days and an average MMSE score of 26 (see Supplementary Appendix A).

Barriers to Social Preferences

Residents cited barriers across all 13 social preference questions. However, some preferences elicited more barriers than others. For example, preferences for being involved with choosing a roommate, having regular contact with friends, giving gifts, and volunteering time consisted of 50% or more barrier comments (see Table 2). Alternatively, barriers related to spending time one-on-one or by yourself were infrequently reported (6% and 5% respectively; see Table 2).

Table 2.

Number and Percentage of Barriers Associated With Each Social Preference Question of the PELI-NH

	Be involved in choosing your own roommate	Regular Contact with Friends	Give Gifts	Volunteer your time	Spend Time with Family	Be a member of a club	Be around children	Reminisce about the past	Participate in religious services or practices	Do things with groups of people	Meet New People	Spend time by yourself	Spend time one-on- one with somebody
Total number of codes assigned for question	N = 239	N = 105	N = 120	N = 157	N = 96	N = 103	N = 135	N = 101	N = 99	N = 107	N = 63	N = 73	N = 82
	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)
Total number (%) of barriers coded	120 (50)	54 (51)	62 (52)	86 (55)	35 (36)	36 (35)	31 (23)	20 (20)	16 (16)	15 (14)	6 (11)	4 (5.5)	4 (5)
Number and (%) of codes with no barrier identified	119 (50)	51 (49)	58 (48)	71 (45)	61 (64)	67 (65)	104 (77)	81 (80)	83 (84)	92 (86)	57 (90)	69 (94.5)	78 (95)

Barriers–Within Person Domain

Perceived Level of Choice/Opportunity

Resident perceived that their level of choice/opportunity was a barrier mentioned across 12 of the 13 social preference questions. Residents did not perceive they could be a member of a club because there were few opportunities: “What clubs? There are no clubs here”.

Similarly, residents did not feel they had the choice to be able to give gifts because there was no opportunity for shopping. For example, one resident mentioned: “I like to but I’m sort of held back because I can’t go out and shop.” Additionally, residents mentioned barriers related to perceived choice/opportunity with regards to volunteering. These comments consisted of statements such as, “I would like to volunteer, but there are no opportunities to volunteer” and “They don’t ask for volunteers in here”. A smaller number of residents mentioned perceived lack of choice in participating in religious services or practices due to “no transportation”, and not being able to attend a ceremony connected to their specific religion: “Can’t do it, I am Ukrainian orthodox and they don’t have those types of services. The religion is close but not exactly. In order to go to Ukrainian orthodox services, then I would need transportation. Since transportation is an issue, I have to accept what is here.” Being around children was another social preference where residents mentioned a perceived lack of choice/opportunity in fulfilling because “we are lacking children here” and “I can’t. No opportunity.”

Level of Personal Resources

The level of personal resources was a barrier mentioned repeatedly regarding preferences for spending time with family, friends, and giving gifts. Residents reflected on the difficulty of not having “any family left”, families being “too busy”, or living far away. Similarly, residents expressed that friends were “dying off”, that there were “no friends here”, and “no one to talk to”. Friends were also unable to visit “because of the distance” of living geographically far away. In other cases, residents indicated that they did not have the means to maintain communication with friends and family. For example, residents mentioned not having access to a telephone: “They cut my phone off to try to talk to my family” and “Well I don’t have a telephone and so I don’t get to talk to my friends very often”. In addition to having few family and friends to connect with, the level of personal resources also reflected finances needed to maintain connections. With regards to giving gifts, residents mentioned that it “made them happy” to give gifts and that they liked “to give a token of appreciation”. However, residents mentioned barriers related to not being able “to afford” to give gifts.

Functional Ability

Residents mentioned functional ability as a barrier to volunteering their time. Residents explained that they “Can’t do that [volunteer] because I haven’t been feeling well” and that volunteering was “predicated on my condition. It’s important, but I can’t do it.” One resident explained “see my time is limited because I go to dialysis 3 times a week”. Doing things with groups of people, a common way activities are delivered in NHs, was also difficult for residents because of their functional ability, as one resident explained: “I can’t hear and I can’t see…. I wish I could do it [spend time with groups of people], but I can’t”. Similarly, in response to asking residents about being a member of a club, residents voiced that “Everything now is such a struggle that it is easier to skip everything” and “You are talking to someone in a nursing home… [I am] limited by my legs, my time is not my own”. In the instance of participating in religious services or practices one resident said that she “Can’t get down to mass. I’m on a water pill and I have to be careful. I’m afraid I’ll have an accident”.

