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International Journal for Quality in Health Care 15:197-206 (2003)
© 2003 International Society for Quality in Health Care

Paper

Validation and application of an instrument for measuring patient relatives’ perception of quality of geriatric care

HENNA VERHO and JUDITH E. ARNETZ

Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden

Objective. To test and validate a questionnaire concerning patient relatives’ perception of the quality of geriatric care.

Design. Three anonymous questionnaire studies.

Settings. A community-based geriatric care organization and a university hospital in Sweden.

Study participants. Three hundred and eighteen relatives of patients within the geriatric care organization and 38 relatives of patients at the university hospital.

Main outcome measures. A questionnaire composed of eight quality of care indices and an overall quality rating. Reliability and validity estimates were compared between the results from the three surveys.

Results. Internal reliability estimates for all indices were >0.65 and consistent over time. Inter-index correlations were >0.60 between certain indices, indicating some overlap. Second order factor analysis resulted in three distinct index groupings: personnel, relative’s role, and care content. These three dimensions summarize relatives’ perceptions of the quality of geriatric care.

Conclusions. There is a need for a confidential patient relatives’ questionnaire in geriatric care. The results revealed good questionnaire reliability and validity. The questionnaire needs to be tested in larger, independent samples in order to validate the indices further.

Keywords: geriatrics, patient relatives, quality of care, questionnaire, reliability, satisfaction, validity

Measuring quality of care from the patient perspective has increasingly been used and accepted in health care [1–6]. Some patient groups, for example individuals with psychiatric illnesses or older people with various forms of dementia, may have difficulties expressing their views about the quality of care [7–10]. In these cases, patient relatives play a significant role in health care processes, and their views concerning the quality of care take on increased importance [11]. It is generally assumed that questioning relatives can generate useful information about the quality of geriatric care [7, 10, 12]. It has also been shown that relatives feel that it is their responsibility to monitor and evaluate the quality of care in nursing homes [13].

The number of elderly people in Sweden and many other industrialized countries is increasing [14, 15]. Since 1992 the municipalities in Sweden are responsible for services for the elderly. Elderly people in need of household or special health services receive them in their own homes or in geriatric care organizations that are run by the municipality [16, 17]. In recent years, the municipalities have experienced problems financing elderly care and recruiting competent personnel. Gerontological nursing is a relatively low-paid and low-status area for nursing staff [15, 18]. Elderly people living in geriatric care organizations in Scandinavia are often in poor physical health and in need of much help and care. In view of these factors, the role of patient relatives as spokesmen and proxies is becoming increasingly important in geriatric care [18].

A number of studies have concerned the role of patient relatives in geriatric care organizations [19–22]. Some studies have dealt with relatives’ perceptions of the staff in geriatric care [23, 24] or relatives’ views of the quality of geriatric care [10, 12, 13, 25, 31]. Relatives’ satisfaction with home care services [26] as well as with hospice care [27, 28] has also been examined. Studies have also been conducted that concern the experiences of relatives of stroke patients [29, 30] and of patients with dementia [11].

Some quantitative instruments have been used to measure relatives’ views, but these were not tested for validity or reliability [10, 12, 25, 31]. Maas, Buckwalter, and Kelley described the reliability and content validity of a questionnaire for measuring perceptions of care from the perspective of Alzheimer patients’ relatives [32]. Several studies have used the well validated Servqual instrument to measure relatives’ expectations and perceptions of service quality in nursing homes [33–35]. However, the Servqual indices do not include relatives’ ratings of specific aspects of care, nor do they measure relatives’ perception of their own involvement in the care process. In the present study, a quantitative measurement instrument was used because the study was conducted in a small municipality where citizens generally know each other, and therefore respondents’ anonymity was important. In addition, a questionnaire with concrete measurement areas would supply a tool that could be used on a regular basis for surveying relatives’ views about different aspects of the quality of geriatric services.

The first aim of the present study was to validate a questionnaire concerning patient relatives’ perceptions of the quality of care in geriatric care organizations. The second aim of this study was to investigate how patient relatives’ perceive the quality of geriatric care.

