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http://jag.sagepub.com/Journal of Applied Gerontology
http://jag.sagepub.com/content/31/3/354The online version of this article can be found at:
DOI: 10.1177/0733464810386222November 2010
2012 31: 354 originally published online 2Journal of Applied GerontologyAlice Ming Lin Chong
ResidentsCognitive Predictors of Satisfaction in Hong Kong Institutional Care
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Journal o Applied Gerontology
31(3) 354376
The Author(s) 2012
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DOI: 10.1177/0733464810386222http://jag.sagepub.com
JAG 31 3 10.1177/0733464810386222ChongJournal of Applied Gerontology TheAuthor(s) 2012
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Manuscript received: November 4, 2009; fnal revision received: August 21, 2010;accepted: September 11, 2010.
1City University o Hong Kong, Hong Kong, Peoples Republic o China
Corresponding Author:
Alice Ming Lin Chong, Department o Applied Social Studies, College o Humanities and Social
Sciences, City University o Hong Kong, Tat Chee Avenue, Hong Kong, Peoples Republic o China
Email: [email protected]
Cognitive Predictors
o Satisaction
in Hong Kong
Institutional
Care Residents
Alice Ming Lin Chong
1
Abstract
This article reports one o the irst known studies which examine the association
between cognitive factors and older peoples satisfaction with residential care. These
actors are conceptually related to but have seldom been examined in institutional
care. They include perceived service performance, service expectation, expectancy
disconfirmation (operationalized as the difference between service expectation and
perceived performance), perceived care need, and care need fulfillment. Face-to-face
interviews were conducted with Chinese Hong Kong residents from 11 government-
unded long-term care homes randomly and proportionately selected rom two
strata based on acility size. Finally, 405 residents were successully interviewed.
Path analysis revealed that perceived performance, expectancy disconfirmation, and
being emale predicted residents satisaction with care. Perceived care need and
care need fulfillment exerted an indirect effect on residents satisfaction through
perceived perormance. It is suggested that cognitive actors as perceived by the
residents be included as predictors o resident satisaction in long-term care.
Keywords
resident satisaction, perceived perormance, expectancy disconfrmation, care
need, care need ulfllment
Article
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Chong 355
Population aging inevitably leads to an increase in both the absolute number and
the percentage of older people who, because of physical and mental impairments,
require institutional care. Hong Kong is no exception. In 2009, 13% of its popula-
tion were aged 65 and above, and this ratio is projected to rise to 25.9% in 2039
(Census and Statistics Department, 2010), mainly due to improved longevity. Insti-
tutional care has emerged as the major alternate option to home care for older
Chinese who require assistance with their daily living (Wu, Tang, & Yan, 2004)
due to the rise of the nuclear family and the crowded living environment.
Due to the frailty and vulnerability of the residents, there has always been a great
concern about the service quality of the institutions. Increasingly, resident satisfac-
tion with care has been used as an outcome indicator of the quality of long-term
care (Atherly, Kane, & Smith, 2004; Chou, Boldy, & Lee, 2002; Kruzich, Clinton,
& Kelber, 1992; Lee, Lee, & Woo, 2005; Sikorska, 1999; Yeh, Sehy, & Lin, 2002).
Castle, Lowe, Lucas, Robinson, and Crystal (2004), for example, found that 86%
of nursing homes in New Jersey monitored quality of care with resident satisfaction
surveys. This reflects a delightful change from past reservation about the ability of
the long-term care residents to give reliable and valid feedbacks (Chou et al., 2002;
Ejaz & Castle, 2007; Straker, Ejaz, McCarthy, & Jones, 2007).
