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. Author manuscript; available in PMC: 2024 Jan 1.
Published in final edited form as: Clin Gerontol. 2021 Dec 28;46(1):111–121. doi: 10.1080/07317115.2021.2007436

Preference Importance Ratings Among African American and White Nursing Home Residents

Nytasia M Hicks a, Allison R Heid b,*, Katherine M Abbott a, Kendall Leser c, Kimberly Van Haitsma d
PMCID: PMC9237178  NIHMSID: NIHMS1766948  PMID: 34962458

Abstract

Objectives:

The Preferences for Everyday Living Inventory (PELI-NH) assesses psychosocial preferences of nursing home (NH) residents. This study explored the association of race with importance ratings of self-dominion preferences (i.e., preferences for control).

Methods:

PELI-NH interviews were conducted with 250 NH residents. Tests of mean differences compared African American (n = 57) and White (n = 193) residents on demographic (age, gender, education, length of stay) and clinical attributes (self-rated health, depressive symptoms, anxiety, functional limitations, hearing, vision, cognition). Stepwise multiple regression accounted first for associations of demographic and clinical attributes then for the unique association of race with total importance of self-dominion preferences to determine whether African American and White residents differ. For between group demographic/clinical differences, interaction effects were tested.

Results:

African Americans were younger and more functionally impaired. After accounting for effects of gender (female), age (younger), anxiety (greater), and functional impairment (less) with higher reports of importance of self-dominion preferences, race was significant. There were no significant moderating effects.

Conclusions:

African American residents reported greater importance of self-dominion preferences than Whites.

Clinical Implications:

Cultural sensitivity is critical; it may be more important to provide opportunities of autonomous decision-making for African American than for White residents.

Keywords: Person-centered care, long-term care, race

Introduction

Person-centered care (PCC) is a multifaceted concept that encourages health care providers to push beyond the medical model and provide care in line with a more holistic bio-psycho-social approach that addresses patient concerns and needs (Koren, 2010). PCC requires input from care recipients and has strong implications for optimal healthcare delivery (Koren, 2010). Although there is no universal definition for PCC, long-term care scholars are consistent in acknowledging that individualized customization of care through the identification of residents’ preferences is key for affecting positive health outcomes, quality of life, and satisfaction with care (Carpenter et al., 2000; Kogan et al., 2016; Koren, 2010; Van Haitsma et al., 2019). Understanding residents’ preferences, therefore, is central to providing optimal nursing home (NH) PCC. Preference assessments can also be a key informant for delivering care that also honors “What matters” to older adults (Laderman et al., 2019).

Historically, assessment tools and strategies to meet individualized care needs were often limited in scope, where care preferences were captured using abbreviated or standardized assessments (Carpenter et al., 2000; Saliba & Buchanan, 2012). Such assessments briefly measured personal values using 7 to 9 item questionnaires (Degenholtz et al., 1997), while other assessments only explored the physical design of home settings (Brennan, Moos, & Lemke, 1988) and NH accommodations (Firestone et al., 1980). The limited scope overlooking personal preferences in these previous assessments lead to the development of the Preference for Everyday Living Inventory (PELI).

To capture the way in which older adults receiving home care services prefer to have their everyday care needs met, the first iteration of the PELI-Home Care (PELI-HC) tool, measured 55 psychosocial preferences of everyday life (Van Haitsma et al., 2013). This tool addresses preferences in five conceptual domains: social contact, growth activities, leisure activities, self-dominion, support aids, and caregivers and care (Carpenter et al., 2000). The PELI-HC asks questions such as “Do you like to eat at restaurants?” and “Do you like to keep in regular contact with your family?”. This measure has been tested for validity and reliability in a home care population (Van Haitsma et al., 2013).

The second iteration of the PELI addressed the everyday psychosocial preferences of NH residents. Modifications of the PELI-HC were informed by cognitive interviews with 70 NH residents to obtain preferences specific to NH settings (Curyto et al., 2016). Findings from the interviews indicated that more than 25% of the PELI-HC items required revisions, including changes to improve language selection so that terms and phrases would be identifiable by NH residents. Additional revisions included the assessment of preference item relevance as community and NH settings vary (Curyto et al., 2016). For example, a preference for taking care of things around the house is applicable in the home, but not in the NH. Revisions resulted in the 72-item PELI-NH.

When assessing preferences for residents, using detailed questions found in the PELI-NH (preferencebasedliving.com) can provide the nuance needed to understand how residents would like to have his/her preferences fulfilled. Research on the PELI-NH has explored the consistency (Van Haitsma et al., 2014) and stability of NH resident preferences (Abbott, Heid et al., 2018), barriers and situational dependencies to honoring preferences (Abbott, Bangerter et al., 2018; Bangerter, Abbott et al., 2015; Heid et al., 2016), and support of residents’ choice and satisfaction with care (Bangerter et al., 2016). Additional research on the PELI-NH has explored the accuracy of proxy respondents (Heid et al., 2017), behavioral symptoms of dementia regarding positive and negative affect among NH residents (Van Haitsma et al., 2015), staff experiences implementing the PELI-NH (Abbott et al., 2016), and NH resident characteristics on stability of autonomy preferences (Heid et al., 2019). Overall, the PELI-NH is a valid and reliable measure to identify care recipients’ preferences of daily life.

