1 ASSOCIATIONS BETWEEN RELATIONAL ASPECTS OF CARE AND SELF-REPORTED HEALTH STATUS OF RESIDENTS LIVING IN LONG TERM RESIDENTIAL CARE HOMES by MARY KATHERINE DELONG A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES We accept this thesis as conforming to the required standard Dr. Richard Sawatzky, Thesis Supervisor ________________________________________ Lena Cuthbertson, Second Reader ________________________________________ Dr. Sheryl Reimer-Kirkham, Third Reader ________________________________________ TRINITY WESTERN UNIVERSITY November 2018 © Mary DeLong, 2018 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 2 Abstract Person-centred care acknowledges the person behind the patient and can enhance the quality of life of long term care residents. Relational aspects of health care are foundational to person-centred care; this study examines associations between relational aspects of care and residents’ self-reported mental and physical health. A secondary analysis of British Columbia Residential Care Survey data (N = 2,108) used hierarchical multivariate linear regression to evaluate the extent to which relational aspects of care explain variation in self-reported physical and mental health, relative to other care experiences. Relative improvement in relational aspects of care was associated with greater self-reported physical and mental health. For self-reported physical health, relational aspects accounted for 34.5% of the explained variance (R2 = 0.279), and for self-reported mental health, accounted for 48.3% of the explained variance (R2 = 0.274). Relational aspects of care do positively influence residents’ physical and mental health outcomes. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 3 Dedication I dedicate this thesis to John and Norma DeLong, who loved me as their own. It has been a privilege to learn about the importance of love and family from you. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 4 Acknowledgements First, I must thank my husband Bob who has been my cheerleader through the entirety of this process – he has cooked countless meals for me and allowed Mary’s Thesis to move in with us, to accompany us on vacations, and generally be a third wheel in all kinds of ways. Although he threatened to retire without me, he stayed by my side and even talked me out of quitting the whole thing not too long ago. I will always be grateful for your support and encouragement as I fully know that being done will impact your life positively just as it will mine! Thank you to my children, Sarah, Greg, and Brian, who have encouraged me throughout this long journey. I know you all were weary of the fact this project took so much of my time and attention. You three are my sunshine and I hope that one day you all have the opportunity to complete your own thesis. I especially wish to thank my thesis supervisor, Dr. Rick Sawatzky. You have been so generous with your time over these last two years. The collaboration with someone of your caliber and understanding of research was a true honour. I so enjoyed everything I learned about statistics and am very grateful that you allowed me to be challenged throughout the process. Your never failing support and messages of Onward kept me going. Thank you to my second reader, Lena Cuthbertson – your passion for those living in LTRC is so evident! Your editing always pushed me to think in new ways and your ability to articulate your thoughts so well have been an inspiration. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 5 I have made lasting friendships among my Masters cohort. Thank you especially to Julianne House, Donna Epp, and Michele Regehr for your prayers, support, and encouragement. Thank you for not giving up on me when I wanted to give up! I wish to thank the British Columbia Office of the Seniors Advocate for the tremendous contribution to understanding the experience of living in residential care in BC. Thank you for listening to the voices of residents through the Residential Care Sector Survey. Thank you to Providence Health Care and Vancouver Coastal Health Authority for allowing me access to the data for this secondary analysis. And finally, thank you to all the residents living in Long Term Residential Care within BC who willingly shared their time and thoughts to complete the OSA survey. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 6 Table of Contents Abstract ................................................................................................................................2 Dedication ............................................................................................................................3 Acknowledgements ..............................................................................................................4 Table of Contents .................................................................................................................6 List of Tables .....................................................................................................................10 List of Figures ....................................................................................................................11 List of Abbreviations .........................................................................................................12 Associations between Relational Aspects of Care and Self-Reported Health Status of Residents Living in Long Term Residential Care Homes .....................................14 Chapter One: Introduction and Background ................................................................14 Background ............................................................................................................16 Definitions..............................................................................................................19 Long Term Residential Care. ...........................................................................19 Seniors..............................................................................................................20 Experiences of Care. ........................................................................................20 Relational Aspects of Care...............................................................................22 Healthcare Providers. .......................................................................................23 Self-Reported Mental and Physical Health Status. ..........................................23 Thesis Purpose .......................................................................................................24 Thesis Method........................................................................................................24 Relevance and Significance ...................................................................................25 Outline of Thesis ....................................................................................................26 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 7 Chapter Summary ..................................................................................................26 Chapter Two: Literature Review .................................................................................27 Conceptual Underpinnings.....................................................................................28 Culture Change Movement. .............................................................................28 Person-Centred Care. .......................................................................................30 Benefits of Person-Centred Care ...........................................................................33 Improved QoL and Satisfaction. ......................................................................33 Health Outcomes. .............................................................................................33 Qualitative Inquiry .................................................................................................35 Quantitative Inquiry ...............................................................................................38 Emerging Conceptual Model .................................................................................43 Chapter Three: Research Methods ...............................................................................46 Study Design and Data Collection .........................................................................46 Sample....................................................................................................................47 Measures ................................................................................................................48 Demographic Data. ..........................................................................................48 Experiences of Care. ........................................................................................48 Self-Reported Mental and Physical Health Status. ..........................................53 Analysis Methods...................................................................................................56 Data Screening. ................................................................................................56 Missing Data. ...................................................................................................56 Descriptive Statistics........................................................................................59 Bivariate Associations. ....................................................................................59 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 8 Hierarchical Multivariate Linear Regression. ..................................................59 Variable Selection. ...........................................................................................61 Evaluation of Assumptions of Linear Regression. ..........................................62 Ethical Considerations ...........................................................................................63 Chapter Summary ..................................................................................................64 Chapter Four: Findings ................................................................................................65 Sample Description ................................................................................................65 Dependent Variable Distributions..........................................................................66 Bivariate Associations ...........................................................................................70 Hierarchical Linear Regression Analysis...............................................................71 Physical Component Score (PCS). ..................................................................73 Mental Component Score (MCS) ....................................................................77 Evaluation of Assumptions for Multiple Linear Regression .................................80 Independence of Observations. ........................................................................80 Homoscedasticity, Linearity, and Multicollinearity. .......................................80 Outliers, High Leverage, or Highly Influential Points. ....................................81 MCS regression. .........................................................................................81 PCS regression. ..........................................................................................82 Normality of Residuals. ...................................................................................82 Chapter Summary ..................................................................................................82 Chapter Five: Discussion .............................................................................................84 Summary of Findings .............................................................................................84 Relationship to the Literature.................................................................................87 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 9 Prior Studies. ....................................................................................................87 Theoretical literature. .......................................................................................91 A relational imperative. .............................................................................91 A relational inquiry approach. ...................................................................93 The relational core of nursing. ...................................................................94 Chapter Summary ..................................................................................................94 Chapter Six – Conclusions and Recommendations .....................................................96 Summary of Study .................................................................................................96 