Satisfaction with care is an experience or a response that is associated with the
consumption of certain services. According to Oliver (1997), satisfaction is theconsumers fulfilment response. It is a judgement that a product or service feature,
or the product or service itself, provided (or is providing) a pleasurable level
of consumption-related fulfilment, including levels of under- or over-fulfilment
(p. 13). An important issue in resident satisfaction study is to identify factors that
would affect residents satisfaction with care to provide crucial information to
long-term care providers and professionals. Yet a review of the literature reveals
that, although personal factors (such as health and age), as well as organizational
factors (such as staffing), have been examined frequently, there is a lack of studyon cognitive-based perceptual factors (such as service expectation, perceived
performance of the facility) that are conceptually related to residents satisfaction
with care. Although cognitive variables are quite commonly used in the marketing
and service industries, to our knowledge, they have seldom been applied to the
context of residential care. Akamigbo and Wolinsky (2006) did examine resident
expectation, but they measured the service expectation of obtaining a nursing home
placement, rather than expectations of service quality. Cognitive factors are impor-
tant because they reflect residents subjective reality and their personal assessment,
which are directly related to their sense of well-being. Moreover, these factors are
more within the control of service providers than the residents personal factors
such as gender and age, which are completely beyond control, and organizational
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356 Journal of Applied Gerontology31(3)
factors such as institutional size, which may involve resources that are not readily
available.
This article reports the findings of a study that examined a group of cognitive
predictors which is very much neglected in nursing home satisfaction. In particular,
the study explored how satisfaction with care might be related to residents service
expectation and perception of their own care needs on one hand and, in their eyes,
the facilities service performance and provision of assistance to meet their care
needs on the other. The study also explored how residents sense of satisfaction
would be related to the discrepancy between their service expectation and perceived
service performance (assessed as expectancy disconfirmation). This study is part
of a larger research on examining the degree of satisfaction and various predictors
of satisfaction among Chinese residents of long-term care homes in Hong Kong
(Chong, 2003; Chong & Chi, 2001).
Resident Satisaction
and Cognitive Determinants
One major issue in satisfaction study is whether the construct of satisfaction is
unidimensional or multidimensional. Levkoff and DeShane (1979) stated that sat-
isfaction appeared to be unidemensional because high satisfaction with service wasfound irrespective of service types. However, many others argue that the construct
of satisfaction is multidimensional (Chou, Boldy, & Lee, 2001; Hayes, 1992; Lee
et al., 2005; Oliver, 1997). Higgs, MacDonald, MadDonald, and Ward (1998)
identified five themes of satisfaction experienced by residents of nursing homes in
United Kingdom, including relation with staff, autonomy, amenities, privacy, and
social environment. Chou et al. (2001) suggests satisfaction consists of six correlated
factors. More recently, Straker et al. (2007), through a survey of 18,560 residents
in Ohio, have identified eight factors (such as activities, choice, administration,meals and dining, laundry), along with an underlying secondary Global Satisfaction
factor. Castles (2007) review of 50 studies on resident satisfaction also found many
tools that ask both overall satisfaction and different care domains, reflecting a
multidimensional approach to satisfaction.
Another challenge in measuring consumer satisfaction is that the notion of
satisfaction has many proxies, such as assessment, good feelings, and service quality.
The last one, namely service quality, is very often used interchangeably with
satisfaction. Bergman and Klefsjo (1994), for example, defined quality as consumer
satisfaction and delight. However, service quality and consumer satisfaction could
be recognized as closely related but distinct constructs. Service quality is defined
as the consumers judgment about a service/products overall excellence or supe-
riority (Oliver, 1997; Parasuraman, Zeithaml, & Berry, 1988), and it is generally
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Chong 357
assumed that higher quality of care would lead to higher level of resident satisfac-
tion (Chou et al., 2002). However, satisfaction is a state felt by a consumer who has
experienced a performance/outcome that has fulfilled his or her expectation (Kotler,
1982), it is primarily a subjective response to a consumption experience and may
involve the interplay of the individuals cognition and emotions or, as suggested by
Oliver (1997, p. 319), a hybrid cognition-emotion. This article argues that long-
term care satisfaction arises from the residents subjective assessment of the quality
of aged care.
A related complexity concerns the way satisfaction and quality of care are opera-
tionalized. Features of care such as food and choice could be taken both as inde-
pendent variables affecting satisfaction and as components of care making up the
satisfaction experience. Some studies (such as those conducted by Chou et al., 2001,
2002; Martin & Kettner, 1996; Straker et al., 2007) used features of care as different
dimensions of satisfaction, whereas other studies (Duffy, Duffy, & Kilbourne, 1997;
Higgs et al., 1998; Kane et al., 1997) used features of care as quality indicators and
not as outcome measures of satisfaction. The present study adopts the second
approach and uses features of care in the measure of perceived performance, service
expectation, and expectancy disconfirmation, to cover major quality indicators
involved in long-term care.
