Mohammed T. Abou-Saleh

728 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYdemonstrated the dynamic character of the structure of institutions.Administrative, care-delivery and physical environmentalchanges in fashion, including remodeling and simple space-usechanges designed to encourage desired behaviors, attest to theability of most institutional elements to be shaped toward higherqualitycare 5 .Thus the literature of quality of care has been characterizedeither by value-based assertions that particular processes wereintrinsically associated with higher quality of care, or werestatistically correlated with overall quality as assessed byexperts. The Institute of Medicine (IOM) report on nursinghome quality called for making direct assessments of performanceoutcomes in terms of clearly undesirable states, such asdeath rate, infection rate, decubitus rate, or malnutrition 6 . Morerecently, other indicators reported on the required periodicassessment contained in the Minimum Data Set of the USnursing home system (MDS) have included accidents, questionablemedication use, restraint use, infections and other obviouslyundesirable outcomes 7,8 .DEFINING QUALITY OF LIFEClearly, poor-quality care will lower overall quality of life. Adistinction between quality of care and quality of life is useful tomake, however. In a rough sense, quality of life must includefeatures of everyday life that enhance enjoyment and sense ofhope or purpose above the average level. An individual’s qualityof life is a subjective assessment made by that person alone.Quality of life of an environment, such as a nursing home, isrepresented by institutional attributes that have a statisticalprobability of leading to higher individually perceived quality oflife for its occupants. There is thus a dual perspective on quality oflife, the individual–subjective and the environmental–objective 9 .If quality of life is to be monitored, both perspectives mustbe assessed. Ideally, positive features of residential care wouldbe identified by their association with positive subjectiveresponses by a majority of the consumers of such care. Theimportance of the consumer was recognized in the regulationsthat followed passage of the Nursing Home Reform section of1987 legislation 10 . Nursing homes are required to solicitopinions on the quality of care and quality of life experiencedby residents.In practice, however, it is not possible to demonstrate a directparallel between nursing home resident perspectives and featuresthat represent quality in the institution. Until the state of the artof measuring both consumer evaluation and environmentalattributes is further advanced, it is necessary to make manyassumptions about what constitutes quality, based on theavailable literature. Thus, the assessment system must encompassa large array of both personal and environmental features.A Conceptual Basis for the Search for QualityKane, Kane and Lawton 11 have found it convenient to organizequality into 11 domains: security; functional competence;comfort; dignity; autonomy; privacy; meaningful activity; socialrelationships; enjoyment; individuality; and spiritual well-being.These domains represent universal individual needs, whosesatisfaction may be enhanced or blocked by the environment inwhich the person pursues the gratification of needs. In overview,an approach to assessment evaluates the extent to which residents’needs are fulfilled and the extent to which environmental featuresrelevant to these needs are present. Although the actual design ofthe measures is still in process, their components may be viewed asa model that could be useful for later investigators.Resident NeedsMany modes of consumer assessment have recently becomeavailable 12,13 . Our own approach queries residents systematicallyabout their evaluation of how well the residential environment fitseach need. All such direct approaches require ordinary comprehensionof questions and the willingness to respond frankly.Because many people in residential care are cognitively impairedand others may be loath to express critical comments, othercomplementary or parallel sources of information must be sought.Resident Needs as Perceived by OthersCaregiving staff and family members are an obvious source ofinformation on some domains. Such characteristics as functionalhealth, cognitive performance, participation in activities ordepression may be rated by an outsider. Some intrinsicallysubjective domains are less amenable to these types of judgments,e.g. the degree to which dignity is experienced in nursing homelife. An outsider may assess a resident’s ongoing affect states butclearly is limited in access to the resident’s actual happiness,sadness or other feeling states 14 .Direct ObservationOn the other hand, systematic observation by research staff orquality-control staff may reveal very concrete instances ofbehavior relevant to quality of care and quality of life. Anobserver may be trained to be less susceptible to bias than theresident in terms of denying socially unacceptable behavior, and iscapable of being instructed in the subtle indicators of quality thatmay be exhibited in settings such as morning care, mealtimes,activities or unprogrammed time. Examples from earlier researchinclude systematic observation of the ‘‘behavior stream’’ or thenon-verbal indicators of emotional state 14,15 . It is also possible totrain experts in more global aspects of direct observation thatfocus on concepts rather than small behavioral acts. TheProfessional Environmental Assessment Protocol (PEAP) 16 , forexample, requires an environmentally trained professional tospend about an hour in a care area, after which global ratings aremade on the environment’s ability to foster orientation, safety andsecurity, privacy, stimulation quality, regulation of stimulation,functional competence, personal control, and continuity of self 17 .One important way in which direct observation adds to thequality attainment process is that it allows for the input ofexpertise in judgments of quality. Not all goal-relevant informationis evident to the consumer. Some of what is learned fromobservation is thus complementary to the resident’s perspective.Integrating the perspectives of residents, significant others andobjectively-viewed phenomena is not a straightforward process.Although most experts would wish to give primacy to the views ofresidents themselves, around 20–40% are cognitively unable toexpress evaluations and preferences that might guide theenhancement of quality 18 . It might be argued that the mostcapable60% should be able to articulate a consumers’ view thatwould also fit the cognitively impaired. We must recognize,however, that major impairments in cognitive and self-care abilitymay also translate into needs quite different from those who areintact. The perspectives of significant others and value-judgmentsbased on observable behavior clearly add something to knowledgeabout quality. Yet we cannot automatically substitute them forthe absent judgments of those who are too impaired to bequestioned. At best, putting together the three perspectives is atpresent more an artistic endeavor than a scientific one. How oneaccounts for biases in perspectives or for the differential weighting