Barriers–Facility Environment Domain

Residents mentioned facility policies as barriers to being involved in choosing a roommate. “They bring in whoever they want” and “We can’t [be involved], we get who we get.” One resident explained: “Whatever’s available, that’s where they put you. Sometimes they think you want a certain type of person, for example one that talks a lot, but that’s not the case. They think they know what you want but they really don’t”. Residents explained that “It is important to have a roommate with similar likes”. When residents had issues with new roommates, they were told that they could change rooms, but often they felt they shouldn’t have to change rooms because “I was in the room first”. Similarly, another explained: “I don’t have a choice. If I don’t like the person, I have to move. I don’t want to do that. She should move”.

Situational Dependencies Related to Social Preferences

Residents spontaneously mentioned examples across all 13 social preferences where they could envision changing their level of preference importance based on the situation. Some items elicited more situational dependencies than others ranging from 51% (spending time one-on-one) to 1% (spending time with family) (Table 3).

Table 3.

Count (%) of Situational Dependencies Associated With Each Social Preference Question of the PELI-NH

	Be involved in choosing your own roommate	Regular Contact with Friends	Give Gifts	Volunteer your time	Spend Time with Family	Be a member of a club	Be around children	Reminisce about the past	Participate in religious services or practices	Do things with groups of people	Meet New People	Spend time by yourself	Spend time one-on- one with somebody
Total number of codes assigned for question	N = 239	N = 105	N = 116	N = 147	N = 96	N = 101	N = 133	N = 100	N = 99	N = 109	N = 63	N = 73	N = 86
	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)
Number (%) of situational dependencies coded	16 (7)	5 (5)	35 (30)	27 (18)	1 (1)	11 (11)	22 (16.5)	13 (13)	10 (10)	33 (30)	15 (25)	13 (17)	44 (51)
Number (%) of codes with no situational dependency identified	223 (93)	100 (95)	81 (70)	120 (82)	95 (99)	90 (89)	111 (83.5)	87 (87)	88 (90)	76 (70)	48 (76)	60 (83)	42 (49)

Situational Dependencies–Within Person Domain

Level of Interest

The level of interest residents had for social preferences was dependent upon the context. Preferences for doing things with groups of people were situationally dependent. “It depends on what the group is”, “If I like it”, and “as long as [I’m] having fun”. Other responses clarified how importance would change: “Only for a trip is it very important” and “If it’s interesting enough”. For being a member of a club residents remarked that it “depends on what it is” and “[it] all depends on the people”. Volunteering your time depended on the type of activity: “If it’s something I want to do then it’s important”, and it “depends on what it’s for”. Finally, residents felt their importance ratings changed when reminiscing about the past. For example, it “depends on who I’m reminiscing with” and “depends on what I’m reminiscing about”. Some residents mentioned that reminiscing can make them feel sad, and one resident mentioned: “Sometimes it’s good. Depends on what you are thinking about”.

We also found that some residents viewed their preferences for spending time alone as “all depends on the situation”. For example, I like to be alone “when on the phone, [watching] TV, or [in] bed” and “I like my quiet time to read and pray”. One resident commented that it “Depends on the reason for being alone. If bathroom habits [are] involved, [it’s] very, very important”. Other residents explained that in the “afternoon I like to take a nap” and “because sometimes I want to be alone”.

Situational Dependencies–Social Environment Domain

Quality of Interaction

Preference importance ratings changed for residents depending on the quality of the interaction. For example, with regards to meeting new people, spending time one-on-one, and doing things with groups of people, residents said repeatedly, “it depends”. For meeting new people, residents made comments similar to it “depends on what they like to do or like to play”. When explaining why a preference importance rating may change for spending time one-on-one a common sentiment was: “It all depends on who the other person is, some are very important, others somewhat important”. Similarly, doing things with groups of people “varies on the subject”, for “friends and relatives it’s very important” and it “depends on their mental health, I need to be able to hold a conversation with them”. A few residents also mentioned the behavior of others when discussing the quality of the relationship regarding roommates: “See the roommate I have now, she tells me I’m mean. We don’t get along. When I moved in here she said ‘who gave you permission to move in here, no one asked me.’ She gave me a hard time in here”.

Type of Nonstaff Relationship

The type of nonstaff relationship as a situational dependency came up during the question of spending time one-on-one with someone. For example, “I have a lady friend and it’s important to be with her”, and “only with my son is it very important”. This situational dependency was also mentioned for giving gifts and being around children. With regards to giving gifts, residents said it “depends on the occasion and depends on who is getting it” and “I like to give my children gifts”. While spending time with children was more important for some people if they were relatives. For example, residents mentioned that it “depends on who. If my kids, it’s very important. I love seeing my 4-year-old great granddaughter”. Other residents explained that they “love little children, but don’t like teenagers”, and “if children are relatives and love them then important. If neighbor’s child not as much”.