However, not yet fully addressed by the literature, is if there are differences in preference importance ratings by race using the PELI-NH. Guided by the life-course framework, we seek to explore if there are racial differences among NH resident preference importance ratings. The life-course framework posits that although individuals may face the same current experience, cumulative advantage/disadvantage informs their experiences (Dannefer, 2003; O’Rand, 1996). Literature documenting racial differences in preferences reveal that African Americans often more strongly prefer listening to the radio, wanting more privacy, having access to larger social networks, and participating in religious activities when compared to their White counterparts (Ajrouch et al., 2001; Hefele, et al., 2016; Singer et al., 2004; Taylor et al., 2007). For example, in assessing over 400 older adults (over age 60) receiving home care services on their preferences on the PELI-HC, Van Haitsma and colleagues (2013) revealed that African American older adults reported greater importance for preferences for religious activity, listening to the radio, and having privacy compared to White older adults. White older adults reported greater importance for preferences related to drinking occasionally and reminiscing about the past compared to African American older adults (Van Haitsma et al., 2013). Researchers suggest that, although there is not one unidimensional explanation for racial differences in preferences, some differences can be explained by cultural upbringing, lack of social support, and distrust for institutions among African Americans (Hefele, et al., 2016; Singer et al., 2004; Taylor et al., 2007; Van Haitsma et al., 2013).

The purpose of this study, therefore, is to evaluate if there are differences in preference importance ratings between African American and White adults in the NH context. Distinct from the home care sample assessed by Van Haitsma et al. (2013), NH residents are typically more impaired in terms of functional and cognitive capacities while receiving care in a highly regulated, more medically oriented setting (Fahey et al., 2003; Unroe et al., 2017), which may differentially impact their ratings of preference importance in everyday care. An increased understanding of potential differences or similarities in preference importance ratings by race within a NH context can inform measurement development and utilization, policy formation regarding preference assessments, and delivery of preference-based care.

In particular, there are clear ramifications for response to autonomy or self-dominion preferences of NH residents. Honoring an individual’s autonomy is a critical psychosocial need throughout one’s life along with relatedness and competence (Deci & Ryan, 2000). Autonomy is linked to morbidity, mortality, and well-being in NHs (Kasser & Ryan, 1999; Persson & Wasterfors, 2009). Specifically, reduced personal autonomy has been linked to mortality one year later (Kasser & Ryan, 1999). And while all three psychological needs of autonomy, competence, and relatedness are linked to well-being, it has been found that autonomy has the strongest association with depressive feelings and life satisfaction in the NH (Kloos et al., 2019). The analyses that follow, therefore, focus specifically on the ratings of self-dominion preferences by African American and White NH residents. Self-dominion preferences are defined as those related to autonomy and an individual’s preference to control one’s schedule, routine, and environment (Carpenter et al., 2000).

Given prior literature finding unique preferences of African Americans (Ajrouch, Antonucci, Janevic, 2001; Hefele, et al., 2016; Roberts et al., 2018; Taylor et al., 2007; Van Haitsma et al., 2013), we hypothesized that, although preferences are inherently individualistic, differences in preference importance between African American and White adults would be expressed with African Americans reporting higher levels of importance than Whites on self-dominion preferences.

Methods

Procedures

Participants (N = 313) were recruited from 28 NHs located in the suburbs of an east coast metropolitan area of the United States. Facilities varied in their demographic make-up, Medicaid/Private-pay clientele, staffing principles, environmental design, and specialized activities. Potential participants that met study eligibility criteria at each NH were identified by NH staff (e.g., social workers and directors of nursing). Eligibility criteria included being English speaking, medically stable, scoring at least 13 on the Mini-Mental State Examination (MMSE; Folstein et al., 1975), and having a NH stay of more than 1-week. Medical stability of each participant was verified by physicians or directors of nursing. Participant or family consent was obtained via research assistants. Consent documents used simplified language to accommodate sensory/cognitive needs of the NH population and used interactive questioning to ensure comprehension. A total of 581 residents were identified by NHs to participate. Of the 581 residents identified, 313 provided consent, scored a 13 or higher on the MMSE, and completed the PELI-NH interview.

For each resident that completed the PELI-NH interview, the most recent annual and quarterly Minimum Dataset 3.0 (MDS 3.0; Saliba & Buchanan, 2009) data were collected from NHs. Of the 313 who provided consent, full MDS 3.0 data were available for 251 residents. The analyses that follow further restrict the sample to only African American and White residents (only one resident identified as Asian). The final sample includes 250 NH residents will full preference and MDS 3.0 data which includes 57 African American and 193 White adults. Residents included in analyses do not differ from the larger participating sample on age, education, length of stay, gender, or race.

Measures

Demographics.