Most of the publications on cognitive determinants of consumer satisfaction arein the field of marketing and service industry which takes consumer satisfaction
as a consumer response to the evaluation of the discrepancy between actual service/
product performance and the consumers different comparison standards (Oliver,
1997). Tse and Wilton (1988) suggest ideal performance, equity, expectation, and
expectancy disconfirmation as possible comparison standards or determinants.
Oliver (1997) argued that satisfaction results from the psychological processing
of service performance, and proposed expectation, expectancy disconfirmation,
needs, need fulfillment, performance, service quality, and fairness as possibly affect-ing the consumers satisfaction or dissatisfaction.
The present study hypothesized that the residents satisfaction with care was
associated with cognitive-based perceptual factors. In particular, resident satisfac-
tion was postulated to be positively related to the perceived performance of the
institution, service expectation, expectancy disconfirmation, and perceived care
need fulfillment and negatively related to perceived care need. In addition to the
direct influence, it was also hypothesized that perceived performance and expecta-
tion exerted an indirect positive effect on satisfaction via expectancy disconfirma-
tion and that perceived care need exerted an indirect and positive effect on
satisfaction through care need fulfillment (Figure 1).
Assessing the perception of service performance has been the traditional approach
in the consumer satisfaction literature (Oliver, 1997). Tse and Wilton (1988) found
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358 Journal of Applied Gerontology31(3)
that perceived performance exerts both a direct influence on satisfaction and an
indirect effect on satisfaction through expectancy disconfirmation. Service expecta-tion refers to pretrial beliefs about a product or service (Faranda, 1996) and are
formed on the basis of peoples past experience with similar situations and the
statement made by friends, operators, or organizations (Kotler, 1982). It includes
ideal or desirable expectation, and practical or realistic expectation (Ellmer &
Olbrisch, 1983). Practical expectation was examined in the present study because
in the pilot study, the participants became confused when being asked about their
desirable expectation. Expectancy disconfirmation has been a dominant measure
in consumer satisfaction in the service industry (Gotlieb, Grewal, & Brown, 1994;Oliver, 1997, Oliver & DeSarbo, 1988). It refers to the difference (positive, nega-
tive, or neutral) between the residents expectation of the service provided by their
institutions and the institutions performance on individual features of care as per-
ceived by the resident (Oliver, 1997; Yi, 1990). Kotler (1982) argued that if perfor-
mance matched the expectation, the consumer was satisfied. If the performance fell
short of the expectation, the consumer was dissatisfied.
The notion ofcare needrefers to fundamental requirements for human survival
and basic well-being. Oliver (1997) differentiates between need and want in that
needs are more aligned with deficits whereas wants result from desired enhance-
ment. Need fulfillment assesses the fit between the care needs of the resident and
the resources/assistance provided by the long-term care home. The question is
whether service performance meets, falls short, or exceeds a consumers care needs
Expectation+
Expectancy
Disconfirmation +
+
Perceived
Performance
+ Resident
Satisfaction
Care Need
Fulfilment+
_
+Perceived Care
Need
+
Figure 1. Conceptual model o the cognitive predictors o resident satisaction
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Chong 359
(Oliver, 1997). As is pointed out by Bradshaw (1977), the concept of need is inher-
ent in the idea of social service, yet there are very few empirical studies on both
the concept of need and need fulfillment, possibly because the concept is too intui-
tively obvious (Oliver, 1997).
Method
Research Design
A cross-sectional survey using face-to-face interview was conducted in Hong Kong
with 405 Chinese residents living in 11 government-funded care-and-attention
homes randomly and proportionately selected from two strata based on facility size.