Discussion

Understanding the social preferences of NH residents is a vital component of providing person-centered care within the long-term care setting. This study focused on gaining a better understanding of the barriers that may preclude preference fulfillment and situational dependencies that are important to consider when attempting to better understand where to intervene or alter efforts for social activities. While our study was able to replicate many of the barriers found in prior studies exploring social interactions among NH residents, it adds insights regarding specific types of social interactions asked in the PELI-NH, a widely used assessment measure in the United States. For example, we identify barriers to a range of social interactions such as volunteering, giving gifts, being a member of a club, and being involved in choosing a roommate. Previous work has shown a positive association between NH residents’ perception of choice and satisfaction with their care preferences being met (Bangerter, Heid, Abbott, & Van Haitsma, 2016). Therefore, we provide recommendations for practice regarding ways of remediating barriers. Finally, through the theoretical framework of SST, we discuss situations where NH residents change their mind about an important preference.

Residents voiced that they had no opportunity to be involved in choosing a roommate. They were not referring to the need for privacy, which Kane (2001) and Kane & Kane (2001) argue is a key component of quality of life, but to the opportunity to give input about who they will be required to share space and time with. Thus, NHs that are not able to offer private rooms, would benefit from engaging residents in the roommate selection process, either directly, or by using information from the PELI-NH as additional data to inform the complex process of matching long-stay residents. For example, identifying common preferences amongst NH residents could potentially allow for a better match of roommates. Two NH residents who prefer to watch movies from the 1950’s may be a good match, whereas one NH resident who prefers to watch sports on TV and one NH resident who has no preference for sports may not be a good roommate match. Alternatively, efforts to match NH residents in shared social or recreational pursuits outside of time spent in their rooms could offset the lack of “good fit” roommate match from the perspective of shared preferences.

Residents felt they had no choice in their ability to volunteer, be a member of a club, be around children, or give gifts because the opportunity did not exist. These are types of activities that enhance social meaning for residents, but are widely underutilized. Providers can seek guidance from their resident advisory boards and family members for ways residents can contribute to the broader community, either through making gifts or selling items they make and donating the money to a charity of their choice. For example, residents could make cards for children’s hospitals or be given the opportunity to donate the items they create during routine craft activities offered at many NHs. Low cost implications for the activities department may include craft programs where residents create an item they plan to give to a family member or employee. In light of these findings, NHs may choose to redefine their policies that do not allow employees to accept gifts and allow things like gifts made during a craft group (jewelry, painting, cards, clay figurines, knitting, cooking dog biscuits, etc.).

Volunteering is a form of social participation, and one way older adults can make new social connections (Wong & Waite, 2016). Residents explained that volunteering is a meaningful activity because “trying to help others is what keeps me going”. Understanding in what way residents would like to volunteer would help develop meaningful ways of fulfilling that preference. For example, partnerships with local preschools and elementary schools for older adults to read to children can be developed and would fulfill both the preference to volunteer and be around children. One example of this comes from the AARP Foundation Experience Corps program supports literacy in schools utilizing volunteers who are 50 and older (http://www.aarp.org/experience-corps/). Similar programs may be developed specifically for NH residents.

Lack of personal resources was a clear barrier to fulfilling social contact preferences. Residents mentioned a lack of resources such as having no one to talk to. Many residents explained that their social network was shrinking due to the death of friends. Making new friends in residential settings is difficult because residents have varying levels of cognitive ability to initiate and maintain a conversation. Communicating resident preferences to direct care and nonclinical staff (e.g., housekeeping) could provide opportunities to identify mutual interests for topics of conversation while care is being provided. In addition, staff can adopt a facilitator role to introduce residents to each other, start, and keep conversations among residents going (Bergland & Kirkevold, 2008). Identifying mutual preferred topics of conversation would be crucial to the success of this activity. The probing questions found in the full version of the PELI-NH can be used to find shared areas of interest among residents.