Participant demographics were collected via chart review of quarterly and annual MDS 3.0 records (Saliba & Buchanan, 2009), including: age (years), education, race, and length of stay in the NH (in days). Participant education was recorded as no schooling, 8th grade or less, 9th-11th grade, high school, technical college, some college, bachelor’s degree, or graduate degree. Race was categorized into five groups: American Indian, Asian, Black or African American, Native Hawaiian or other Pacific Islander, and White. Only one resident reported a race other than African American/White and was dropped from the data (n = 1 Asian) data. A dichotomous indicator was created as 1 (African American) or 0 (White).

Clinical attributes.

Self-rated health was measured with five SF-36 items (Ware & Sherbourne, 1992). Residents were asked to rate their perceived general health on a scale of 1 (excellent) to 5 (poor), and to compare their health to others with 4-items on a scale of 1 (definitely true) to 5 (definitely false). Negative items were reverse-coded, and a mean item-total score was computed (α = .67). Depressive symptoms were assessed with the Patient Health Questionnaire (PHQ-8; Kroenke et al., 2009). Participants were asked if they were bothered over the past week by a list of eight symptoms, using a 4-point Likert scale of 0 (not at all) to 4 (nearly every day). A mean-item total score was computed (α = .73). To rate anxiety a 25-item self-report measure was administered to rate how often they had experienced anxiety-related symptoms within the past week from 0 (not at all) to 3 (nearly every day; Geriatric Anxiety Scale (GAS); Segal et al., 2010). A mean-item total score was computed (α = .90). Cognitive ability was determined by administration of the MMSE. The MMSE is a 30-point screener for cognitive impairment (Folstein et al., 1975). Its reliability and validity have been well-established among older adults (Tombaugh & McIntyre, 1992) and individuals who were mild to moderately cognitively capable (MMSE ≥ 13) were eligible to participate (Range: 13 to 30). Functional limitations, hearing impairment, and vision impairment were all drawn from the MDS 3.0. Functional limitations were assessed with 10-items of Activities of Daily Living (ADL) rated from 0 (independent) to 4 (total dependence, activity only occurred once or twice or did not occur), and a mean item-total score was computed (α = .90). Hearing impairment was rated with a single item from 0 (adequate hearing) to 3 (highly impaired); vision impairment was rated from 0 (adequate vision) to 4 (severely impaired).

Preferences of Everyday Living Inventory-Nursing Home version (PELI-NH).

The PELI-NH (preferencebasedliving.com) was used to obtain information regarding residents’ everyday psychosocial preferences (Van Haitsma et al., 2013). Participants were asked to respond to a question stem that started with “How important is it to you to… [insert preference]” with a 4-point Likert scale of 1 (very important) to 4 (not important at all). The 72-questions cover five psychosocial preference domains including (1) Self-Dominion (i.e., preferences for control over one’s schedule, routine, and environment, such as having privacy, choosing what to eat), (2) Enlisting others in care (preferences for access to medical care, relationships with caregivers, and involvement of specific individuals in care such as having a caregiver be of the same gender), (3) Leisure and Diversionary (preferences for activities geared toward relaxation, diversion, and entertainment such as watching television), (4) Social Contact (preferences for general social contact such as meeting new people), and (5) Growth Activities (preferences for activities that provide a potential for personal growth, achievement, or self-enhancement, such as exercise; Carpenter et al., 2020; Van Haitsma et al., 2013). The analyses that follow focus specifically on items in the self-dominion domain (n = 25-items), including the subset of items that focus on control and autonomy in care such as: choose when to get up in the morning, set up your room the way you want, and choose how to care for your hair. All preference responses were reverse coded to have higher scores indicate greater preference importance to ease interpretation of findings. A mean-item total score was computed for self-dominion preferences (α = .88).

Analysis

Descriptive statistics were calculated using SPSS version 25. Tests of mean difference (t-test and chi square) were used to compare means and frequencies of African American and White residents on all demographic (age, gender, education, length of stay) and clinical attributes (self-rated health, depressive symptoms, anxiety, functional limitations, hearing, vision, cognition). Pearson product moment correlations were run among demographic and clinical constructs. Finally, stepwise multiple regression was utilized to examine the independent association of each construct with preference importance ratings of self-dominion preferences and the unique association of race with importance ratings. Attributes of individuals were entered in sequentially, first demographics (age, gender, education, length of stay), then clinical attributes, then race (self-rated health, depressive symptoms, anxiety, functional limitations, hearing, vision, cognition). Non-significant constructs were trimmed at each step to ensure model parsimony. Where significant differences by race were present at the mean-level, interaction terms with race were computed and tested in the model (i.e., age*race, functional limitations*race). Non-significant interactions were removed. The final model included age, gender, anxiety, functional limitations, and race.

Results

Table 1 presents full sample characteristics and characteristics by racial group. NH residents in the sample were mostly female (68% of sample, n = 170). Nationally, a little over 85% of NH residents stay 100 days or longer (Harris-Kojetin et al., 2019), in this study the length of stay for residents was an average of 924 days, indicating a longer tenure in the NHs surveyed. On average, African American participants were significantly younger (74 years of age) than White NH participants (83 years of age) (p < .001). African Americans reported greater functional limitations (M(SD) = 24.12(7.11)) than White residents (M(SD) = 21.27(8.48); p < .05). African American and White NH residents in this sample did not differ on gender, education length of stay, ratings of self-rated health, depressive symptoms, anxiety, cognitive ability, hearing impairment or vision impairment.