Recommendations for Practice ..............................................................................98 Recommendations for Education .........................................................................101 Recommendations for Research ..........................................................................102 Limitations of this Research ................................................................................103 Conclusion ...........................................................................................................105 References ........................................................................................................................106 Appendix A: Search Terms for Literature Review ..........................................................118 Appendix B: Literature Search Flow Chart .....................................................................119 Appendix C: Certificates of Approval for Research ........................................................121 Appendix D: Heirarchical Multivariate Model Summaries: PCS and MCS ...................123 Appendix E: PCS and MCS Standardized Residuals: Histograms and P-P Plots ...........131 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 10 List of Tables Table 1 Possible Range and Internal Consistency of interRAI SQoL-LTCF Summary Scales .....................................................................................................53 Table 2 Demographic Characteristics of Resident Sample ...............................................67 Table 3 Prevalence of Disease Diagnoses in Resident Sample .........................................68 Table 4 Distributions of Dependent Variables – PCS, MCS, Original, and Imputed .......69 Table 5 Pearsons’ Correlations – Dependent Variables and interRAI Summary Scales ..71 Table 6 Variables Included in Final Regression Models...................................................72 Table 7 Hierarchical Multivariate Regression Model Summary – Physical Health .........75 Table 8 Multivariable Regression and Relative Importance of Variables Explaining Physical Health ......................................................................................................75 Table 9 Hierarchical Multivariate Regression Model Summary – Mental Health ...........78 Table 10 Multivariable Regression and Relative Importance of Variables Explaining Mental Health ........................................................................................................79 Table D1 Hierarchical Multivariate Model Summary – Physical Component Score (PCS)..........................................................................................................123 Table D2 Hierarchical Multivariate Regression Model Summary – Mental Component Score (MCS) .........................................................................................................127 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 11 List of Figures Figure 1. Experiences of care and their influence on health outcomes. ............................45 Figure 2. Experiences of care and their influence on health outcomes, including measures.................................................................................................55 Figure 3. Histograms of physical component score (PCS), original and imputed data.....69 Figure 4. Normal Q-Q plot of physical component score (PCS), original and imputed data. ..........................................................................................................69 Figure 5. Histogram of mental component score (MCS), original and imputed data .......70 Figure 6. Normal Q-Q plot of mental component score (MCS), original and imputed data ...........................................................................................................70 Figure E1. Histograms of standardized residuals – dependent variable PCS..................131 Figure E2. P-P plots of standardized residuals – dependent variable PCS. ....................134 Figure E3. Histograms of standardized residuals – dependent variable MCS. ...............138 Figure E4. P-P plots of standardized residuals – dependent variable MCS. ...................140 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 12 List of Abbreviations BC British Columbia BCEHI British Columbia Ethics Harmonization Initiative CIHI Canadian Institute for Health Information CINAHL Cumulative Index to Nursing and Allied Health Literature COPD Chronic obstructive pulmonary disease CVA Cerebral vascular accident EM Expectation maximization FCS Fully conditional specification FIML Full information maximum likelihood HRQoL Health-related quality of life interRAI international Resident Assessment Instrument interRAI SQoL-LTCF interRAI Self-Reported Quality of Life Survey for Long Term Care Facilities LTCF Long term care facilities LTC Long term care LTRC Long term residential care MAR Missing at random MCAR Missing completely at random MCS Mental component score MI Multiple imputation OSA Office of the Seniors Advocate PCC Person centred care RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 13 PCS Physical component score PREMs Patient-reported experience measures PROMs Patient-reported outcome measures QoL Quality of life RAI-MDS Resident Assessment Instrument – Minimum Data Set RAND SF-36/SF-12 RAND Short Form Survey – 36 item; RAND Short Form Survey – 12 item - Family of instruments measuring self-reported physical and mental health SEM Structural equation modeling SPSS Statistical Package for the Social Sciences VCHA Vancouver Coastal Health Authority VIF Variance inflation factors VR-12 Veterans RAND 12 item health survey VR-36 Veterans RAND 36 item health survey RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 14 Associations between Relational Aspects of Care and Self-Reported Health Status of Residents Living in Long Term Residential Care Homes Chapter One: Introduction and Background In recent years, there has been a shift from a focus on ‘what’s the matter’ with people who need health care to recognizing the importance of ‘what matters to’ the individual and obtaining his or her perspective concerning his or her own care. In the area of long-term residential care (LTRC), this interest has been entwined with a decadeslong culture shift away from an institutional, medical model of care to one that reflects a ‘home’ for seniors that is more aligned with resident preferences and person-centredness. To find out what matters to residents living in long-term care homes, we must ask them. To this end, the British Columbia (BC) Office of the Seniors Advocate (OSA) conducted a province-wide coordinated survey between June 2016 and September 2017 of all residents (N = 22,162) living in 292 residential care facilities, asking about their experiences of care (OSA British Columbia, 2017). This large-scale survey focused on the perceptions of residents with the purpose of giving a collective voice to those affected by the experience of living in residential care in BC. The OSA survey provided a unique opportunity to learn about day-to-day residential care experiences from the residents’ point of view. Furthermore, the OSA survey data can offer clues about what matters most to residents and help identify those care experiences associated with improved health outcomes. It can be difficult to delineate the concept of ‘what matters to’ an elderly resident, or what may constitute a ‘good life’. Varieties of terms in the literature attempt to describe the concept of a ‘good life’, including quality of life (QoL), satisfaction, well- RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 15 being, thriving…, and yet there is no consensus on these definitions (Sullivan & Asselin, 2013). How should we determine those practices and experiences that contribute meaning to one’s life…that provide joy, contentment, and fulfillment? If we hope to understand which experiences contribute to residents’ overall quality of life, we need to hear directly from those living in LTRC about their opinions of life in a residential care facility. Clinicians, policy makers, care providers, researchers, and family members must take note of these opinions and become intentional in their efforts to make improvements that hold meaning for residents. Long-term residential care often has a negative societal image (Edvardsson, Sjogren, Lood, Bergland, Kirkevold, & Sandman, 2017) and many individuals fear becoming a resident in one of these facilities, which ultimately becomes the final, permanent home for a number of older adults. Some authors (Edvardsson et al., 2017) suggest care homes should be places where older people be supported to thrive, rather than simply survive. In long-term care, thriving is a subjective experience of wellbeing or an experience of “a good life, despite ill health and dependence” (Edvardsson et al., 2017, p. 2). Edvardsson et al. explain that both a caring environment and a personcentred approach can facilitate thriving. A crucial component of person-centred care is a focus on relationships (Nolan, Davies, Brown, Keady, & Nolan, 2004; Wasserman & McNamee, 2010). Indeed, McCormack (2004) views “being in relation” (p. 31) as one of four key concepts underpinning person-centredness. Thus, person-centred care requires relationship and relational practice. Paying attention to the relationship between care provider and resident can optimize personcentredness and ideally (at least partially) contribute to a sense of connection for our RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 16 elders. Relational aspects of health care are foundational to person-centred care and involve authenticity, human connection and relatedness, dignity and respect, and “consciously deciding to be guided by the patient’s perspective, which requires knowledge of the patient’s history, culture, and stories” (Koloroutis & Trout, 2012, p. 52). The focus of the current study is on residential care experiences involving relational aspects of care between care providers and residents. In the OSA survey, residents gave input on care experiences across a number of categories, including privacy, security, comfort, food, autonomy, respect, relationships with staff, staff responsiveness, activities, friendships, medications, and physician care. Residents also shared perceptions of their physical and mental health status and how their health may limit their activities. To focus this thesis on relational practice within LTRC, this author identified specific questions within the OSA survey as pertaining to relational aspects of care. These questions involved interactions between care providers and residents and the manner in which care was provided. This study will examine associations between these relational aspects of care and residents’ self-reported mental and physical health status. It is hoped by demonstrating that relational aspects of care hold meaning for and contribute to improved health outcomes for residents, caregivers might commit to making intentional improvements to these aspects of care. Background Canada’s population is aging. Seniors (those aged 65 and over) account for an increasing proportion of Canada’s population and this trend is expected to continue (CIHI, 2011; Statistics Canada, 2010). It is estimated that Canada’s senior population (4.7 million in 2009) will more than double by 2036 (Statistics Canada, 2010, p. 46). RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 17 With advancing age, some individuals will inevitably experience health challenges and changes in their ability to function independently. Those with the most complex clinical challenges who require professional nursing care often end up living out their life in a long-term residential care facility. In 2008-2009, 46 per 1,000 Canadian seniors were in long-term residential care beds (CIHI, 2011). Many policy makers, governments, care providers and stakeholder groups are aware of the increased need for LTRC in the future and are taking steps to enhance capacity in both home and residential care settings. However, we must do more than create new capacity – we must continue conducting research to test approaches that can facilitate thriving, thus enhancing QoL for frail and vulnerable elderly residents. Much literature supports a person-centred approach to enhance the wellbeing and QoL of LTRC residents (Jones, 2011; McCormack, 2004; McCormack, Roberts, Meyer, Morgan, & Boscart, 2012). The person-centred approach can be distinguished from patient-centred care (Ekman et al., 2011) in how it draws attention to the person as a capable being (Öhlén et al., 2017). Ekman et al. (2011) view the term ‘patient’ as someone who has been objectified as “a mere recipient of medical services” (p. 249) whereas being person-centred implies an acknowledgment of “the person behind the patient” (p. 249). Tom Kitwood’s (1997) work in dementia care was influential in defining personhood as “…a standing or status that is bestowed upon one human being, by others, in the context of relationship and social being. It implies recognition, respect and trust” (p. 8). An essential factor in the provision of person-centred care is attention to nurturing (or therapeutic) relationships. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 18 The philosopher Martin Buber influenced the approach to therapeutic relationships in his classic description of dialogical encounters (Buber, 1996; Koloroutis & Trout, 2012). He described interpersonal relationships as “I-It” or “I-Thou” encounters (Buber, 1996; Koloroutis & Trout, 2012, p. 38). An I-It relationship allows the “I” to view the “It” as an object rather than a human being. Conversely, an I-Thou relationship is an authentic, shared human connection that emphasizes mutuality and reciprocity (Koloroutis & Trout, 2012). In an I-It relationship, care providers can become detached and task oriented in their approach to care, thereby viewing patients as merely “part of our workload” (Koloroutis & Trout, 2012, p. 38). Care providers can become disengaged and disconnected from their residents, as their tasks become the focus. Similar to this dichotomous approach to relationships, two distinct aspects to the provision of nursing care have been described. In the health care literature, some authors (Benner, Sutphen, Leonard, & Day, 2010; Koloroutis & Trout, 2012) have explained the distinction between the instrumental and relational aspects of care. Whereas the instrumental aspects of care are more technical, task-oriented, or environment focused, relational aspects of care center on the therapeutic relationship with the patient. Relational aspects of care naturally involve human connection, respect, preservation of dignity, authenticity, and “seeking to understand the meaning of the experience through the eyes of the individual” (Koloroutis & Trout, 2012, p. 40). In explaining the importance of relational care, Koloroutis and Trout suggest, “the relational aspects of health care are as much a part of our discipline as the instrumental aspects. Healing is threatened if the relational aspect is missing” (p. 381). Some argue that this aspect of care is more crucial in elder care (McCormack, 2004), and that “people’s sensitivity to RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 19 insincerity and disconnection gets stronger when they’re vulnerable” (Koloroutis & Trout, 2012, p.10). Thus, it is possible that by acting to provide a relational approach in LTRC we could provide a tangible action toward more person-centred care, thereby enhancing QoL for residents. The OSA survey provides a wealth of information on resident perceptions of LTRC in BC. The survey was based on two validated instruments known as the interRAI Self-Reported Quality of Life Survey for Long Term Care Facilities (Morris et al., 2016) and the Veterans RAND 12 Item Health Survey (VR12), plus additional BC custom questions. The interRAI section and BC custom questions are designed to describe resident perceptions around their experiences of care, whereas the VR12 questions address how residents perceive their mental and physical health. The data from this survey can be analyzed for important associations that may suggest approaches to enhance both care experiences and health outcomes for residents living in LTRC homes. I will first define key concepts to this thesis as the basis for subsequently describing the purpose and relevance of this research. Definitions Long term residential care. In BC, Long Term Residential Care provides “a secure supervised physical environment, accommodation and care to clients who cannot have their care needs met at home or in an assisted living residence” (BC Ministry of Health, 2016, Policy 6A, p. 3). In BC, criteria for admission to a residential care facility, referred to as a care home, include the requirement for three hours of basic care per day. Although LTRC provides varying levels of care to residents, all residents are deemed to require professional nursing supervision; residents may have severe continuous RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 20 behavioural problems, be cognitively impaired or physically dependent, or be clinically complex with multiple disabilities and/or complex medical conditions (BC Ministry of Health, 2016, Policy 6C, pp. 1-2). These licensed facilities commonly become the permanent home for the residents. The OSA estimates approximately 3.7% of BC seniors live in residential care facilities (OSA, 2015, p. 17); the Canadian Institute of Health Information [CIHI] (2016) reports over 44,000 individuals live in LTRC within BC. ‘Long-term’ implies a permanency as opposed to a respite or temporary residency. This thesis will refer to LTRC as distinct from assisted-living facilities. Assisted living provides enhanced supports to maintain residents’ independence; those living in assisted living facilities are less dependent, may come and go as they please, and do not require round-the-clock professional care (OSA, 2015, p. 11). Seniors. Although typically a senior is considered someone aged 65 years and older, the vast majority of seniors in LTRC are much older. In 2015-2016, the average age of LTRC residents in BC was 85 with 59.77% of residents being 85 or older (CIHI, 2016, Table 3). The OSA survey included all residents in publically funded residential care facilities, regardless of age. Indeed, in 2015-2016, only 4.8% of those in residential care in BC were under age 65 (CIHI, 2016, Table 2). Even though not all residents of LTRC are seniors, the population remains overwhelmingly older, and the majority of the OSA survey respondents comprised the old-old, or those 85 years and older. Consequently, this study frequently refers to survey respondents as seniors, elders, or older adults and uses these terms interchangeably. Experiences of care. When determining what matters to older people living in LTRC homes, we must develop methods to assess both their personal quality of life at the RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 21 LTRC home and quality of care provided. Instruments known as patient-reported experience measures (PREMs) evaluate an individual’s experience and satisfaction with care (CIHI, 2015). Many of these experiences within LTRC are relevant to and contribute to one’s QoL, including experiences related to social life and activities, a sense of personal control, food experiences, staff responsiveness, and caring behaviours by staff (Morris et al., 2018). Defining both the construct and measurement of QoL is challenging, as explained by Mark Rapley (2003) in his suggestion that there is: …no reason at all that service planners, providers and evaluators, as well as governmental policymakers, should not use ‘quality of life’ as a sensitizing notion. However, in the case of using QoL as a formally operationalized and measurable construct, it seems clear that the problems involved probably outweigh the putative benefits. (p. 223) We as care providers must ascertain which experiences of care matter most to residents living in LTRC homes. Subjective aspects of QoL such as dignity, respect, and being recognized as a person have been shown to hold higher importance to individuals than objective aspects, such as physical and cognitive function (Godin, Keefe, Kelloway, & Hirdes, 2015; Iris, DeBacker, Benner, Hammerman, & Ridings, 2012). Hence, while acknowledging that each individual will be unique in their preferences, determining those experiences of care that matter most to the population of older people living in LTRC requires assessment of how residents view their life and the care they receive. In development of the PREM used in the OSA survey, the interRAI Self-Reported Quality of Life Survey for LTC Facilities, Morris and colleagues (2018) used factor analysis to create five summary scales representing different aspects of life in residential RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 22 care that are relevant to QoL. Three of the summary scales describe how residents perceive aspects of their life (Social Life Scale, Personal Control Scale, and Food Scale), and two describe aspects of the provided care (Caring Staff Scale and Staff Responsiveness Scale) (Morris et al, 2018). Taken together, the five summary scales and 15 of the BC custom questions describe residents’ viewpoints on a number of experiences of care. In this study, the experiences of care measured by the instrument will be evaluated for associations with self-reported health status. Relational aspects of care. Relational aspects of care are those elements of the care experience that involve interpersonal interactions between healthcare provider and resident. They require a therapeutic relationship in which the care provider achieves an authentic connection with the resident and views the resident as a worthy and capable being. This involves being compassionate and emotionally present, preserving dignity, and supporting, informing, and comforting the resident, along with a commitment to knowing the resident, their biography, and what they value (Koloroutis & Trout, 2012). These relational practices also respect residents’ choices and acknowledge their likes and dislikes. Survey questions that involve relational aspects of care included those comprising the interRAI summary scales for Caring Staff and Staff Responsiveness, as well as nine of the 15 BC custom questions on experiences of care. Examples of specific survey questions included those related to staff knowing the resident, treating them with respect, supporting their likes/dislikes, acting on residents’ suggestions, providing assistance when needed, having time for residents, providing explanations to residents, responding to resident needs, knowing a resident’s story, and considering a staff member a friend. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 23 Healthcare providers. Because relational aspects of care are defined above as involving the interpersonal interactions between healthcare providers and residents, it is essential to explain what is meant by healthcare provider. Healthcare providers are those involved in all aspects of care provided within a long-term care facility. When asking questions of residents, the OSA survey referred to ‘staff’ which includes care aides, physiotherapists, recreation directors, nurses, housekeepers, and more. Essentially, anyone who comes in contact with the resident has the opportunity to interact with and contribute to relational care. Self-reported mental and physical health status. Residents’ self-reported mental and physical health statuses reflect residents’ perceptions of their own health and are increasingly viewed as important outcomes of care. These outcomes can be measured using standardized questionnaire-style instruments, which are referred to as PatientReported Outcome Measures (PROMs). More generally, PROMs describe aspects of health and wellbeing (e.g., physical, emotional, psychological, social) that are relevant to one’s quality of life, and are sometimes referred to as measures of health-related quality of life (HRQoL) (CIHI, 2015). Within the OSA survey, a PROM known as the Veterans RAND 12 Item Health Survey (VR-12) was adapted for residential care and included as a HRQoL instrument for measuring perceived physical and mental health. The VR-12 considers the impact of illness or disease on a patient’s ability to function in their environment (Kazis et al., 2004, p. 72). In so doing, it measures residents’ perceived capacity to function physically and to what degree their physical health might limit them (CIHI, 2015); it also meansures their perceived emotional health and to what degree emotional health might limit their activities. This study will utilize summary measures of RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 24 self-reported mental and physical health based on an adapted version of the VR12 for use in residential care, which was included in the OSA survey. Thesis Purpose The purpose of this study is to examine the associations between relational aspects of residential care experiences and self-reported mental and physical health of residents living in residential care. In particular, this thesis will address the following research question: To what extent do relational aspects of care explain variation in self-reported mental and physical health of residents living in long-term residential care? Thesis Method The study design is a secondary analysis of existing data obtained from the BC Office of the Seniors Advocate’s 2016/17 Residential Care Sector Survey. All residents in publicly funded residential care beds in British Columbia were invited to participate in a survey interview between May 2016 and May 2017. This thesis is limited to data collected within Providence Health Care’s five and Vancouver Coastal Health Authority’s 55 residential care homes during the OSA survey. A quantitative analysis was conducted to examine associations between relational aspects of care and selfreported mental and physical health outcomes of residents. The analysis included descriptive statistics, bivariate analyses, and multivariable linear regression to examine residents’ self-reported care experiences and self-reported mental and physical health outcomes. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 25 Relevance and Significance There is a wide range of literature addressing both QoL and quality of care in LTRC and increasing numbers of researchers, clinical leaders, and policy makers are recognizing the importance of obtaining residents’ viewpoints on these issues. However, an overwhelming sense among the general population persists that, in many cases, provision of LTRC continues to be based on a medical model with its focus on illness and frailty. Although considerable literature speaks to enhancing LTRC residents’ experiences through a person-centred care approach, there remains work to be done in enacting change. Although large-scale culture shifts and structural changes to facilities have been recommended (Armstrong & Braedley, 2016; Hill, Kolanowski, Milone-Nuzzo, & Yevchak, 2011) and attempted in some cases, I would argue that individual health care providers could make a difference to the quality of caring by being intentional in their relational practice with residents. Both relational aspects and instrumental aspects of care are necessary to provide a therapeutic connection and milieu. By determining the extent that relational aspects of care might influence a resident’s health outcomes, one could demonstrate that making a difference to our residents’ health and quality of life is within all of our reach. To be sure, large-scale culture change is worthwhile and necessary and this thesis does not intend to diminish that goal, but rather hopes to highlight the extent that relational aspects of care can influence the health outcomes of residents living in LTRC homes. The analysis of the OSA survey data will address the research question with the fundamental goal to suggest care approaches that will ultimately make a difference to residents. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 26 Outline of Thesis This thesis is organized into six chapters. This first chapter has provided background and definitions, introduced the purpose and significance of the study, and outlined the research question. Chapter Two focuses on the literature review, including the search and retrieval strategies. Chapter Three describes the research methodology, ethical considerations, and statistical approaches to analysis. Chapter Four presents the findings of the data analysis while Chapter Five discusses these findings in light of existing research literature. Finally, Chapter Six outlines study limitations and provides recommendations for enhancing residents’ ability to thrive in LTRC. Chapter Summary This first introductory chapter discussed the importance of obtaining resident viewpoints on their care experiences if we are to truly provide a person-centred care approach within LTRC. Relational aspects of care were introduced as those care experiences involving interpersonal interactions between a resident and care provider. A quantitative research approach was suggested to examine associations between relational aspects of care and self-reported mental and physical health of LTRC residents. Ultimately, it is hoped that this thesis will encourage care providers to be intentional in their relational approach to care by demonstrating that relational aspects of care are associated with improved health outcomes for residents. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 27 Chapter Two: Literature Review A literature review was conducted to find evidence-based research regarding resident perceptions of their experience living in LTRC. While providing a crucial understanding of the literature, the search also revealed gaps in knowledge around associations of relational aspects of care and resident perceived physical and mental health. The identified gaps substantiated the need for the current study. Primary sources (qualitative or quantitative), and secondary sources (integrative or systematic reviews) were reviewed. The Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, and PsycINFO databases were searched using keywords for three concept areas (population, type of care facility, and patient satisfaction). The population included keywords such as elder*, “older adult”, geriatric*, gerontolo*, and senior*. Type of facility was searched on keywords ltc, “long term care”, “resident* care”, “care home*”, and “nursing home”. The final search looked for studies of resident perceptions and had an extensive list of keywords. Sample keywords included “patient satisfaction”, “person satisfaction”, “resident satisfaction”, “PROM”, “PREM”, “person-reported experience*”, “resident-reported experience”, “patient perception*”, “resident perception*”, “client* perception*”, “person perception*”, patient* n3 satisf*, “patient perceive* physical health”, “patient perceive* mental health”, “quality of life”, QoL, and more. Subject headings were also included where applicable. Search limiters applied included: English language; scholarly, peer reviewed; publication date between January 2007 and December 2017. Searches were made with “find all my search terms” and the expander “apply related words”. Refer to Appendix A for a complete list of search keywords. The three areas of interest were combined with RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 28 the Boolean operator AND to yield 831 records that were exported to EndNote for further scrutiny. A majority of articles were eliminated based on an initial review of title or description. Upon subsequent screening, 63 articles were identified for full text review, of which 21 were retained. Forward citation searching and searching for ‘Related Articles’ yielded an additional four articles. See Appendix B for a flow diagram depicting the literature search, including exclusion criteria. As the chosen articles were reviewed, it was decided to return to the literature for a more thorough conceptual understanding of Person-Centred Care (PCC). A similar search process was completed and yielded five additional discussion articles included in this thesis (See Appendix A for keywords). No new studies were identified during this later search. The literature review generated seven qualitative studies, one systematic qualitative review, eight quantitative studies, two integrative reviews, and seven discussion articles used within this thesis. Scholars’ viewpoints on concepts central to this study are explored; the discussion papers in this review lend conceptual understanding to the issues. Next, integrative reviews that look at outcomes of PCC are discussed. Current qualitative and quantitative research findings examining resident perceptions of their LTRC experiences are then reviewed. In this section, resident viewpoints on what matters most to them are explored, with an emphasis on relational aspects of care that may emerge. Finally, policy directions are discussed. Conceptual Underpinnings Culture change movement. Prior to the 1990s, care within LTC facilities was almost exclusively based on the medical model (Brune, 2011). Facilities were fashioned RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 29 after hospitals and operated based on the needs of the organization; they were hierarchical and departmentalized with a top-down management style (Brune, 2011). The physical environment resembled a hospital, with resident rooms arranged along corridors providing staff easy access to residents. The approach toward residents was task oriented, highly structured, and focused primarily on physiological needs (bathing, feeding, toileting, mobility, etc.). In the early 1990s, awareness developed of the need for a better way to provide care, since this was now the residents’ home. Thus, culture change became the movement for transformation of older adult care. During the first Canadian culture change conference, Walk with Me: Changing the Culture of Aging in Canada (2014), culture change was defined as “an ongoing, holistic journey, that includes re-examining values, beliefs, attitudes, language, practices and policies and exploring the full range of efforts needed to transform the culture into a community where everyone thrives” (Research Institute for Aging, 2015, p. 7). Brune (2011) attributes the culture change movement as originating in 1991 with Dr. Bill Thomas’ Eden Alternative model. Thomas argued against the institutional model of care for our elders; the Eden Alternative is predicated on the belief that seniors can thrive in an environment that addresses the ‘three plagues’ of nursing homes, namely loneliness, helplessness, and boredom (Thomas, 2004). Aims of the Eden Alternative include restoration of relationships and spontaneity to the daily life of elders by including the presence of children, plants, and animals and improving autonomy in decisionmaking (Thomas, 2004). Other organizations and individuals formulated their own alternatives that placed residents at the center of care. Numerous formal culture change models were developed, RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 30 including the Green House Project, which uses small houses of no more than 12 elders living in a homelike environment (Zimmerman et al., 2016), the Wellspring Model, and the Pioneer Network (Jones, 2011). What is similar across all culture change models is that they are resident, or person centric. Although a number of terms describe the philosophy inherent in culture change models (resident centred, resident directed, patient centred, person centred, person directed, and more), the most frequently used within the literature and studies evaluating culture change is Person-Centred Care (PCC). In the elder care literature, PCC has become almost synonymous with culture change; however, PCC is the result of the movement for transformation of older adult care. Person-centred care. Although PCC may have resulted from the culture change movement, there were other factors prominent in this process. The psychologist Carl Rogers contributed to the understanding of the concept of personhood (McCormack et al., 2012). Rogers (1990) believed that humans have an innate drive towards growth and fulfillment (which he called an actualizing tendency); this human potential could be realized through positive relationships in which conditions of self-worth (genuineness, unconditional positive regard, and empathy) were present (McCormack et al., 2012). Rogers’ humanistic theories became the basis for some nursing theorists’ work (e.g., Watson) and were considered foundational to the art of nursing’s caring practices (McCormack et al., 2012). Rogers was also influential in Kitwood’s (1997) emphasis on personhood in dementia care. Thus, PCC is founded upon the concept of personhood that recognizes the inherent worth of an individual. To operationalize this concept, one must use genuineness, authenticity, empathy, and respect for an individual’s right to self- RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 31 determination and dignity. Person-centred care is the opposite of task centred care and objectification of individuals (McCormack et al., 2012). A wide variety of recommendations exist in the healthcare literature regarding how to operationalize PCC. Brune (2011) suggests the voices of elders must be considered and respected for care to be person-centred. Ideally, management decisions should be decentralized and moved to the lowest level, which is the front line staff together with residents (Brune, 2011). Staff having familiarity with a resident’s history and values, and honouring their life patterns is important (Brune, 2011; Jones, 2011). In his discussion of five models of person-centred practice that take a particular nursing focus, McCormack (2004) described the common themes as “knowing the person (of the patient and nurse), values, biography, relationships, seeing beyond the immediate needs and authenticity” (p. 36). How to make a LTRC facility more person-centred is complex and can involve a number of different facets of the organization in addition to the care provided. In summary, Jones (2011, p. 20) lists the following attributes of PCC: • Resident schedule is designed by resident and caregiver; • Consistent staff who have knowledge of older adults; • Decision making includes residents and frontline caregiving staff; • Environment is homelike and spontaneous; • Activities are available around the clock; • Staff are invested in relationship with resident based on resident individual needs; • There is a sense of belonging; RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES • 32 PCC is part of the facility mission, policy and procedures, job descriptions, and education; • Involvement and commitment is present at all levels of facility; and • Resident’s family, friends, and social network are involved. An essential factor in the provision of person-centred care is attention to nurturing (or therapeutic) relationships. In fact, some scholars (Nolan et al., 2004) suggest that a relationship centred approach is more appropriate than person-centred care. Some view PCC as focused on independence, autonomy, and individualism rather than interconnectedness and partnership (McCormack, 2001). Nolan argues that “personhood is best understood in the context of relationships” (p. 47) and that valuing interdependence is paramount. Considering all of the individuals in the relationship (resident, family carer, staff) is vital for a truly interdependent approach (Nolan, et al., 2004). Moreover, Wasserman and McNamee (2010) contend that PCC is about caring relationships and believes “what is required is a relational sensitivity; that is, an understanding that there is nothing more important than what we create together in our interactions” (p. 315). Wasserman and McNamee advocate for letting go of the problem focused conversations and assumptions and returning to a primary focus on caring relationships. Whether one supports the person-centred or relationship centred terminology and approach, it is clear that relationships between residents and staff are integral to either view. The nature of how care is provided in the context of relationship is what is crucial. McCormack (2004) reminds us that relationships are only one component of personhood, and similarly, relational aspects of care (as examined in this study) are only one aspect of PCC. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 33 Benefits of Person-Centred Care Research has been largely inconclusive when studying effects of using a PCC approach; results are mixed when systematically looking at resident outcomes across studies (Hill et al., 2011; Li & Porock, 2014). Moreover, Rahman and Schnelle (2008) point out the culture change movement lacks a solid research base backing its claims to improve QoL; they advocate for rigorous, empirical research to support the movement. Improved QoL and satisfaction. PCC approaches are often undertaken with the goal of increasing resident satisfaction and perceived QoL (Rahman & Schnelle, 2008). Some literature appears to support a person-centred approach to enhance the QoL and wellbeing of LTRC residents (McCormack, 2004). Some scholars suggest negative consequences may result from failing to use a PCC approach. Buron (2007) asserts that failing to meet higher level needs as described by Maslow (1943), and instead focusing only on meeting biologic needs, can lead to anxiety, depression, and at times, impersonal care; this failure to treat each individual with attention and respect leads to a loss of self and a loss of personhood. Health outcomes. Ideally, implementation of PCC and/or culture change initiatives benefits residents’ health, whether that be physical, psychological, social, or spiritual. A number of researchers have completed experimental or quasi-experimental design studies to investigate implementation of culture change on resident health outcomes. Hill et al. (2011) completed an integrated review of eleven studies to assess the effect of comprehensive culture change models in LTRC on health outcomes. The culture change models included eight studies on the Eden Alternative, one on Wellspring, one on Green House, and one on Resident Centred Care (Hill et al., 2011). While some RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 34 of the Eden Alternative approaches demonstrated benefits to psychosocial health (decreased depression scores, decreased helplessness and boredom scores, and increased positive engagement with the environment), the overall review concluded the state of evidence supporting the benefits of culture change is underdeveloped (Hill et al., 2011). Many of the measured health outcomes came from administrative health assessment data from medical records, rather than resident perceptions. In their integrative review of 24 studies, Li and Porock (2014) looked at current evidence of effects of PCC models on resident outcomes. They included 15 studies of elders considered cognitively intact or with minor cognitive impairment, and 9 studies of residents with dementia. Eight of their studies overlapped with the Hill et al. (2011) review. Various PCC models were included with a wide mix of outcome measures (observation, validated subjective measures, surveys, chart review, and staff reports). Findings for the cognitively intact group suggest culture change models, specifically the Eden Alternative, demonstrated some beneficial effects on residents’ psychological wellbeing (Li & Porock, 2014). Benefits included improvements in levels of depression, loneliness, helplessness, and boredom, which are areas meant to be addressed by the Eden model. However, effectiveness of culture change models in terms of other outcomes were inconclusive (Li & Porock, 2014). The findings for the PCC models for cognitively impaired residents showed significant effects of decreasing both behavioural symptoms and psychotropic medication use in residents (Li & Porock, 2014). Li and Porock (2014) recommend an agreed upon definition of PCC, rigorous study design, and both objective and subjective outcome measurements to guide researchers and clinicians regarding PCC. The researchers mention that a lack of RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 35 reliability and validity of the subjective instruments used could threaten the validity of the outcomes. Li and Porock (2014) discuss the challenge of insufficient empirical evidence to support PCC moving forward: Despite the limited research evidence, PCC seems to carry with it a moral authority which means that the PCC movement has gained traction based on the approach simply being seen as ‘the right thing to do’. However, without further evidence, this moral imperative will not be sufficient to change and sustain the overall culture of care. (p. 1413) Qualitative Inquiry A number of qualitative researchers have sought to understand LTRC residents’ viewpoints regarding their experiences of care (Drageset, Haugan, & Tranvag, 2017). Indeed, hearing residents’ viewpoints is crucial and can inform the current study. Although the chosen qualitative literature all examined resident perspectives of their experiences living in LTRC, these were described in varying terms. Some of the literature spoke to QoL or resident-centred care specifically, while others used terms such as ‘living well’ (Bradshaw, Playford, & Riazi, 2012), ‘quality of care’ (Nakrem, Vinsnes, & Seim, 2011), ‘experience’ (Slettebø, 2008), or even ‘everyday preferences’ (Bangerter, Van Haitsma, Heid, &Abbott, 2016). Following their systematic review of 31 qualitative studies examining care home life and factors that influence QoL, Bradshaw et al. (2012) asserted care homes need to provide a person-centred home for each resident. They found a carer relationship-centred approach focusing on residents’ preferences is necessary if residents are to maintain their autonomy, self-identity and independence. In their review, four key themes emerged, RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 36 including: (a) acceptance and adaptation; (b) connectedness with others; (c) homelike environment, including having control over routines; and (d) caring practices (Bradshaw et al., 2012). Overall, there was a lack of autonomy and difficulty in residents forming relationships with others. Although close relationships with peers contributed greatly to connectedness, having a relationship with staff was also seen to contribute to good care home life. Bradshaw et al. (2012) found that while competent care was important to residents, considerate care was equally important. A caring attitude, competence, and having knowledge of the residents’ personal needs and life story, all fostered a sense of self-worth for residents (Bradshaw et al., 2012). In addition to Bradshaw et al.’s (2012) review, seven qualitative studies were examined (Anderberg & Berglund, 2010; Bangerter et al., 2016; Donnelly & MacEntee, 2016; Drageset et al., 2017; Moyle et al., 2011; Nakrem, Vinsnes, & Seim, 2011; Slettebø, 2008). Across studies, residents spoke to the importance of relationships or interactions. Some specific interactions viewed as important included staff greeting residents, displaying friendliness, and showing care and respect (Bangerter et al., 2016; Drageset et al., 2017). Drageset et al. (2017) asserts that staff can be very important people in a resident’s daily life and often provide the most frequent interpersonal contact that some residents receive. Furthermore, compassion and charity displayed by staff towards residents can affirm residents’ sense of worth and subsequent sense of meaning and well-being (Drageset et al., 2017, p. 4). Anderberg and Berglund (2010) found residents want to “strive towards natural relationships with the caring staff with the risk of feeling unwanted” (p. 66). In a study with resident elders with dementia, it was found relationships with family, staff, or co-residents could contribute to enhanced QoL (Moyle RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 37 et al., 2011). However, some of these residents reported their days were long and lonely and staff members were perceived as ‘too busy’ to have conversations (Moyle et al., 2011). Similarly, Slettebø’s (2008) main finding was that residents felt safe, but were lonely. Residents also expressed a need to have more control over their lives and more choice in daily decisions (Donnelly & MacEntee, 2016; Moyle et al., 2011; Nakrem et al., 2011). Residents in Anderberg and Berglund’s (2010) study reported they “wished to be listened to and understood on their own terms” (p. 66). Preservation of dignity was specifically outlined as important in many of the studies (Donnelly & MacEntee, 2016; Moyle et al., 2011; Nakrem et al., 2011; Slettebø, 2008). Residents described experiencing indignity (Donnelly & MacEntee, 2016; Nakrem et al., 2011), and some questioned whether they were being respected or not (Slettebø, 2008). Some residents even challenged the claim that their care home was providing PCC (Donnelly & MacEntee, 2016). The most concerning findings came from a study of 23 resident interviews from seven care homes, all of which advertised the provision of PCC (Donnelly & MacEntee, 2016). Residents gave examples of poor care, lack of empathy from staff, and human indignities such as being wheeled down the hall in a lift “…with your privates hanging out” (Donnelly & MacEntee, 2016, p. 153). Residents described having to get used to wearing a ‘pad’ because staff did not have enough nurses to help them to the toilet. Residents described staff as preoccupied with paperwork and routine tasks and in many cases described their relationships with staff as unbalanced and overly task oriented (Donnelly & MacEntee, 2016). This study found that the consistent assignment of staff RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 38 (a principle of PCC) can sometimes have a detrimental effect; when a resident was in need of care, they were told they were ‘not theirs’ from a different staff member who was then unwilling to assist (Donnelly & MacEntee, 2016). Regrettably, Donnelly and MacEntee (2016) reported that residents “manage[d] these indignities with resiliency and resignation” (p. 155) as one expressed, “you have to go with it sometimes, whether you like it or not” (p. 155). The findings from these qualitative studies echo the findings in Bradshaw et al.’s (2012) review. Quantitative Inquiry Data can be obtained from a larger sample of residents with survey research, which can then be used to uncover patterns and make inferences about the population of residents living in LTRC homes. It is essential to remember that although measurement instruments can lend credence to “areas of general importance at the population level, they may not accurately or comprehensively reflect individuals’ stories or narratives regarding quality of life concerns and healthcare experiences…” (Öhlén et al., 2017, p. 4). A number of existing survey instruments are designed to measure experiences of care for residents living in LTRC homes; several of these purport to measure QoL, though, as mentioned earlier, measuring such a concept presents challenges. In their review of QoL in LTRC, Sullivan and Asselin (2013) list 23 different instruments used to assess QoL and explain there is a lack of agreement as to which components and subscales to include. In the eight quantitative studies reviewed here, there are nine distinct measurement instruments used to capture resident perceptions of experiences of care. The quantitative research varied in terms of the named constructs each studied, however, all included resident perceptions of their experience living in LTRC. Some RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 39 included the PREM instrument used within their study as the independent