Sample and Setting
There are two main types of long-term care homes for older people in Hong Kong:
government-funded and privately funded homes. The focus of this study was
on government-funded care-and-attention homes, which provide the bulk of pub-
licly funded institutional care. Care-and-attention homes mainly provide personal
care and limited nursing care to their residents and, compared with long-term carehomes in the West such as in the United States, fall somewhere between continuous
care residential centers and long-term care institutions. Although the majority of
long-term care residents in the United States are cognitively impaired, the percent-
age tends to be lower in Hong Kong because some residents have been institutional-
ized due to social instead of nursing needs (Lee et al., 2005). These homes are in
great demand among older people. As of February 28, 2010, 25,879 older people
were on the central waiting list for residential care and 75% of them were waiting
for care-and-attention homes. The average waiting time was as high as 30 months(Social Welfare Department, 2010).
There was an absence of a complete list of institutionalized older people in
Hong Kong; the only available information was the list of long-term care homes,
which indicated that there were 8,519 beds in 78 care-and-attention homes at the
time of the study. All institutions were financed by the government according to
a standard subvention formula based on the capacity of the institutions and thus the
resource input would be very similar among institutions of similar size. Proportion-
ate stratified random sampling was used, taking 150 beds as the cutting point
between large and small institutions according to government practice. Under this
classification, there were 56 small institutions and 22 large ones, providing 47%
and 53% beds, respectively.
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360 Journal of Applied Gerontology31(3)
The sample size was calculated by adopting the formula (t2p[1 - p]) / d2, where
t= .05 significance level for making a Type 1 error,p= estimated proportion of
residents who were satisfied and was assumed to be 50%, and d= acceptable error
of 5% that the estimated proportion will lie outside p 5%. The resulted figure of
384.16 was around up to a sample size of 400, which, in proportion should include
189 respondents from small institutions and 211 from large ones. Letters with reply
slips were sent to institutions down the two randomized list of institutions until
the quota was met. A total of 18 care-and-attention homes were approached and
11 consented, giving a response rate of 61%. This rate, though low, is in fact higher
than the rate of 55% of another study on government-funded long-term care homes
(Chong & Kwan, 2001). Moreover, phone contact was made with superintendents
of the seven institutions to detect any possible bias among institutions which refused
to participate. Being busy with preparing for external assessment newly introduced
by the government was given by all the superintendents. Other reasons were as
follows: the decision of the senior management, being preoccupied with preparing
its own opening ceremony, and having just gone through massive renovation and
the whole home had not yet settled down.
The 11 institutions were asked to carry out the initial screening according to the
sampling criteria, which is not an uncommon practice in research on residential care
(Uman & Urman, 1997), because the institution staff should be knowledgeable aboutwhether individual residents met the selection criteria. Each responsible staff was
provided by the research team with a standardized information sheet and briefing
on the selection criteria, namely ageing 60 or older, being capable of communicating
clearly, not suffering from severe cognitive or physical impairments, and having
lived in the facilities for not less than 3 months. In particular, the staff was asked to
screen out only residents who were diagnosed by physicians to be severely impaired
physically or cognitively or both, but to retain residents about whose eligibility they
were not sure. The 10-item Chinese version of Pfeiffers Short Portable Mental StatusQuestionnaire (SPMSQ) was administered as a screening test to ascertain individual
residents level of cognitive competence. Residents with an adjusted SPMSQ summed
score lower than 5 were excluded, as they would not be able to give reliable responses
(Chi & Boey, 1992). These selection measures were intended to reduce selection
bias and to retain as many residents as possible, including those who were having
mild to moderate cognitive impairment.
After the screening test, 474 (54.9%) out of the 864 residents from these
11 institutions were identified as eligible for the study and were interviewed by
trained interviewers. Finally, 405 residents were successfully interviewed, giving
a response rate of 85%. The reasons for the 69 residents who were eligible but did
not participate mainly concerned health issues such as feeling unwell, sleeping at
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Chong 361
the time of interview, attending medical appointment, and hospitalization (13%).
Some were attending activities or having visitors (1.5%), a few found the interview
too long (0.5%). Among the respondents, 193 (47.7%) lived in 6 small institutions
and 212 (52.3%) in 5 large institutions, which was an accurate reflection of the
actual distribution of beds in the two types of institutions. T-tests found no significant
difference in the distribution of age and gender of respondents from large and
small homes.