Table 1.

Sample Descriptive Characteristics for the full sample and by Racial group

Full Sample (N = 250) African-Americans (N = 57) Whites (N = 193) Test of Mean Difference
M(SD)/%(N) M(SD)/%(N) M(SD)/%(N)
Demographic Characteristics
Age 80.95 (11.31) 74.05 (12.13) 82.98 (10.24) t(249) = 5.50***
Gender (Male) 32% (80) 36% (21) 31% (59) N.S. a
Education N.S.
 8th grade or less 2% (6) 0% (0) 3% (6)
 9th-11th grade 12% (29) 11% (6) 12% (23)
 High School 48% (121) 44% (25) 50% (96)
 Technical School 4% (11) 0% (0) 6% (11)
 Some College 9% (23) 14% (8) 8% (15)
 Bachelor’s Degree 9% (23) 9% (5) 9% (18)
 Graduate Degree 5% (12) 4% (2) 5% (10)
Length of Stay (Days) 924.41 (908.37) 920.13 (1002.47) 925.69 (881.28) N.S.
Clinical Characteristics
Self-rated health 51.06 (14.03) 48.77 (16.59) 51.74 (13.16) N.S.
Depressive Symptoms 4.66 (4.40) 4.74 (3.74) 4.64 (4.58) N.S.
Anxiety 11.78 (11.42) 13.73 (11.22) 11.20 (11.44) N.S.
Functional Limitations 21.92 (8.26) 24.12 (7.11) 21.27 (8.48) t(110.88) = −2.51*
Cognitive Ability 24.54 (3.93) 24.47 (3.97) 24.56 (3.93) N.S.
Hearing (Adequate) 78% (194) 83% (47) 76% (147) N.S.
Vision (Adequate) 83% (208) 84% (48) 83% (160) N.S.
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Note.

*

p < .05,

**

p < .01,

***

p < .001.

a

N.S. = No Significant group differences.

Table 2 depicts correlations among constructs of interest and the primary dependent variable of total importance of self-dominion preferences. Inter-item correlations indicate a significant positive association of race and anxiety with total reports of importance of self-dominion preferences. African Americans and those reporting higher levels of anxiety reported more importance of self-dominion preferences. Age and vision were significantly negatively associated with self-dominion preferences. Younger residents and those with less impairment reported more importance.

Table 2.

Correlations among Ratings of Preference Importance, Demographic characteristics, and Clinical attributes

1 2 3 4 5 6 7 8 9 10 11
1. Mean Importance of Self-Dominion Preferences -- -- -- -- -- -- -- -- -- -- --
2. Age −.18** -- -- -- -- -- -- -- -- -- --
3. Gender (Male = 1) −.11+ −.20*** -- -- -- -- -- -- -- -- --
4. Race (African American = 1) .19** −.33*** .06 -- -- -- -- -- -- -- --
5. Self-rated Health −.01 .15* .09 −.09 -- -- -- -- -- -- --
6. Depressive Symptoms .13* −.16* −.05 .01 −.21*** -- -- -- -- -- --
7. Anxiety .21*** −.17** −.13* .09 −.07 .27*** -- -- -- -- --
8. Functional Limitations −.11+ −.07 −.06 .15* −.07 .03 −.07 -- -- -- --
9. Cognitive Ability .00 −.13* .02 −.01 −.01 .05 −.05 −.25*** -- --
10. Hearing −.01 .35*** .02 −.07 .07 .06 .05 −.14* .04 -- --
11. Vision −.15* .05 .09 −.02 .02 .01 −.04 .10 −.14* .15* --
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Note.

+

p < .10,

*

p < .05,

**

p < .01,

***

p < .001

Stepwise linear regression indicated that gender, age, anxiety, functional impairment, and race were all independently associated with importance of self-dominion preferences. Females reported greater importance than males; younger age was associated with greater reported importance; greater anxiety was associated with greater reported importance, and less functional impairment (ADL) was associated with greater reported importance. After accounting for these effects of demographic and clinical attributes, race was significant. African Americans reported greater importance of self-dominion preferences than Whites. Moderating effects of age and functional limitations by race were not significant, indicating that the association of race with importance was not due to African Americans being younger or more functionally impaired.

Discussion

This study sought to test whether African American and White NH residents differ on reports of total importance of self-dominion preferences in daily care. Our findings demonstrate that after accounting for demographic and clinical attributes of residents, race (African American/White) is uniquely associated with importance ratings of self-dominion preferences. African American NH residents reported on average greater importance of self-dominion preferences than White residents. Despite African Americans being younger and more physically disabled, age and functional ability did not moderate the association between race and preference importance ratings. The findings provide evidence that the PELI-NH can capture differences in importance ratings of preferences by racial groups and that African Americans place a differential level of importance on self-dominion preferences than White residents. Findings carry implications for assessment and practice.