Methods

Setting 1: Örebro University Hospital, Sweden
The development of a questionnaire for patient relatives began in the year 2000 at Örebro University Hospital (USÖ) in Sweden. Hospital personnel from five departments—geriatrics, medicine, neurology, orthopedics, and the intensive care unit—found that it was increasingly difficult to obtain the views of many of their elderly patients and they felt a need for a patient relatives’ questionnaire. A total of 22 structured interviews were held with patient relatives by a nurse on each of the five departments. The purpose of the interviews was to develop relevant questionnaire themes. A 62-item questionnaire (excluding background questions) was developed and piloted in the spring of 2000. The basic structure for the questionnaire was the Pyramid patient questionnaire developed by researchers in cooperation with USÖ [8, 36]. A number of questions, specifically those regarding waiting times in the hospital and relatives’ contact with specific staff members, were judged by respondents as ‘not applicable’ and were therefore omitted. The revised, 57-item questionnaire was administered again in the autumn of 2001. Staff on the five hospital units distributed a total of 63 questionnaires during a 6-week period to relatives of patients who could not respond to a patient questionnaire themselves.

Setting 2: the municipality of Bengtsfors, Sweden
The development of a questionnaire geared to patient relatives continued in 2001 in a geriatric care organization in Bengtsfors, a municipality in western Sweden. Bengtsfors has seven geriatric care units with approximately 570 patients/residents and 430 staff members. The organization offers services and health care for elderly people living in their own homes, as well as providing care in nursing homes. Development of a questionnaire for measuring relatives’ perception of quality of care was a part of a larger research project, which will be described in a forthcoming article. The relative questionnaire developed at the university hospital provided the foundation for the community questionnaire. A focus group discussion with patient relatives in Bengtsfors was held in the autumn of 2000. The discussion confirmed the relevance of most of the questions in the hospital questionnaire for this relative group. Questions regarding hospital treatment and information about treatment were excluded, while questions regarding physical and social activity were added to the community questionnaire. A preliminary, 42-item (excluding background questions) version of the questionnaire was sent to all relatives who were registered as a primary family member to patients in the geriatric care organization. A total of 402 questionnaires were posted in April of 2001. The pilot study resulted in the addition of two background items regarding the relative’s frequency of contact with the elderly patient and geriatric care staff. The main questionnaires were posted to 387 patient relatives in October 2001 in Bengtsfors. As in the pilot study, an introductory letter and stamped, addressed return envelope were enclosed. The questionnaire responses were anonymous and no follow-up letter was sent.

Questionnaires
Quality of care questions in both questionnaires asked the relatives to rate a specific item on a 4-point Likert-type scale, identical to that used in the original patient questionnaire: ‘Yes, to a great degree’, ‘Yes, somewhat’, ‘No, not especially’ or ‘No, not at all’ [36]. In keeping with the original Pyramid questionnaire, the relative questionnaire included questions concerning relatives’ perceptions of the staff work environment. This is a unique aspect of the Pyramid instruments and is based on the theory that patients and relatives will be more satisfied with the quality of care they receive in a work environment that they perceive as positive [36–39]. Finally, relatives were asked to give their overall rating of the quality of geriatric care on a visual analog scale (VAS). One on the scale was defined as ‘very negative’ and 10 was ‘very positive’.

Quality of care indices
Exploratory factor analysis was conducted on the hospital study data in order to study the correlations between all questionnaire items. Correlations between the items in the resulting indices were studied further by a means of confirmatory factor analysis. Confirmatory factor analysis was then conducted on the community study data. Principal components analysis was used for factor extraction, using scree plots and varimax rotation.

Reliability
Internal reliability, or homogeneity, of the indices was measured using Cronbach’s alpha. Reliability estimates for all three studies—the hospital study, pilot study, and the main study in the community—were compared.

Validity
Content validity concerns the extent to which the content of the instrument covers all relevant concepts of the attributes to be measured and uses the judgments of experts and lay groups [40, 41]. In the current study, content validity was established through literature searches, structured interviews with patient relatives in hospital, and through focus group discussions with patient relatives in community geriatric care. The questionnaire that was piloted in the community included questions concerning the relevance of the questions and the length of the questionnaire.

Construct validity concerns ‘the extent to which a particular measure relates to other measures consistent with theoretically derived hypotheses concerning the concepts that are being measured’ [41]. Correlations between the quality of care indices in the community main study were analysed by Pearson product–moment correlations (r). Correlation analysis was used to examine independency of indices and to examine correlations of all items to all indices, in order to ensure that correlations of items to other indices were lower than correlations of items within indices. Second order factor analysis was carried out on the community data, in order to investigate further the inter-scale correlations by forcing all of the indices to a limited number of dimensions. Principal components analysis with scree plots and varimax rotation was used.