Measures
Six of the seven measurement tools used in the study were specially constructed
for use with older Chinese and were validated through a systematic validation
process that included a literature review, a focus group discussion with 5 residents
with different health conditions, a review by 8 multidisciplinary experts in long-term
care, a pretest with 20 residents, and a pilot survey of 99 residents (Chong, 2003;
Chong & Chi, 2001).
The four-item Residential Care Satisfaction Scale (RCSS; Chong, 2003) measured
the dependent variable of resident satisfaction and explored different behavioral
emotive dimensions of satisfaction. The first two items measured the behavioral
dimension of satisfaction and asked residents whether they would recommend theirinstitution to their friends and choose their institution again should they be able
to start afresh. The last two items measured the affective dimension of satisfaction,
asked them whether they were happy to live in their institution at the time of inter-
view, and their overall satisfaction or dissatisfaction with their institution. A 4-point
Likert-type scale was used in the first three items, with higher scores indicating a
higher degree of satisfaction. For the last item, a 20-point Likert-type scale was
used to obtain a fine differentiation of the degree of satisfaction or dissatisfaction.
RCSS has previously reported to have satisfactory validity and factor analysis foundall four items clustering under one factor, accounting for 44.13% of the variance
(Chong, 2003). In terms of reliability, its Cronbachs alpha was only .58, which
was quite low even after taking into consideration the fact that it has four items only.
The Perceived Performance Scale (PPS), Expectation Scale (ES), and Expectancy
Disconfirmation Scale (EDS) each was composed of the same 28-item battery of
quality indicators (Chong & Chi, 2001). These 28 items were developed from a list
of 72 items identified through residents focus group discussion and literature review,
it was cut down to 55 through a review by eight experts and a pretest with 20 resi-
dents, and was further shortened and validated through a pilot study of 98 residents.
The 35-item scale was used in the present survey, and 7 items were deleted after
the repeated interactive sequence of computing alphas (deleting item if item-total
correlation was below .1 and if removal improved correlation alpha) and factors
analysis (deleting item if factor loading was below .3). The same 28 items were used
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362 Journal of Applied Gerontology31(3)
in PPS, ES, and EDS to facilitate matching and comparison among the three scales.
The score of each scale was the means of the summated score of all 28 items.
The PPS asks respondents to assess the performance of their institution for each
of the indicators, with a response format ranging from 1 =never like this, to
4 =always like this. The ES asks respondents about their service expectation,
measured on a 5-point Likert-type scale with 0 being no expectation and 1 being
definitely should not be like this to 4 being definitely should be like this; the higher
the score, the higher the expectation. The EDS was operationalized by multiplying
the perceived performance score by the expectation score to give the interaction
value. The Cronbachs alphas were .81, .86, and .87 for PPS, ES, and EDS, respec-
tively, reflecting high internal consistency.
The construct care need in this study is related to the residents perceived
difficulties in functional and sensory activities, including activities of daily living
(such as bathing and dressing), instrumental activities of daily living (such as
getting outside and handling money), and basic sensory functioning such as hearing
and reading abilities in the past 3 months. Care need fulfillment assesses the degree
of fit, in the eyes of the residents, between their perceived difficulties and the
assistance provided by the long-term care homes. The 4-point Likert-type scale was
used in the 13-item Perceived Care Need Scale (PCNS), ranged from 1 =no difficulty
to 4 =cannot do it, whereas Care Need Fulfilment Scale (CNFS) asks whether thelevel of assistance provided by the institution for each of the 13 activities was 1=too
little, 2 =too much, or 3 =appropriate. The Cronbachs alphas were .83 and .80,
respectively, which suggest high internal consistency.
Cognitive competence of the residents was measured with the 10-item Chinese
version of SPMSQ which asked respondents to give the date, their age, name of
district they were living, and to subtract 3 from 20 all the way down. It has been
translated into Chinese and validated by Chi and Boey (1992) and is commonly
used in Hong Kong. Its scores range from 0 to 11 and are adjusted by the educationlevel of the participants by giving one additional point to participants without any
formal education. Respondents with adjusted SPMSQ scores below 5 were con-
sidered too severely impaired cognitively to give reliable responses. This screening
test is in response to the concern to include residents with cognitive impairment
(Ejaz & Castle, 2007). With population ageing, an increasing number of demented
residents is expected, and their views are important to design services that meet
with their expectation and care needs.