First, the results presented here indicate that the PELI-NH is capable of detecting differences in levels of importance of self-dominion preferences for both African American and White older adults in NHs. While this finding could indicate that African American and White older adults interpret the PELI-NH items differently, cognitive interviewing in the formative stages of the PELI-NH relied on input from both African American and White older adults (Curyto et al., 2016). The inclusion of both African American and White older adults’ perspectives in crafting wording of each item contributed to word selection that was comprehended across both groups. This development process allows for the opportunity to detect importance differences between racial groups, as found here.

Second, after accounting for demographic (age, gender) and clinical attributes (anxiety, functional limitations) associated with reports of total importance of self-dominion preferences, significant differences in reports of preference importance were found between racial groups. African American residents reported higher levels of importance for self-dominion preferences compared to White residents. The differences were not explained by African Americans being younger or more functionally impaired. Rather, the differences in importance ratings may be the result of unique cultural and life course experiences. Cumulative disadvantages caused by systemic racism experienced by African American older adults where autonomy has been limited over the life course (Mor et al., 2004; Rosenblatt, 2009) could explain the differences. Cumulative disadvantage may result in a higher endorsement of importance because of prior suppression. Or greater endorsement may be explained by the extensive history of distrust between health professionals and African Americans (Hansen, Hodgson, & Gitlin, 2016). According to Hansen and colleagues (2016), African Americans have experienced negative health care encounters where some providers often disregard their preferences through actions, including lack of respect and the assumption of stereotypical preferences (e.g., less educated or being referred to as Ma’am). This may result in a greater emphasis placed on the importance of autonomy preferences by African American residents than White residents in NHs. For instance, African American NH residents’ distrust for institutions may increase their feeling of importance for privacy. In addition, African American residents report fear of not being treated as equally as White residents, experiencing racial slurs or attacks by White residents or staff (Rosenblatt, 2009). Thus, when asked about preferences for autonomy in this context, African Americans may rate items as more important as a way of expressing their need for respect. Overall, additional work is needed to test the hypothesized mechanisms to determine why African Americans report differences in importance level.

Third, of note before accounting for race, we found that younger and female NH residents and those with greater anxiety and fewer functional limitations (more ability), reported higher levels of importance of self-dominion preferences. It may be that individuals with these attributes feel more restricted in their control over their living experience and as a result express a greater importance for self-dominion preferences. For example, younger residents who are the minority in a nursing home may feel they do not belong or are not interested in activities offered and, therefore, express a greater preference for control in their life. Women in NHs may have generationally experienced greater marginalization or discrimination in their lives than men resulting in a greater expression for control in their current daily rhythms. Or these preferences may need to be expanded to include what is more important to males (Roberts et al., 2018). Individuals with higher levels of anxiety may be experiencing a lack of control in other areas of their life, which may result in attempts to assert control when able. And, individuals less functionally impaired, may have the capacity to still manage their daily lives, or feel they should, and assert higher levels of desired autonomy and choice. Future work should test these associations and hypotheses to determine the mechanisms for why and how such individual attributes affect self-dominion preferences.

Recommendations for Practice

This study has implications for practice. Broadly, findings encourage providers to assess and integrate important preferences into each resident’s daily routine regardless of race. When assessing preferences for residents, using detailed questions found in the 72-Item PELI-NH, providers can elicit details about how a person would like to have an important preference honored. Intentional communication that seeks to assess such preferences of NH residents can improve care delivery (Williams et al., 2017; Williams et al., 2016). For example, most NH residents would state that choosing what clothes to wear is important, but each person may prefer this to be accomplished in different ways. By providers having more detailed conversations about psychosocial preferences with NH residents, opportunities to honor resident preferences and autonomy may be increased (Williams et al., 2016). Specifically, for African American residents, results indicate that taking the time to ask an individual what is important is critical and this may lead to improved trust between African American residents and staff (Hansen, Hodgson, & Gitlin, 2016). Additional efforts should be made to avoid stereotypical assumptions about individuals of African descent as well (e.g., that they are uneducated; Hansen, Hodgson, & Gitlin, 2016) and allow for choice in care.

By carefully assessing preferences of residents, providers can focus on opportunities to honor self-dominion preferences of all residents, specifically African American residents. Cultural sensitivity can be improved by determining strategies to meet self-dominion preferences that are reported as more important by African American adults. Staff can identify through the detailed questions on the 72-item PELI-NH how African American residents wish to have their autonomy honored and either support the resident in doing that activity or develop new ways to honor those preferences (Abbott, Bangerter et al., 2018).