Convergent validity examines the correlations with other indicators intending to measure the same concept, i.e. the resulting measures should have a higher correlation with theoretically related variables. Discriminant validity examines the lack of correlations with theoretically unrelated indicators [40, 42]. Convergent validity and discriminant validity were examined by comparing the correlations between the overall quality rating and a number of work environment variables in the main study in community geriatric care. The questionnaire instrument was created based on the theory that there is a direct association between the work environment of health care personnel and the patient’s/patient relative’s perception of the quality of care [37–39, 43, 44]. Based on this theory, the hypothesis was that correlations between the overall quality rating and work environment variables would be higher than correlations between the overall quality rating and, for example, variables concerned with relatives’ ratings of participation in their relative’s care.

Concurrent validity concerns ‘the correlations with an existing measure of the same construct’ [40], a type of ‘gold standard’ [41]. Due to the lack of validated questionnaires for measuring quality of geriatric care from the view of patients’ relatives, establishing concurrent validity was limited in the present study.

Predictive validity concerns ‘correlations against other measures to assess predictive powers’ [40]. Forward stepping multiple regression analysis was used to determine factors that predict a positive overall quality rating from relatives. The overall rating (1–10 scale) was converted to a percentage, treated as a continuous variable and entered into the model as the dependent variable. Each of the indices was entered into the model as independent variables, along with age and gender of respondents as well as patients. Similar regression analyses were also conducted to determine whether predictors of the overall rating were different for relatives with more frequent contact with the geriatric care organization. An additional regression was performed to examine whether all of the factors in the second order factor analysis would predict the overall quality rating.

Chi-square analysis was used to investigate possible significant differences in characteristics of the three patient relative populations, and to compare the gender distribution of the response population in the main study to the municipality’s register of patient relatives. Index values were calculated for each individual respondent by totaling the scores on the component index items. The resulting sum was then converted to a percentage of the maximal achievable index score. Each index had a maximum value of 100% and a minimum value of 0%. The overall quality rating was also converted to a percentage and thus treated as a continuous variable. One-way ANOVA with Tukey’s post hoc tests was used to examine possible differences in mean index values between the three studies.

The SPSS statistical software package (version 11.0 for Windows) was used for all statistical analysis. Statistical significance was set at 0.05 (two-tailed) for all analyses.

Results

Questionnaire respondents
The number of questionnaire respondents in each of the three studies is presented in Table 1. The hospital study had a higher response rate, but a smaller sample size than the two studies conducted in community geriatric care.


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  		Table 1 Number of respondents in all three studies

 

Characteristics of the respondents in all three studies are summarized in Table 2. In the hospital study, four respondents were excluded from the analysis because they were relatives of children. There were significantly more spouses and less sons/daughters that responded to the questionnaire in the hospital study compared with community geriatric care. Otherwise there were no significant differences between respondents in the three studies. There were no significant differences in the gender distribution of the response population in the main study compared to the municipality’s register of primary family members.


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  		Table 2 Characteristics of respondents in all three studies

 

Quality of care indices
Exploratory factor analysis resulted in five quality of care indices in the hospital study. These were further investigated in the community studies by means of confirmatory factor analysis. Factor loadings from each of the three studies were compared (Table 3). In general, the factor loadings of individual items exceeded 0.70, with only two exceptions, which were >0.60. Three additional indices, in the community studies only, were composed of items with factor loadings that exceeded 0.70.


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  		Table 3 Item content, factor loadings and reliability estimates (Cronbach’s alpha) for quality of care indices in all three studies

 

Reliability
Homogeneity of each index was estimated by means of the Cronbach’s alpha statistic (Table 3). The indices had alpha values of >=0.70 in all three studies, with the exception of the index ‘activity’ in the community pilot study, where the alpha value was 0.65.

Validity
Content validity was examined by means of literature searches, structured interviews, and focus group discussions carried out before using the questionnaire. In the community pilot study, relatives were also asked their opinion of the relevance and length of the questionnaire. Over 80% considered the questionnaire to be relevant and of reasonable length. Despite the lack of validated questionnaires measuring quality of care from the view of patient relatives, some of the domains were found to be similar to other studies. Finnema et al. [12] used questions regarding communication, contact, and participation. McCartan-Quinn et al. [45] used a questionnaire that included the domains support, empathy, information, and social integration. Maas et al. [32] measured relatives’ perception of care with six subscales: staff knowledge, resources, care environment, nursing care, care by non-nursing professions, and relationship between staff and patients/relatives. The content validity of the questionnaire is thus considered good.

Construct validity was examined by means of correlation analysis (Table 4). Both ‘nursing staff’ and ‘work environment’ showed relatively high inter-scale correlations with each other and with the indices of ‘caring processes’, ‘contact’, and ‘social support’. Correlation analysis resulted in similar inter-index correlations in the two other studies. This could indicate that some indices measure similar aspects of geriatric care.