Procedure
Participants were interviewed by interviewers who were social work undergradu-
ates selected on their empathetic communication skills and prior practicum experi-
ence with the senior citizens. Two training sessions were organized to strengthen
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Chong 363
their ability to communicate with older people with different levels of physical and
cognitive impairment. Face-to-face interviews would only take place after obtaining
the residents informed consent. If the residents could not be contacted (such as
when they were out for medical consultation or were attending activities), or if they
were unfit for interview due to poor health or being asleep, the interviewer would
make no less than three attempts to contact them before the respondents were
dropped from the list. If the respondents became tired, the interviewers would sug-
gest a break or arrange another appointment. On average, each interview took about
40 to 60 min. The interview took place in a place free from disturbances such as the
conference room, the nursing room, or a quiet corner of the residents bedroom.
Data Analysis
With the use of SPSS, frequency tables were computed to find out the demographic
profile of the participants and their mean scores in the various scales. Pearsons
correlation coefficients were calculated to determine the correlation between the
various independent and dependent variables. Regression analysis was conducted
to control for the effect of confounding variables. Satisfaction was regressed on
all five cognitive variables together with basic demographic variables to identify
which independent variables might predict satisfaction with care. Path analysiswas then conducted to examine the goodness-of-fit between the hypothesized
model (Figure 1) and the extracted model based on data of the survey and to identify
the predictors of resident satisfaction.
Results
Participants Profile
On average, the participants were 82 years old (SD= 7.33). The majority (63.7%)
were aged 80 years or above, and approximately 70% were female. More than half
(56.3%) were widowed, a quarter (24.7%) were married, 14.3% had never been
married, and 3.7% were divorced or separated. The participants had received an
average of 2.42 years (SD=3.57) of formal education, but about half (51.5%) had
no education. The demographic distribution of the participants was very similar to
that found by the Thematic Household Survey conducted by the Census and Statistics
DepartmentHong Kong (2005) to examine the long-term care needs of older
persons residing in institutions, suggesting the representativeness of the sample.
The majority (75%) of the respondents had lived in their facilities for 5 years
or below, 15.3% more than 5 years but less than 10 years, 8.7% more than 10 years
but less than 20 years, and 1% more than 20 years. As mentioned above, only residents
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with adjusted SPMSQ scores of 5 and above would be interviewed. The cognitive
levels of the participants were quite evenly distributed among adjusted SPMSQ
scores from 5 to 11, ranging from 13.3% to 18.3%, and the average score was 7.6
(SD= 1.8). The only exception was with those who had the highest score of 11 mean-
ing good cognitive competence, which was only 3.5%.
Descriptive Analysis
Resident satisfaction. To render the response format of the 20-point general sat-
isfaction item comparable with that of the other three items in the RCSS Scale, it
was recoded into four categories by recoding the original points 1 to 5 as 1 mean-
ing very dissatisfied, 6 to 10 as 2 meaningslightly dissatisfied, 11 to 15 as 3
meaningslightly satisfied, and 16 to 20 as 4 meaning very satisfied. The average
summated scores of the RCSS revealed that nearly half (46.4%) of the participants
were very satisfied with the service performance of their long-term care homes,
44.7% were somewhat satisfied, 8.6% were somewhat dissatisfied, and 0.2% were
very dissatisfied. The means of the scale was 3.37 (SD= .65) out of 4.
Cognitive variables. The means of individual items of the PPS, ES, EDS, PCNS,
and CNFS are given in Tables 1 and 2. The PPS had an average score of 3.13
(SD= .32) on a 4-point scale, which reflected generally good perceived performance,with the means of individual items ranging from 1.44 to 3.91.