Limitations

As with all studies, this work is not without limitations. First, only participants who were capable of verbal communication were included in this study. Therefore, perspectives of individuals who are unable to communicate were not represented (i.e., those with advanced dementia). Second, participants were referred to the study by NH staff. As a result, the sample is only representative of those who staff thought would enjoy participating in preference-based interviews and/or were perceived to have the capacity to do so. Third, we could only explore the differences between African American and White residents due to small numbers of participants in other racial groups (e.g., Asian, Hispanic). The PELI-NH can benefit from additional testing with additional racial/ethnic groups to increase understanding and ability to assess preferences across other diverse groups. Fourth, future work should test for differences in importance ratings by other background or demographic attributes, as this may further inform clinical practice. Fifth, the findings from this work are drawn from experiences of NH residents residing in one geographic region, future work should explore if the findings hold in other regions. Last, additional work should consider the impact of nursing home level characteristics (i.e., payer source, medical vs. person-entered orientation, and/or percentage of African American residents in the NH) on preference importance ratings. It may be that residents living in specific environments report higher levels of self-dominion importance than others.

Conclusion

This study takes a critical step in advancing our understanding of the how race (African-America/White) is associated with differences in preference importance ratings of self-dominion preferences on the PELI-NH. When controlling for demographic and clinical attributes of residents, African Americans report higher levels of importance of preferences. Implementing strategies to carefully assess the preferences of African American residents is a crucial step toward providing culturally sensitive, PCC (Van Haitsma et al., 2013; Van Haitsma et al., 2015). The findings expand on previous PCC work by strengthening our understanding of the utility of an evidenced-based tool for the assessment of psychosocial preferences among NH residents (PELI-NH).

Table 3.

Stepwise Multiple Regression of Demographic characteristics and Clinical attributes associated with Importance Ratings of Self-Dominion Preferences

Model 1 Model 2 Model 3
B SE ß B SE ß B SE ß
Constant 4.05*** 0.21 -- 4.07*** 0.23 -- 3.92*** 0.24 --
Age −0.01*** 0.00 −0.22 −0.01*** 0.00 −0.20 −0.01* 0.00 −0.15
Gender (Male = 1) −0.16** 0.06 −0.17 −0.15* 0.06 −0.16 −0.15* 0.06 −0.16
Anxiety -- -- -- 0.01* 0.00 0.15 0.01* 0.00 0.14
Functional Limitations -- -- -- −0.01* 0.00 −0.13 −0.01* 0.00 −0.15
Race (African American = 1) -- -- -- -- -- -- 0.16* 0.07 0.15
R2 .06 .10 .12
F 7.90*** 6.86*** 6.67***
ΔR2 -- .04 .02
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Note.

*

p < .05,

**

p < .01,

***

p < .001

Clinical Implications.

  • African Americans report higher levels of importance of self-dominion preferences on average than White NH residents.

  • Providing increased choice and autonomy in care for African Americans may increase cultural sensitivity in the delivery of preference-based, person-centered care.

Acknowledgements:

We would like to thank Karen Eshraghi and Christina Duntzee, the research team members who worked diligently to collect these data, and the older adults who participated in the project.

Funding:

This work was made possible by generous funding from an NINR grant (R21NR011334: PI Van Haitsma). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research or the National Institutes of Health.

Footnotes

Author Note:: N/A.

Conflict of Interest: We have no conflict of interest to declare.

Data availability:

Data are available upon request from authors.