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  		Table 4 Intercorrelation (r) of quality of care indices in the main community study

 

The correlations between the indices were thus studied further by means of a second order factor analysis. Using principal components analysis with scree plots and varimax rotation, the eight quality of care indices were forced into one, two, three, and four factors, respectively. The best model was composed of three distinct dimensions: ‘personnel’, ‘relatives’ role’, and ‘care content’. Together these dimensions explained 83% of the total variance (Figure 1).



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  		Figure 1 First and second order factor analysis with index factor loadings.

 

Convergent and discriminant validity were examined by comparing correlations between the overall quality rating and other questionnaire variables. In the main community study, the correlation coefficient for relatives’ perception of a positive work climate among staff and their perception of working towards the same goal was 0.70. Relatives’ ratings of the overall rating and their views about the opportunities to discuss treatment goals with the staff had a correlation of 0.41. The correlation between the overall quality rating and relatives’ ratings of how personnel made use of relatives’ knowledge about the patient was 0.35. The correlation between the overall quality rating and relatives’ views of their own participation in the planning of their relative’s care was 0.12.

The predictive validity of the community questionnaire was analysed using regression analysis. In the main community study, ‘work environment’ (adjusted r2 = 0.57, P = 0.016), ‘nursing staff’ (adjusted r2 = 0.05, P = 0.011) and ‘caring processes’ (adjusted r2 = 0.02, P = 0.028) were the only significant predictors of a positive overall quality rating from patient relatives in this model, explaining 65% of the variance. The same analysis performed on the community pilot study and on the hospital study found ‘work environment’ and ‘information’ to be the only significant predictors in both studies. Predictors of the overall quality rating for relatives with more frequent contact with the geriatric care staff (80% of the main study respondents) were ‘nursing staff’ (adjusted r2 = 0.66, P = 0.000), ‘work environment’ (adjusted r2 = 0.06, P = 0.002), ‘information’ (adjusted r2 = 0.02, P = 0.040), and ‘contact’ (adjusted r2 = 0.03, P = 0.017). In this model, the predictors explained 77% of the total variance. All analyses controlled for sex and age of both relatives and patients, but these variables did not enter in to any of the final regression models. A final regression analysis was conducted on the total number of respondents, with the overall quality rating as the dependent variable and each of the three quality dimensions, ‘personnel’, ‘relatives’ role’ and ‘care content’ (Figure 1), as independent variables. ‘Personnel’, which encompasses four indices, was the only significant predictor of the overall rating in this model, explaining 67% of the variance (P = 0.000).

Questionnaire results
Figure 2 shows patient relatives’ ratings of the quality indices and the overall quality grade in all three studies. In both of the community studies, relatives gave highest ratings to the index ‘caring processes’, where the mean value for all respondents was 86% (main) and 89% (pilot). In the hospital study, patient relatives gave highest ratings to ‘social support’, with a mean value of 85%. The indices ‘information’ and ‘participation’ received lower ratings from relatives in all three studies, with mean values <60%. Relatives in the community study gave lowest ratings to the index ‘activity’ (mean values <55%).



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  		Figure 2 Quality of care indices: mean values for relatives in all three studies.

 

Discussion

The purpose of this study was to test and validate a questionnaire concerning patient relatives’ perception of the quality of geriatric care. This study showed that the questionnaire demonstrated good reliability. Internal reliability ratings of the eight quality of care indices exceeded 0.70 in all but one index (Table 3), which has been regarded as satisfactory [46, 47].

In the present study, inter-index correlations for some indices were higher than in the original Pyramid questionnaires concerning patient and parent perception of the quality of care (Table 4) [8, 36]. This indicates that there is some overlap between these indices. Further investigations with a second order factor analysis revealed that the eight quality indices formed three distinct dimensions: personnel, relatives’ role, and care content (Figure 1). The first dimension concerns relatives’ views of staff and their behaviour, both towards the patient and towards the relatives themselves. The second dimension includes questions about relatives’ own behaviour and participation in the care process. The focus is on the relatives themselves rather than on the personnel. The third dimension concerns the content of care from the relatives’ point of view. These three dimensions seem to summarize elderly care from the perspective of patient relatives.