The average score for the ES was 2.99 (SD= .52). Participants had the lowest
expectations on choice of main dish (M= 1.89, SD= 1.26) and life is routinized
and boring here (M= 1.90, SD= 1.24; Table 1), and they had the highest expecta-
tion (M= 3.72, SD= .66) on room is clean and tidy. Generally speaking, participants
did not have high expectations on the service quality of their care home. Score of
each item of EDS was calculated by multiplying ES and PPS score of the concerned
item. The means of the EDS was 10.04 (SD= 2.18).Table 2 shows that among the 13 PCNS items, the participants had the greatest
difficulty in writing (M= 2.87), reading (M= 2.74), climbing up and down stairs
(M= 2.27), and getting outside (M= 2.23). Overall, the participants need for
assistance was not very high (M= 1.93, SD= .58). However, residents suffering
from severe frailty would have been screened out by the institutions in accordance
with the selection criteria. The means of the CNFS was 2.75 (SD= .34) on a 3-point
scale, reflecting a high proportion of appropriate assistance.
Correlation Between Variables
Pearson correlation coefficients between the dependent variable of resident satis-
faction and the independent variables of perceived performance, service expectation,
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Table1.MeansofthePerceivedPerformanceScale,E
xpectationScale,andExpectancyDisconfirmationScale(N=4
05)
Perceived
Performancea
Expectationb
Expe
ctancy
Disconfirmationc
Qualityindicators
M
SD
M
SD
M
SD
Systematicorientationprogramsareorg
anizedtopromotethe
adjustmentofnewcomers.
2.65
1.17
2.97
1.31
8.59
5.67
Sufficientfam
ilyactivitiesareorganizedforresidentsandtheir
familymemb
ers.
2.61
1.01
2.65
1.40
7.59
5.29
Thepurchase
servicecanhelpyoubuythefoodordaily
necessitiest
hatyouwant.
3.50
0.77
3.46
0.94
12.35
4.40
Manysociala
ndrecreationalprogramsareorganizedforresidents.
3.49
0.58
3.39
0.98
11.90
4.11
Arrangement
saremadetoenableresidentstoengageintheir
ownreligiou
sbeliefs.
2.37
1.25
2.31
1.49
6.20
5.69
Youareregularlyinformedofwhatishappeninginthehome.
2.44
1.17
2.79
1.38
7.64
5.59
Youarewelcometogivesuggestionstothemanagement.
3.05
1.06
2.70
1.38
8.98
5.91
Staffarepolit
eandrespectyou.
3.68
0.63
3.45
1.04
12.82
4.48
Staffshowco
ncern.
3.67
0.65
3.63
0.74
13.38
3.68
Someofyourpersonalbelongingshaved
isappeared.d
3.63
0.73
2.08
1.28
7.52
4.92
Staffarenice
andcarefulintakingcareo
fresidentswholackself-
careability.
3.71
0.66
3.57
0.79
13.37
3.85
Youcanseea
doctorquicklywhenyouaresick.
3.82
0.50
3.62
0.76
13.87
3.49
Yourroomis
tidyandclean.
3.91
0.33
3.72
0.66
14.56
2.86
Thewashroo
misclean,w
ithoutunpleasantodor.
3.75
0.56
3.57
0.71
13.88
3.42
Foodandcutleryareclean.
3.85
0.45
3.69
0.67
14.25
3.14
Thefacilitiesandphysicale
nvironmento
fthehomemeetthe
olderpeoplesneeds.
3.53
0.58
3.40
1.00
12.17
4.30
(continued)
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Perceived
Performancea
Expectationb
Expe
ctancy
Disconfirmationc
Qualityindicators
M
SD
M
SD
M
SD
Youhavelimitedspaceinthehomeandstayinyourroom/sitting
roommostofthetime.
d
3.05
0.84
2.04
1.28
6.36
4.63
Thefoodisgood.
3.41
0.68
2.97
1.29
10.23
5.00
Lifeisroutinizedandboringhere.d
3.11
1.06
1.90
1.24
5.90
4.56
Healthtalksandexercisesorganizedbythehomeareeffective
inpromotingyourhealth.
3.23
0.80
3.46
0.95
11.40
4.33
Therearealotofrestrictionshere.d
3.60
0.70
2.09
1.31
7.48
5.01
Relationshipwithroommates.
3.58
0.93
3.02
0.74
13.80
5.18
Relationshipwithotherresidents.
3.45
0.75
2.97
0.74
12.70
4.45
Thereisachoiceofmaindish.
1.44
0.93
1.89
1.26
3.24
4.02
Sufficientassistanceisprovidedforresid
entstoseekconsultation
aboutnon-W
esternmedication.