Functional ability was a barrier to preference fulfillment; residents expressed that social preferences were important, but that they were unable to fulfill a preference due to a physical, functional, sensory, or cognitive limitation. Providers are required to develop specific care plans around the 16 preferences in the Minimum Data Set (MDS 3.0) Section F. for NH residents that state a preference is “important, but I can’t do it” (Saliba & Buchanan, 2009). Creating an opportunity for a resident to use his or her current abilities to fulfill an important preference is vital to providing person-centered care and has been linked to positive outcomes for NH residents (Kolanowski, Litaker, Buettner, Moeller, & Costa, 2011; Van Haitsma et al., 2015). Certified Therapeutic Recreation Specialists (CTRS) are trained to adapt activities to meet the level of functional impairment (American Therapeutic Recreation Association www.atra-online.com, National Council for Therapeutic Recreation Certification www.NCTRC.org). This approach is supported by the model of selective optimization with compensation (SOC; Baltes, 1997) which entails the selection of personal goals, achieving these desired goals through optimal approaches, and using alternative methods to achieve goals amidst age-related decline. The goal of the SOC approach is to provide a modified activity, that is adapted both on functional ability and is goal directed to improve or maintain current level of functioning. An example case study is Mrs. Washington, a fully oriented resident who requires physical assistance to move throughout the building, suffers from moderate depression and often refuses to participate in recreational activities. Her interests are keeping in touch with old friends via the computer and interacting with children. The building only has Wi-Fi access in certain areas. Ways to support her goals include matching Mrs. Washington with a child volunteer, who can safely transport her throughout the building, and to whom she could read books or play board games with. In addition, a schedule could be created for when she can use the room with Wi-Fi to interact with friends living outside the community via E-mail or social media. Preferences are not stagnant, and are likely to change depending on many different circumstances. Thus, it is critical to understand what may cause a resident to change their mind about a particular preference. NH residents were able to explain situations when they may change their mind about an important preference including the quality of the interaction and their level of interest. Many residents stated that the quality of the interaction and with whom the interaction would be with, would impact the importance of social preferences. The quality of interactions can be improved by understanding who the resident would prefer to spend time with. Some residents explained that they would like to spend time with family and friends, but had less interest in meeting new people or doing things with groups of people. The transitory nature of the long-term services and supports environment makes some people shy away from developing close friendships in case they move or pass away (Sefcik & Abbott, 2014). Likewise, SST posits that older individuals prefer to invest in existing relationships over new relationships (Carstensen, 1995). Thus, a key recommendation from our work is that providers consider the implications of applying SST to service delivery (Burnett-Wolle, 2009) and focus programmatic efforts on helping residents maintain existing valued relationships. This may entail offering the technology necessary to maintain geographically distant important social relationships (e.g., smart phone, skype, facetime) as well as assisting residents in more traditional forms of communication such as helping them write letters or E-mails. Indeed, it may be that maintaining social ties with younger generations (e.g., children and grandchildren) is more amenable to modern technology.

The importance rating of a preference may change depending on resident level of interest. For example, preferences for doing things with groups of people and volunteering were highly dependent upon the activity being something that was of interest to the resident. We recommend providers use the probing questions found in the full PELI-NH version to identify areas of interest and develop tailored social activities based on resident interest and functional abilities. Though some providers may not have the bandwidth to administer the PELI-NH in its entirety, at the very least, providers should make it a goal to have these conversations with residents, and can gain valuable information from residents’ comments about their social preferences. Seeking information about what programming is of interest to residents can assist with developing activities that are meaningful and important to residents. We also recommend giving residents the choice to participate in an activity and not assume that a resident who has never participated in a particular activity would not be interested in that activity in the future (or vice versa).

Limitations and Next Steps

In this study, we spoke to NH residents who were both cognitively capable and moderately cognitively impaired. Therefore, we cannot generalize to NH residents with severe cognitive impairment. Future observational studies are needed with individuals who are unable to communicate their social contact preferences to explore if resident affect can be used to identify preferred social contacts. In addition, the questions included in the social contact domain of the PELI were empirically derived (Carpenter et al., 2000) and are not exhaustive of all social contact preferences. It may be that there are additional preferences, such as spending time with pets that should also be considered in this domain. We may also need to explore how to ask about preferences for social contact in a way that could facilitate social integration. Future studies are needed to understand how NH providers can remediate barriers and use a better understanding situational dependencies to fulfill residents social contact preferences. In addition, the unstructured design of data collection recorded spontaneous comments and could have biased our data because only data from residents who offered to explain were included. It is likely that had we specifically asked residents to speak about barriers and situational dependencies to preference fulfillment we would have received additional responses from residents who may not have thought to explain their response. Finally, it is possible that some participants contributed the same information twice if they made similar comments at both T1 and T3, which could have inflated the frequency of a specific barrier or situational dependency.

Conclusion

Social preferences are a major aspect of daily life, and are particularly salient in the NH setting. Our study identified multiple barriers to fulfilling social contact preferences of NH residents. Residents’ perceive that they have few choices, few resources, and explain how their functional ability is a barrier to meeting their preferences for social contacts. In addition to barriers, NH residents explained situations when they may change their mind about an important preference, primarily because of the quality of the interaction and their level of interest. Knowledge of barriers regarding social preferences can inform care efforts that may prove vital to advancing the delivery of quality care. Understanding the reasons why NH resident preferences change based upon context can help providers with staff training and lead to more tailored, person-centered care.

Supplementary Material

Supplementary data are available at The Gerontologist online.

Funding

This work was made possible in part by funding from The Patrick and Catherine Weldon Donaghue Medical Research Foundation and Award number R21NR011334 from the National Institute of Nursing Research. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research, the National Institutes of Health, or the Donaghue Foundation.