Multiple regression analysis revealed relatives’ views of the staff work environment to be the most important predictor of a positive overall quality rating in all three studies. This may also be an indication of the importance of the staff and their work environment to patient relatives in geriatric care. However, for relatives with more frequent contact with geriatric care staff, the index nursing staff was the strongest predictor, followed by work environment, information, and contact. An additional regression analysis investigated whether all three quality dimensions would predict the overall quality rating. Personnel, the dimension that best describes the staff and their work environment, was the only significant predictor in this model. Previous studies have also supported a positive correlation between staff work environment and quality of care [36, 37, 44]. Results of the present study offer support for the theoretical Quality-Work-Competence (QWC) model on which the Pyramid questionnaires are constructed [36]. This model suggests that the quality of the work environment and the quality of care are interactive and mutually dependent.

These analyses indicate that all of the quality indices were not significant predictors of relatives’ overall quality rating. However, the overall rating, while a convenient tool, is not a complete measure of relatives’ views of the quality of geriatric care. In addition, predictors were different for different groups of relatives. The best model only explained 77% of the variance in the overall quality rating, indicating that we still lack some information as to what constitutes relatives’ satisfaction with geriatric care. Both structured interviews and focus group discussions revealed the importance of other domains, such as participation and activity, in relatives’ judgements of care. These domains offer concrete information to the geriatric care organization as to what needs to be improved, which is the key to all quality improvement efforts [48–51]. Thus, while the three primary dimensions provide a summary of relatives’ perceptions of geriatric care, they do not invalidate the use of the eight individual indices.

Correlation analysis confirmed a higher correlation between relatives’ overall quality rating and various work environment variables, compared with variables concerned with relatives’ participation. Previous Pyramid studies have shown similar results [8, 36]. These results support the hypothesis that correlations between the overall quality rating and work environment variables would be higher than correlations between the overall rating and relatives’ ratings of participation. This also offers support for the theory that there is an association between staff work environment and patient relatives’ perception of the quality of care [36–39]. Thus, the convergent and discriminant validities of the questionnaire are considered good. However, recent research indicates that relatives’ role in the care of elderly patients is unclear and may vary depending on the culture and circumstances [9, 21, 22]. Future research should focus on defining relatives’ participation and involvement in geriatric care.

In all three studies, relatives gave lowest ratings to the indices ‘information’ and ‘participation’. Relatives have also had critical views on information and communication in other studies [12, 23]. Relatives’ ratings of the index ‘activity’ were especially low, which is in line with the studies by Maas, Buckwalter, and Kelley [32], and Ryan and Scullion [22]. The overall ratings given by relatives for the quality of community geriatric care (71% pilot study and 75% main study) were low compared with other studies using pyramid questionnaires [8, 36], where overall ratings between 85% and 90% were common. This result is in contrast to previous studies, which found relatives’ satisfaction with geriatric care to be high [10, 12, 13, 22, 31]. This could indicate that relatives in the community studies dared to express their views of the quality of care honestly and that they did not overvalue the quality in order to maintain a good relationship with the staff.

The purpose of measuring patient relatives’ perception of geriatric care is not to ignore the patients’ view on care. Their opinion on the quality of care is still important, but it is reported that elderly patients may be too confused to criticize health care [52] and that elderly people might not dare to express their views on quality [53]. A patient relative questionnaire can be used together with patient questionnaires in order to achieve a broader perspective on quality issues. The need for a relatives’ questionnaire is expected to increase in the future. Relatives of elderly patients will be more informed and demanding concerning the quality of care [54]. These factors indicate a need for a confidential patient relatives’ questionnaire.

Limitations
There are some limitations to the present study. The low response rate in community geriatric care limits the interpretations of the results. These results can not necessarily be generalized to concern all patient relatives in the municipality. The response rate in the hospital study was higher, but the sample size was small. Future studies that focus on possible non-response bias need to be conducted in studies of patient relatives. Low response rates and small sample size limit the validation process of the questionnaire. Future studies including larger samples are necessary in order to study further the relatively high inter-index correlations and to validate further the measurement areas.

This study was supported financially by The Vardal Foundation, Swedish Agency for Innovation Systems VINNOVA, Örebro University Hospital, and the municipality of Bengtsfors. The authors wish to thank all of the patient relatives who participated in these studies. Special thanks to Associate Professor Marianne Carlsson for expert advice on factor analysis and Johan Lökk, MD, PhD, for helpful comments on this manuscript. The authors extend sincere thanks to two anonymous reviewers for their insightful comments on this manuscript.

Address reprint requests to H. Verho, Department of Public Health and Caring Sciences, Uppsala University, Uppsala Science Park, SE 751 85 Uppsala, Sweden. E-mail: henna.verho{at}pubcare.uu.se The complete questionnaire is available as supplementary material at IJQHC Online. Back

Accepted for publication January 15, 2003.

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