1.63
0.92
2.44
1.40
4.16
4.02
Youcandecid
ewhetherstaffassistanceis
neededwithtakingabath.
3.15
1.24
2.94
1.32
10.02
6.11
Staffwills
eek
yourconsentbeforetidyin
gyourpersonaldrawer.
3.32
1.08
3.20
1.23
10.90
5.65
Thephysicalenvironmentoftheinstitutionresemblesthatofa
domesticho
me.
2.18
1.05
2.33
1.40
5.72
5.04
Meansofscale
3.13
0.32
2.99
0.52
10.00
2.18
a.R
esponseformatofthePerceivedPerform
anceScale:1=n
everto4=alw
ays.
b.R
esponseformatoftheExpectationScale:0=n
oexpectation,1=d
efinitelyshouldnotto4=d
efinitelyshould.
c.S
coreofExp
ectancyDisconfirmationiscalc
ulatedbymultiplyingthescore
ofPerceivedPerformanceand
thescoreofExpectationtogether,g
iving
theinteraction
valueofExpectancyDisconfirmation.
d.R
eversedscore.
Table1.
(co
ntinued)
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Chong 367
expectancy disconfirmation, and care need fulfillment were .47, .29, .44, and .27,
respectively, all significant atp< .001. However, perceived care need was nega-
tively correlated with satisfaction (r=-.13,p< .01). Although the levels of signifi-cance of the correlation between all these variables are high, the magnitude of the
correlations is only moderate or weak, ranging from .13 to .47.
Pearson correlation showed that all the cognitive variables were significantly
(p< .001) related with each other. However, the magnitude of the correlations were
not high; the exception was found between service expectation and expectancy
disconfirmation which was as high as .90 (Table 3), and so in further data analysis,
only expectancy disconfirmation would be used. It is because expectancy discon-
firmation is usually regarded as the most important predictor in consumer satisfaction
studies (Oliver, 1997; Tse, Nicosia, & Wilton, 1990). Moreover, regression analysis
of all five cognitive variables only found perceived performance and expectancy
disconfirmation predicted respondents satisfaction with care. Care need and need
fulfillment were also expected to be related to each other. However, the finding that
Table 2. Means o Perceived Care Need Scale and Care Need Fulilment Scale(N= 405)
PerceivedCare Needa
Care NeedFulilmentb
General unctional abilities M SD M SD
Bathing 1.91 1.17 2.87 0.44
Dressing/personal grooming 1.48 0.89 2.87 0.49
Getting in and out o bed or chair 1.36 0.75 2.85 0.53
Climbing up and down the staircases 2.27 1.14 2.72 0.68
Getting outside 2.23 1.11 2.72 0.69
Handling your own money 1.30 0.76 2.84 0.5
Shopping or grocery or personal items 1.79 1.13 2.87 0.46
Walking indoors 1.98 1.01 2.72 0.68
Laying on your bed 1.76 1.08 2.89 0.44
Listening (hearing ability) 1.51 0.70 2.73 0.68
Seeing (eyesight) 1.87 0.81 2.53 0.85
Reading 2.74 1.19 2.48 0.88
Writing 2.87 1.21 2.66 0.76
Means o scale 1.93 0.58 2.75 0.34
a. Perceived Care Need Scale: 1 =no difficultyto 4 =cannot do it.b. Care Need Fulilment Scale: 1 =too little assistance, 2 = too much assistance, 3 =appropriateassistance.
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Table3.PearsonCorrelationAmongth
eCognitiveVariablesandResidentSatisfaction(N=405)
Perceived
Performance
Scale
Expec
tation
Scale
Expectancy
Disconfirmation
Scale
Perceived
Care
Need
Scale
Care
Need
Fulfilment
Scale
ExpectationS
cale
0.46**
ExpectancyD
isconfirmationScale
0.76**
0.9
0**
PerceivedCareNeedScale
-0.29**
-0.1
8**
-0.28**
CareNeedFulfilmentScale
0.45**
0.1
6**
0.33**
-0.16**
ResidentialCareSatisfactionScale
0.47**
0.2
9**
0.44**
-0.13*
0.27**
*p