References

  1. Abbott KM, Bangerter LR, Humes S, Klumpp R, & Van Haitsma K (2018). “It’s important, but…”: Perceived barriers and situational dependencies to social contact preferences of nursing home residents. The Gerontologist, 58(6), 1126–1135. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Abbott KM, Heid AR, Kleban M, Rovine M,J, & Van Haitsma K (2018). The change in nursing home residents’ preferences over time. Journal of the American Medical Directors Association, 19(12): 1092–1098. 10.1016/J.JAMDA.2018.08.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Abbott KM, Heid AR, & Van Haitsma K (2016). “We can’t provide season tickets to the opera”: Staff perceptions of providing preference based person centered care. Clinical Gerontologist, 39, 190–209. doi: 10.1080/07317115.2016/1151968 [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Ajrouch KJ, Antonucci TC, & Janevic MR (2001). Social networks among Blacks and Whites: The interaction between race and age. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 56(2), S112–S118. [DOI] [PubMed] [Google Scholar]
  5. Bangerter LR, Abbott K, Heid AR, Klumpp RE, & Van Haitsma K (2015). Health care preferences among nursing home residents: Perceived barriers and situational dependencies to person-centered care. Journal of Gerontological Nursing, 42(2), 11–16. doi: 10.3928/00989134-20151218-02 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Bangerter LR, Heid AR, Abbott K, & Van Haitsma K (2016). Honoring the everyday preferences of nursing home residents: Perceived choice and satisfaction with care. The Gerontologist. doi: 10.1093/geront/gnv697 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Brennan PL, Moos RH, & Lemke S (1988). Preferences of older adults and experts for physical and architectural features of group living facilities. The Gerontologist, 28(1), 84–90. [DOI] [PubMed] [Google Scholar]
  8. Carpenter BD, Van Haitsma K, Ruckdeschel K, & Lawton MP (2000). The Psychosocial Preferences of Older Adults: A pilot examination of content and structure. The Gerontologist, 40(3), 335–348. [DOI] [PubMed] [Google Scholar]
  9. Curyto K, Van Haitsma KS, & Towsley GL (2016). Cognitive interviewing: Revising the preferences for everyday living inventory for use in the nursing home. Research in Gerontological Nursing. doi: 10.3928/19404921-20150522-04 [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Dannefer D (2003). Cumulative advantage/disadvantage and the life course: Cross-fertilizing age and social science theory. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 58(6), S327–S337. [DOI] [PubMed] [Google Scholar]
  11. Deci EL, & Ryan RM (2000). The” what” and” why” of goal pursuits: Human needs and the self-determination of behavior. Psychological Inquiry, 11(4), 227–268. [Google Scholar]
  12. Degenholtz H, Kane RA, & Kivnick HQ (1997). Care-related preferences and values of elderly community-based LTC consumers: Can case managers learn what’s important to clients? The Gerontologist, 37(6), 767–776. [DOI] [PubMed] [Google Scholar]
  13. Fahey T, Montgomery AA, Barnes J, & Protheroe J (2003). Quality of care for elderly residents in nursing homes and elderly people living at home: controlled observational study. Bmj, 326(7389), 580. doi: 10.1136/bmj.326.7389.580 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Firestone IJ, Lichtman CM, & Evans JR (1980). Privacy and solidarity: Effects of nursing home accommodation on environmental perception and sociability preferences. The International Journal of Aging and Human Development, 11(3), 229–241. [DOI] [PubMed] [Google Scholar]
  15. Folstein MF, Folstein SE, & McHugh PR (1975). “Mini-mental state”: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3), 189–198. [DOI] [PubMed] [Google Scholar]
  16. Groger L (2002). Coming to terms: African Americans’ complex ways of coping with life in a nursing home. The International Journal of Aging and Human Development, 55(3), 183–205. [DOI] [PubMed] [Google Scholar]
  17. Hansen BR, Hodgson NA, & Gitlin LN (2016). It’s a matter of trust: Older African Americans speak about their health care encounters. Journal of Applied Gerontology, 35(10), 1058–1076. doi: 10.1177/0733464815570662 [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Harris-Kojetin L, Sengupta M, Lendon JP, Rome V, Valverde R, & Caffrey C (2019). Long-term care providers and services users in the United States, 2015–2016. Vital Health Statistics; [PubMed] [Google Scholar]
  19. Hefele JG, Acevedo A, Nsiah-Jefferson L, Bishop C, Abbas Y, Damien E, & Ramos C (2016). Choosing a nursing home: What do consumers want to know, and do preferences vary across race/ethnicity? Health Services Research, 51, 1167–1187. 10.1111/1475-6773.12457 [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Heid AR, Abbott KM, Kleban M, Rovine MJ, & Van Haitsma K (2019). The impact of nursing home residents’ characteristics on ratings of importance of autonomy preferences in daily care over time. Aging & Mental Health, 1–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Heid AR, Bangerter MA, Abbott KM, Van Haitsma K (2017). Do family proxies get it right? Concordance in reports of nursing home residents’ everyday preferences. Journal of Applied Gerontology, Vol. 36, No. 6, pg 667–691. doi: 10.1177/0733464815581485. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Heid AR, Eshraghi K, Duntzee C, Abbott K, Curyto K, & Van Haitsma K (2016). “It depends”: Reasons why nursing home residents change their minds about care preferences. The Gerontologist, 56, 243–255. doi: 10.1093/geront/gnu040 [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Kasser VG, & Ryan RM (1999). The relation of psychological needs for autonomy and relatedness to vitality, well-being, and mortality in a nursing home. Journal of Applied Social Psychology, 29, 935–954. doi: 10.1111/j.1559-1816.1999.tb00133.x [DOI] [Google Scholar]
  24. Kayser-Jones J, 1996. Mealtime in nursing homes: The importance of individualized care. Journal of Gerontological Nursing, 22(3), pp.26–31. [DOI] [PubMed] [Google Scholar]
  25. Kloos N, Tormpetter H, Bohlmeijer ET, & Westerhof GJ (2019). Longitudinal associations of autonomy, relatedness, and competence with the well-being of nursing home residents. The Gerontologist, 59(4), 635–643. doi: 10.1093/geront/gny005 [DOI] [PubMed] [Google Scholar]
  26. Kogan AC, Wilber K, & Mosqueda L (2016). Person-centered care for older adults with chronic conditions and functional impairment: A systematic literature review. Journal of the American Geriatrics Society, 64(1), e1–e7. doi: 10.1111/jgs.13873 [DOI] [PubMed] [Google Scholar]
  27. Koren MJ (2010). Person-centered care for nursing home residents: The culture-change movement. Health Affairs, 29(2), 312–317. 10.1377/hlthaff.2009.0966 [DOI] [PubMed] [Google Scholar]
  28. Kroenke K, Strine TW, Spitzer RL, Williams JBW, Berry JT, & Mokdad AH (2009). The PHQ-8 as a measure of current depression in the general population. Journal of Affective Disorders, 114(1–3), 163–173. doi: 10.1016/j.jad.2008.06.026 [DOI] [PubMed] [Google Scholar]
  29. Laderman M, Jackson C, Little K, Duong T, & Pelton L (2019). “What matters” to older adults? A toolkit for health systems to design better care with older adults. Age-Friendly Health Systems. [Google Scholar]
  30. Mor V, Zinn J, Angelelli J, Teno JM, & Miller SC (2004). Driven to tiers: Socioeconomic and racial disparities in the quality of nursing home care. The Milbank Quarterly, 82(2), 227–256. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. O’Rand AM (1996). The precious and the precocious: Understanding cumulative disadvantage and cumulative advantage over the life course. The Gerontologist, 36(2), 230–238. [DOI] [PubMed] [Google Scholar]
  32. Persson T, & Wasterfors D (2009). “Such trivial matters”: How staff account for restrictions of residents’ influence in nursing homes. Journal of Aging Studies, 23, 1–11. doi: 10.1016/j.jaging.2007.09.005 [DOI] [Google Scholar]
  33. Roberts TJ, Gilmore-Bykovskyi A, Lor M, Liebzeit D, Crnich CJ, & Saliba D (2018). Important care and activity preferences in a nationally representative sample of nursing home residents. Journal of the American Medical Directors Association, 19(1), 25–32. doi: 10.1016/j.jamda.2017.06.028 [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Saliba D, & Buchanan J (2009). Development and validation of a revised nursing home assessment tool: MDS 3.0 (Report for Centers for Medicare and Medicaid Services). United States Department of Health and Human Services. [Google Scholar]
  35. Saliba D, & Buchanan J (2012). Making the investment count: Revision of the minimum data set for nursing homes, MDS 3.0. Journal of the American Medical Directors Association, 13(7), 602–610. 10.1016/j.jamda.2012.06.002 [DOI] [PubMed] [Google Scholar]
  36. Segal DL, June A, Payne M, Coolidge FL, & Yochim B (2010). Development and initial validation of a self-report assessment tool for anxiety among older adults: The Geriatric Anxiety Scale. Journal of Anxiety Disorders, 24, 709–714. doi: 10.1016/j.janxdis.2010.05.002 [DOI] [PubMed] [Google Scholar]
  37. Singer E, Antonucci T, & Van Hoewyk J (2004). Racial and ethnic variations in knowledge and attitudes about genetic testing. Genetic Testing, 8, 31–43. doi: 10.1089/109065704323016012 [DOI] [PubMed] [Google Scholar]
  38. Taylor RJ, Chatters LM, & Jackson JS (2007). Religious and spiritual involvement among older African Americans, Caribbean blacks, and non-Hispanic whites: Findings from the national survey of American life. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 62(4), S238–S250. 10.1093/geronb/62.4.S238 [DOI] [PubMed] [Google Scholar]
  39. Tombaugh TN, & McIntyre NJ (1992). The mini-mental state examination: a comprehensive review. Journal of the American Geriatrics Society, 40(9), 922–935. [DOI] [PubMed] [Google Scholar]
  40. Unroe KT, Bernard B, Stump TE, Tu W, & Callahan CM (2017). Variation in hospice services by location of care: nursing home versus assisted living facility versus home. Journal of the American Geriatrics Society, 65(7), 1490–1496. 10.1111/jgs.14826 [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Van Haitsma K, Abbott KM, Arbogast A, Bangerter LR, Heid AR, Behrens LL, & Madrigal C (2019). A Preference-based model of care: An integrative theoretical Model of the role of preferences in person-centered care. The Gerontologist. 10.1093/geront/gnz075 [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Van Haitsma K, Abbott KM, Heid AR, Carpenter B, Curyto K, Kleban M, Eshraghi K, Suntzee C, & Spector A (2014). The consistency of self-reported preferences for everyday living: Implications for person centered care delivery. Journal of Gerontological Nursing, 40(1), 34–46. doi: 10.3928/00989134-20140820-01 [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Van Haitsma K, Curyto K, Spector A, Towsley G, Kleban M, Carpenter B, Ruckdeschel K, Felderman PH, & Koren MJ (2013). The preferences for everyday living inventory: Scale development and description of psychosocial preferences responses in community-dwelling elders. The Gerontologist, 53(4), 582–595. doi: 10.1093/geront/gns102 [DOI] [PubMed] [Google Scholar]
  44. Van Haitsma KS, Curyto K, Abbott KM, Towsley GL, Spector A, & Kleban M (2015). A randomized controlled trial for an individualized positive psychosocial intervention for the affective and behavioral symptoms of dementia in nursing home residents. Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 70(1), 35–45. 10.1093/geronb/gbt102 [DOI] [PubMed] [Google Scholar]
  45. Williams K, Abd-Hamid NH, & Perkhounkova Y (2017). Transitioning communication education to an interactive online module format. The Journal of Continuing Education in Nursing, 48(7), 320–328. doi: 10.3928/00220124-20170616-09. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Williams KN, Ilten TB, & Bower H (2016). Meeting communication needs: topics of talk in the nursing home. Journal of Psychosocial Nursing and Mental Health Services, 43(7), 38–45. 10.3928/02793695-20050701-05 [DOI] [PubMed] [Google Scholar]

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