variable (Burack, Weiner, Reinhardt, & Annunziato, 2012; Custers, Westerhof, Kuin, & RiksenWalraven, 2010; Yeung & Rodgers, 2017), whereas others used it as the dependent variable (Kehyayan, Hirdes, Tyas, & Stolee, 2016; Poey et al., 2017). Some researchers (Burack et al., 2012; Custers et al., 2010) focused on overall satisfaction measures as their dependent variable, while Andrew and Meeks (2018) studied a single dimension of well-being (loneliness). In their study of 928 LTRC residents across six Canadian provinces, Kehyayan et al. (2016) used the same PREM as the current study (interRAI Self-Reported QoL Survey for LTC Facilities). The researchers utilized sociodemographic, clinical, and facility variables as independent categorical variables and the interRAI category (privacy, food, safety, comfort, decisions, respect, staff responsiveness, staff-resident bonding, activities, and personal relationships) scores as continuous dependent variables in their bivariate analyses. Linear regression was used to explain variance in overall QoL scores (Kehyayen et al., 2016). Findings suggested that religiosity was positively associated with QoL while education level was negatively associated (Kehyayan et al., 2016). Residents with poorer functional ability scored lower on QoL measures. Regarding facility type, those living in municipal and private care homes reported higher QoL; those in rural settings had significantly higher QoL than those in urban settings (Kehyayan et al., 2016). Poey et al. (2017) used mixed regression to assess the relationship between facility implementation of PCC principles in 265 facilities in Kansas, USA and outcome variables of QoL, quality of care, quality of services, and global satisfaction. Their data RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 40 described which stage of PCC implementation each facility had reached and examined their outcome variables as measured with a Resident Satisfaction Survey (My InnerView, as cited in Poey et al., 2017). Their findings demonstrated resident QoL and satisfaction ratings trended upwards as the stage (or level) of PCC increased. Those who had fully implemented PCC had a significantly higher proportion of resident ratings of ‘excellent’ or ‘good’ than facilities who were non-participants in PCC initiatives (Poey et al., 2017). Two studies (Burack et al, 2012; Yeung & Rodgers, 2017) used the Quality of Life Scales for Nursing Home Residents, developed by Kane et al. (2003), which measures residents’ perceived QoL. They used correlations (Yeung & Rodgers, 2017) and regression (Burack et al, 2012) to examine associations between QoL measures and questions on overall satisfaction or overall QoL. Yeung and Rodgers (2017) found dignity and relationships were the most important elements contributing to QoL, whereas Burack et al. found dignity to be a significant predictor of satisfaction with staff. Food enjoyment, spiritual well-being, and dignity were all significant predictors for overall nursing home satisfaction (Burack et al, 2012). In their 2015 study, which utilized the Self-Reported QoL Survey for LTC Facilities, Kehyayan, Hirdes, Tyas, and Stolee reported on the distributions of positive ratings found for each QoL measure. They found residents value their personal choice and autonomy; several residents reported having no choice on bathing or showering frequency, nor any ability to control who entered their room (Kehyayan et al., 2015). They found 59% of residents reported the LTRC facility felt like home; their study concluded, “There is a gap between philosophies of care and their translation into a care environment where care is truly resident-directed” (Kehyayan et al., 2015, p. 158). RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 41 Andrew and Meeks (2018) took a different approach in their study of resident experiences. They measured fulfilled preferences of residents, loneliness, perceived control, and life satisfaction and analyzed the relationships between them. They utilized three instruments to measure experiences, including the UCLA Loneliness Scale (Russell, 1996), the Preferences for Everyday Living Inventory (Carpenter, Van Haitsma, Ruckdeschel, & Lawton, 2000), and the Satisfaction with Life Scale (Diener, Emmons, Larsen, & Griffin, 1985). Having one’s preferences fulfilled was associated with lower loneliness scores, higher perceived control, and higher life satisfaction. Regression and mediation analysis demonstrated a negative association between having one’s preferences fulfilled and loneliness; both perceived control and life satisfaction were shown to mediate that relationship (Andrews & Meeks, 2018). Consequently, control and fulfilled preferences may play a role in mitigating loneliness. They postulate that implementing PCC approaches may lead to increased life satisfaction, which also may lessen loneliness (Andrew & Meeks, 2018). Two of the quantitative studies focused specifically on resident-staff interactions (Custers et al., 2010; Haugan, 2014). Custers et al. (2010) interviewed 88 residents in nursing homes in the Netherlands to measure need fulfillment in the caring relationship and its association with well-being in residents. The theoretical basis for Custers et al.’s (2010) study was a social-psychological model of self-determination that distinguishes three basic psychological needs (competence, relatedness, and autonomy). Need fulfillment in the caring relationship was measured using the Basic Need Satisfaction in Relationships Questionnaire (LaGuardia, Ryan, Couchman, & Deci, 2000) while need fulfillment in general was measured with the Basic Need Satisfaction in Life Scale RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 42 (Gagne, 2003). Need fulfillment in the caring relationship was measured on all three areas of basic needs described above (competence, relatedness, and autonomy). Questions such as “When I am with someone of the nursing staff, I have a say in what happens, and I can voice my opinion” (Custers et al., 2010, p. 734), focused on the need for autonomy. The need for relatedness was measured with questions such as “When I am with someone of the nursing staff, I feel loved and cared about” (Custers et al., 2010, p. 734). Similar questions measured the need for competence. Subjective well-being (the outcome variable) was estimated via depressive feelings and life satisfaction measures (Custers et al., 2010). Need fulfillment in the caring relationship significantly predicted less depressive feelings and increased life satisfaction. The researchers found that need fulfillment in general mediated the relationship between need fulfillment in the caring relationship and depressive feelings (Custers et al., 2010). Based on the incidence of depression (39.8%) and lower life satisfaction ratings in their sample, the authors remarked on the interesting finding that subjective ratings of need fulfillment were relatively high (Custers et al., 2010). They surmised that older residents may be hesitant to criticize their caregivers, may have lowered their expectations after living in the nursing home for a time, or that potentially need fulfillment may be higher in the Netherlands, compared to other countries (Custers et al., 2010). The study by Haugan (2014) sought to investigate associations between nursepatient interaction and meaning-in-life in cognitively intact nursing home patients. Haugan (2014) suggests meaning is derived through relationships and connectedness; nurse-patient interaction was hypothesized to positively associate with nursing home RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 43 residents’ meaning-in-life. Nurse-patient interactions were measured using the NursePatient Interaction Scale (Haugan, 2014). Questionnaire items focused on confidence in staff, being taken seriously, and “experiences of being respected and recognized as a person, being listened to and feeling good as a result of nurse-patient interaction” (Haugan, 2014, p. 110). Using structural equation modeling (SEM), Haugan found that high quality nurse-patient interaction displayed a significant positive association with meaning-in-life. Enhanced nurse-patient interactions may support residents’ perceived purpose and meaning-in-life, thereby contributing to overall well-being (Haugan, 2014). Emerging Conceptual Model When examining this body of research as a whole, certain factors appear to matter most to residents living in LTRC. Dignity, respect, autonomy, personal choice, connectedness, and relationships are repeated as important to residents’ overall satisfaction and QoL (Bradshaw et al., 2012; Burack et al., 2012; Custers et al., 2010; Haugan, 2014; Hill et al., 2011; Slettebø, 2008; Sullivan & Asselin, 2013). These studies support the theory that the manner in which staff interact with residents can have a profound impact on the sense of personhood, sense of meaning, and overall well-being of residents; in other words, the relational aspects of care matter. These interactions are paramount to the preservation of dignity and self-worth and can contribute to feelings of connectedness for residents. In all areas, the approach and attitude of caring staff is crucial in bringing these factors to fruition. Even though some studies looked at associations between residents’ perceptions of care experiences and factors such as satisfaction, or a sense of QoL or well-being, no studies were located that examined associations with self-reports of physical and mental health. Residents’ perceived health RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 44 is appropriate as an outcome measure of care. Furthermore, only two of the studies focused specifically on staff-resident interactions within the PCC approaches. Following the literature review, an emerging model for this study began to take shape. It was apparent that a wide variety of care experiences hold meaning for and are important to residents, and can impact residents’ overall well-being. The OSA survey has collected data on these experiences as well as residents’ perceived mental and physical health. This study will examine the experiences of care detailed in the OSA survey with a particular focus on those concerning relational aspects of care between healthcare provider and resident. For the purposes of this thesis, resident experiences of living in LTRC will be classified as either relational aspects of care (relational care), or non-relational aspects of care (non-relational care). It is hypothesized that both relational care and non-relational care contribute to health outcomes; this thesis will examine to what degree relational aspects of care are associated with physical and mental health outcomes. This is depicted in Figure 1, which represents experiences of care grouped by relational and non-relational care, and their influence on mental and physical health outcomes. Even though some of the non-relational care items do, in fact, involve relationships, these are not relationships between resident and healthcare provider. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 45 Figure 1. Experiences of care and their influence on health outcomes. This study will address the apparent gap in the literature by examining associations between relational aspects of care and resident self-reports of physical and mental health. The next chapter will outline the research design, methods, and proposed analysis for the current study. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 46 Chapter Three: Research Methods This thesis has set out to examine relational aspects of care and their associations with self-reported physical and mental health for individuals living in LTRC homes. The current chapter will briefly introduce the original data collection done by the OSA and will explain the design and methodology for this study. The measurement instruments and approaches to data analysis will be described, followed by discussion of scientific quality. Lastly, this chapter will outline ethical considerations for the current study. Study Design and Data Collection The study design was quantitative, and involved a secondary analysis of existing cross-sectional survey data obtained from the BC Office of the Seniors Advocate’s (OSA’s) 2016/17 Residential Care Sector survey. A secondary analysis uses data from a previous study to answer a new research question (Polit & Beck, 2017); this study used data from the OSA survey. All residents in publicly funded residential care beds in British Columbia (BC) were invited to participate in a survey interview between June 2016 and September 2017. Trained interviewers conducted in person interviews with residents using the interRAI Self-Reported Quality of Life Survey for LTC Facilities with additional BC custom questions and the Veterans RAND 12 Item Health Survey (VR12), which was adapted for use in residential care (Wilson, Cuthbertson, Russell, Parsons, & Sawatzky, 2017). This survey is referred to as the OSA’s Residential Care survey. The current study was limited to OSA survey data collected within Providence Health Care’s five residential care homes and Vancouver Coastal Health Authority’s 55 residential care homes (N = 2,108). Demographic data obtained from the Resident Assessment Instrument – Minimum Data Set (RAI-MDS 2.0) (CIHI, n.d.a) was included RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 47 in the analysis. The RAI-MDS 2.0 is a standardized clinical assessment tool used in residential care (CIHI, n.d.a). Sample The study sample (N = 2,108) included residents living in publicly funded beds within Providence Health Care’s Elder Care program and Vancouver Coastal Health Authority’s (VCHA) residential care homes. Providence Health Care’s five residential care homes are all located in Vancouver; the 55 VCHA care homes are located in and around Vancouver or in northern coastal communities of British Columbia. Providence Health Care’s residential care homes are directly owned and operated whereas VCHA’s care homes are a mixture of private (contracted by the health authority) and public (health authority owned and operated) ownership. All residents were invited to participate in the OSA survey regardless of cognitive level; participants had to express both a desire and consent to participate, as well as demonstrate the ability to provide feedback on the evaluative questions of the OSA survey. The surveys were translated into nine languages common amongst LTRC residents in BC and were administered by trained volunteers in the language the resident was most comfortable speaking (OSA British Columbia, 2016). Inclusion criteria for the OSA survey were all residents regardless of age with a completed initial Resident Assessment Instrument-Minimum Data Set (RAI-MDS) (CIHI, n.d.a). Residents in temporary beds, health authority owned and operated facilities, and publicly funded beds in private facilities were included. Residents were excluded if they were in designated respite or convalescent beds, at the end-of-life/ in palliative care beds, in flex beds, in special care/ behavioural units, in tertiary mental health units, or if they declined/refused to participate or were unresponsive/unable to RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 48 participate. No residents were excluded based on cognitive status alone. In addition, residents whose behaviour on the day of the interview would put the interviewer at risk were excluded. The response rate for the OSA survey was over 43% (OSA British Columbia, 2017). Although the OSA survey fielded a separate questionnaire with each resident’s most frequent visitor (OSA British Columbia, 2017), this study was limited to the data collected from resident self-reports. Measures This study analyzed three separate categories of measures. These included demographic data on the residents (potential covariates), self-reported experiences of residential care (predictor variables), and self-reported mental and physical health status (outcome variables). Demographic data. Almost all of the demographic data included in this study was obtained by the LTRC facilities during completion of the RAI-MDS 2.0 that is performed both on admission and ongoing for all residents. The RAI-MDS 2.0 is a tool completed by clinicians to assess a resident’s care needs for care planning purposes (CIHI, n.d.a). The basic demographic data obtained from linked RAI-MDS data included age, gender, marital status, disease, cognitive status, and time in facility. Time in facility was calculated from date of admission to date of survey. Self-reported ethnicity was ascertained using demographic questions on the OSA survey. Experiences of care. Residents’ experiences of residential care were measured using the interRAI Self-Reported Quality of Life Survey for LTC Facilities (Morris et al., 2016) plus additional questions developed in BC. The interRAI organization describes itself as a collaborative network of researchers from over 30 countries dedicated to RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 49 improving care for vulnerable persons across a variety of health and social settings (Morris et al., 2016). They developed a suite of branded interRAI assessment instruments for a number of health care settings, including the widely used Resident Assessment Instrument - Minimum Data Set (RAI-MDS). The first instruments in the interRAI suite to assess subjective patient perceptions are the Self-Reported Quality of Life Surveys. A number of Quality of Life survey instruments for various health settings have been developed. The OSA survey used the interRAI Self-Reported Quality of Life Survey for LTC Facilities (SQoL-LTCF) (Morris et al., 2016). This instrument assesses “how residents perceive the life they live and the services they receive” (Morris et al., 2018, p. 208) and includes questions related to privacy, food, safety, comfort, decision-making, respect by staff, staff responsiveness, staff-resident bonding, activities, and personal relationships with co-residents. Kehyayan et al. (2015) reported on psychometric testing of the interRAI instrument. They found the instrument to have moderate test-retest reliability, good convergent validity, and “sufficient content validity for assessing LTC facility residents’ QoL” (Kehyayan et al., 2015, p. 155). They further concluded that the instrument demonstrated good internal consistency, with a Cronbach’s alpha value of 0.93 for the overall score (Kehyayan et al., 2015, p. 154). This work by Kehyayan et al. (2015) was subsequently taken up by the interRAI group (Morris et al., 2018), who refined the instrument and combined survey items into summary scales. A problematic finding arising from the literature review is the lack of consistency in the use of the terms domain(s), category(ies), and scale(s). Often these terms are used interchangeably; other times the terms are not clearly defined and the reader is left unsure RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 50 whether the concepts to which scores are applied are comparable or not. For the purposes of this thesis, two terms will be used in reference to the analyses of the interRAI SelfReported Quality of Life Survey for LTC Facilities used in the OSA's survey: (a) items, and (b) scales. The term ‘item’ will be used to refer to a single question on a patient reported experience or outcome measure. More than one item will be referred to in the plural, ‘items’. To be consistent with the language used by interRAI, groups of questions will be referred to as belonging to a ‘scale’. More than one scale will be referred to in the plural, as ‘scales’. The interRAI group (Morris et al., 2018) defined five scales derived from the Self-Reported Quality of Life Survey for LTC Facilities’ instrument that deal with: (a) the residents' social life in the care home, (b) food, (c) the residents' sense of control over daily decisions, (d) the extent to which staff are caring in their approach, and (e) the responsiveness of staff members to the residents’ needs. Morris et al. (2018) used factor analysis to identify five standardized, reliable scales derived from 34 of the 50 items found on the interRAI SQoL-LTCF. Their international study used data from 16,017 individuals residing in 355 LTCFs across eight countries in Europe, North America, Australia, and Africa (Morris et al., 2018). Survey respondents were included if they had the ability to understand and respond to the questions. The Social Life Scale, Personal Control Scale, and Food Scale express how residents perceive aspects of their life, whereas the Caring Staff and Staff Responsiveness Scales describe aspects of care (Morris et al., 2018). The internal consistency reliability scores (Cronbach’s alpha) for each of the summary scales ranged between .73 and .86 (see Table 2) (Morris et al., 2018). RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 51 The BC team conducting the OSA survey added 20 custom questions to the interRAI SQoL-LTCF portion of the survey. The OSA survey included 50 items from the interRAI instrument, 20 BC custom questions, and 12 questions from the adapted VR-12 instrument. Of the BC custom questions, 15 were directly related to experiences of care, three were demographic questions, and two were overall rating questions on quality of care. All interRAI items and most BC custom items were scored on a fivelevel response scale (never, rarely, sometimes, most of the time, always); a few BC custom questions were scored with a dichotomous yes/no scale. Other options included ‘don’t know’, ‘refused’, and ‘no response’ (Kehyayen et al., 2015; Morris et al., 2016); these options were coded as missing. Two custom BC questions about receiving help to eat or help to the bathroom had a ‘not applicable’ category. After considering those participants needing assistance versus not needing assistance, it was decided that keeping the ‘not applicable’ category would not add meaning to the analysis in light of the research question. Therefore, the ‘not applicable’ category was coded as missing. Scale scores of the interRAI SQoL-LTCF were calculated using Morris et al.’s (2018) method: ‘never’ and ‘rarely’ were collapsed and assigned a value of 0, ‘sometimes’ assigned a 1, ‘most of the time’ assigned a 2, and ‘always’ assigned a score of 3. Items within each scale were then summed for each overall scale score as displayed in Table 1. Because this study examined relational aspects of care as its primary construct, those OSA survey items considered to address relational aspects needed to be identified. Based on theoretical considerations, this author deemed relational aspects of care to be those experiences of care that pertain to interactions between residents and healthcare providers. Upon inspection of the five interRAI summary scales and the 15 BC custom RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 52 items measuring experiences of care, the following were identified as involving relational aspects of care: • interRAI Caring Staff Scale (made up of five items); • interRAI Staff Responsiveness Scale (made up of eight items); • nine BC custom items: o I get help to eat when I need it, o I get help to the toilet when I need it, o I tell the staff when I am not happy about something, o My problem gets solved when I tell staff I am not happy about something, o Staff explains what they are doing when they give me care, o Staff tries to relieve my physical discomfort, o Staff tries to understand what I’m feeling, o The doctor comes to see me when I am sick, and o The doctor comes to see me even when I am not sick. Experience of care measures not pertaining to relational aspects of care included: • interRAI Social Life Scale (made up of ten items); • interRAI Personal Control Scale (made up of eight items); • interRAI Food Scale (made up of three items); • six BC custom items: o I am treated with respect by other residents who live here, o My family and friends are welcome to visit whenever they choose, o Do you know what drugs you are taking, o Do you know what you’re taking the drugs for, RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 53 o Were you consulted about taking the drugs, and o Do you want to live here. Table 1 Possible Range and Internal Consistency of interRAI SQoL-LTCF Summary Scales Summary Scales Social Life Scale Personal Control Scale Food Scale Caring Staff Scale Staff Responsiveness Scale Items Included 10 8 3 5 8 Note. Adapted from Morris et al., 2018, p. 212. Possible Range 0-30 0-24 0-9 0-15 0-24 Cronbach’s Alpha .80 .76 .76 .73 .86 Self-reported mental and physical health status. Residents’ self-reported mental and physical health statuses were measured using a version of the Veterans RAND 12 Item Health Survey (VR-12) adapted in BC for LTRC. The VR-12 is a widely accepted patient-reported outcome measure (PROM) developed from the RAND SF36/SF-12 family of instruments that provides measures of physical and mental health (CIHI, 2015; Kazis, Selim, Rogers, Qian, & Brazier, 2012). The questions on the instrument consider patient perceptions of different aspects of health arising from eight distinct domains. These domains include physical functioning, role limitations due to physical problems, bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems, and mental health (CIHI, 2015; Kazis et al., 2012). The VR-12 is considered a generic PROM described as measuring Health Related QoL (HRQoL); generic PROMs are developed for a general population and can be used across different disease states (CIHI, 2015). The OSA’s survey included an adapted version of the VR-12, which is specific to LTRC (Wilson et al., 2017). The adapted version includes modified questions that are more suitable for someone living in LTRC (e.g., removal of all references to ‘work’). Dr. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 54 Lewis Kazis, developer of the VR-12, supported the adaptation of the VR-12 for the version fielded in BC, named VR-12vLTRC. The VR-12vLTRC assessment provides two summary scores - a physical component score (PCS) and mental component score (MCS), which comprise the outcome variables in this study. Due to the adaptations made, the original VR-12 scoring algorithm for calculating PCS and MCS could not be applied. Therefore, the analyses of PCS and MCS in this study were standardized factor scores from a previously conducted confirmative factor analysis by Wilson et al. (2017) using data from the entire provincial sample (N = 22,162). The factor model was based on the theoretical measurement structure of the original SF-36 from which the VR-12 was derived (McHorney, Ware, & Raczek, 1993). Thus, the PCS and MCS scores in this study are scaled based on the provincial sample with a mean of zero and variance of one (Boston University, n.d.). The VR-12 is widely tested to be reliable and valid in measuring physical and mental health outcomes (Kazis et al., 2012) and is a subset of items from the Veterans RAND 36 Item Health Survey (VR-36). The VR-12 instrument is used extensively in ambulatory seniors’ populations within the Veterans Administration and the Medicare Advantage program in the United States; it is well established as a rigorous measure of physical and mental health outcomes in populations experiencing chronic health conditions (CIHI, 2015; Kazis et al., 2012). Strong evidence supports the reliability and validity of the VR-36/VR-12 instruments (CIHI, 2015; Kazis et al., 2012). Psychometric testing of the adapted version for use in LTRC is currently in progress as part of a separate project (Wilson et al., 2017). Scientific quality for this study is further enhanced by the use of multiple (60) long-term care facilities in the sample. Further, a particular RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 55 advantage in the OSA’s survey was the simultaneous collection of both the independent (interRAI) and dependent (VR-12) data. To summarize, the following care experience measures were included in the analyses for this study as predictors of self-reported physical and mental health, depicted in Figure 2: relational experiences of care (two summary scales and nine individual BC items) and non-relational care experiences (three summary scales and six individual BC items). In addition, five demographic items (age, time in facility, gender, ethnicity, and marital status) were included as covariates (not shown in Figure 2). Figure 2. Experiences of care and their influence on health outcomes, including measures. 1) based on the interRAI Self-Reported Quality of Life Survey for LTC Facilities. 2) based on the adapted version of the Veterans RAND 12 Item Health Survey (VR-12) for LTRC RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 56 Analysis Methods Data screening. Univariate descriptive statistics obtained through SPSS were examined for accuracy of input and completeness of data. Frequency tables were reviewed for categorical and ordinal variables, and binary variables were examined for unusual splits. A few obvious errors were noted and recoded as missing. Two cases were found to have no valid data on any variables and were deleted. Assumptions necessary for completing a multivariable linear regression include having a continuous dependent variable and two or more independent variables that are either continuous or nominal (Laerd Statistics, 2015). The PCS and MCS scores (comprising the dependent variables in this study) were measured on a continuous scale. The interRAI summary scales were continuous, and all ordinal variables from Likert type scores were dummy coded. Demographic nominal variables with more than two categories were also dummy coded. Remaining assumptions for linear regression (linearity, independence of errors, homoscedasticity, multicollinearity, significant outliers, and normality of residuals) (Field, 2013; Laerd Statistics, 2015) were assessed based on the output of the regression analysis and will be discussed at length in the results chapter. Missing data. Each variable was assessed for missing data using SPSS. VR-12 PCS and MCS were missing for 13.1% of the sample. Percentage of missing data for the demographic variables ranged from 7.1 to 12.9 %. The date of admission was missing for 12.2% of the sample and date of survey was missing for 7.2%, which resulted in 19.1% missing for the Time in Facility variable. The experience of care items ranged from 6.1 to 58.2% missing. Of 100 variables, none had complete data. Only 2.37% of cases were complete on all variables, and overall, there was 15.28% of missing data, RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 57 according to SPSS’s Missing Value Analysis. SPSS was used to calculate Little’s chisquare statistic for testing whether values are missing completely at random (MCAR). Results of this statistic were χ² (99,342, N = 2,108) = 103,223.8, p < .001, therefore one cannot assume MCAR in this dataset. Consequently, complete case analysis and mean imputation methods were not warranted as these assume data to be missing completely at random. The missingness patterns and Separate Variance t Tests were examined with several significant results suggesting a relationship between the missingness on the dependent variables and other variables (Tabachnick & Fidell, 2013). Given these findings, the data are likely missing at random (MAR), and multiple imputation (MI) was considered the best option for dealing with missing values. The goal when dealing with missing data is to have “unbiased estimates of the parameters of interest” (Graham, 2012, p. 5), which would suggest the dataset will be representative of the population of interest. Using complete case analysis (or omitting all cases with missing data) is based on the assumption that the missing cases as a whole are a representative subsample of the entire sample and are missing completely at random (MCAR) (Schafer, 1999; Tabachnick & Fidell, 2013). However, MCAR is often not a tenable assumption. Multiple imputation methods are therefore often recommended to impute missing values based on the less stringent assumption of data being missing at random (MAR) when taking all variables into account (Schafer, 1999). Multiple imputation uses the valid data to predict parameter distributions. Random draws from the predicted distributions complete the missing data to provide multiple simulated and complete datasets (Schafer, 1999). These “results are later combined to produce estimates and confidence intervals that incorporate missing-data uncertainty” (Schafer, RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 58 1999, p. 3). In MI, the inferences for the missing data values are based on the known data, and provide a superior estimate over simply taking a mean or ignoring it altogether. This contributes to a more representative sample of the population than using alternative methods such as case deletion and mean imputation. Accordingly, Tabachnick and Fidell (2013) suggest that multiple imputation is the most respectable method of dealing with missing data. Further, Johnson and Young (2011) recommend the best practice to deal with missing data is either multiple imputation or full information maximum likelihood (FIML) methods. In their comparisons with actual data, Johnson and Young (2011) substantiate the view in the literature that both MI and FIML produce equivalent results and they recommend that practical considerations (software availability, familiarity, and whether the planned analysis can be done with the chosen missing data method) can guide one’s choice between them. Although they do not recommend the single imputation expectation maximization (EM) algorithm within SPSS, they found that the new MI process in SPSS “is a preferred alternative for researchers who are most familiar with SPSS for their analyses” (Johnson & Young, 2011, p. 935). The new MI procedure within SPSS is based on a chained equation procedure (also known as fully conditional specification [FCS]); it uses linear regression to estimate continuous variables, logistic regression to estimate binary variables, and ordinal regression to estimate categorical variables with three or more categories (Johnson & Young, 2011). After cleaning the data, MI with 20 imputations was completed using the SPSS MI module. In their study on the number of imputations needed, Graham, Olchowski, and Gilreath (2007) suggest “the number of imputations required is substantially greater than previously thought” (p. 212). For a RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 59 fraction of missing information up to 0.30, Graham et al. recommend 20 imputations are sufficient to approach equivalence with FIML procedures. Descriptive statistics. Descriptive statistics were used to summarize demographic characteristics for participating residents within Providence Health Care and Vancouver Coastal Health Authority in BC; descriptive statistics were completed using the unimputed dataset. Diseases were expected to correlate highly with the outcome measures in the study, and therefore were included only as descriptive statistics and were not used in the regression analysis. Including diseases as predictors of health outcomes would have increased the risk of washing out the effect of the variables of interest (relational aspects of care) while also potentially increasing multicollinearity. Frequencies, percentages, means, and standard deviations were reviewed to inspect the distributional properties of the data. The histograms, Q-Q plots, skewness and kurtosis values of the continuous dependent variables were evaluated for assumption of normality. Distributional properties were assessed for both unimputed and imputed dependent variables. Bivariate associations. Bivariate analysis was used to examine correlations between predictor and outcome variables and to assess for multicollinearity among independent variables. The Pearson correlation matrix was closely reviewed for any highly correlated (r > .7) independent variables. Hierarchical multivariate linear regression. A hierarchical multivariate linear regression was undertaken to examine associations between residents’ reported care experiences and measures of their physical (PCS) and mental health (MCS) outcomes. A goal of this analysis was to identify the extent that relational aspects of care explain RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 60 variance in self-reported mental and physical health of residents. A hierarchical approach can identify the unique, added variance in the dependent variable attributed to a specific block of the regression equation (Field, 2013; Polit & Beck, 2017). Two separate regression analyses were conducted with the residential care adapted VR-12 scores (PCS and MCS) analyzed as separate outcome variables. The predictor (independent) variables potentially included the five interRAI Summary Scales and the 15 BC custom questions measuring experiences of care. Potential covariates were demographic variables including age, time in facility, gender, marital status, and ethnicity. Using a sequential, hierarchical regression model building approach, the summary scales and individual BC items that examined relational aspects of care were analyzed for their contribution to variance in health outcomes. A hierarchical approach was planned based on theoretical considerations with respect to the research question. Predictor variables were entered in a series of blocks. Initially, demographic variables were entered into the regression equation to statistically control for potential confounding variables. Following that, the two relational Summary Scales (Caring Staff and Staff Responsiveness) were entered as a block, followed by significant relational BC questions. Finally, the last two blocks comprised the remaining non-relational care Summary Scales, followed by the significant non-relational care individual BC questions. The results of the linear regression were augmented by calculating the Pratt index to assess relative variable importance (Thomas, Hughes, & Zumbo, 1998). The calculation of the Pratt index requires standardized regression coefficients for each variable, which are not pooled as part of the SPSS output for multiply imputed data. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 61 Therefore, variables were converted to standardized scores and the regressions rerun to obtain pooled regression coefficients. Although effect size measures such as Cohen’s d (Cohen, 1988) can be used to measure relative importance, they “do not account for the correlations amongst the variables” (Sajobi et al., n.d., p. 5). The Pratt index of relative variable importance can be calculated using the Pearson’s correlation and standardized regression coefficients for each variable, along with the total explained variance (R²) in the model (Sajobi et al., n.d.). All values in the Pratt index add up to 1.0; in essence, they serve as percentages of importance relative to all variables in the model. As described in Thomas et al. (1998), the Pratt index can be used additively to define the importance of a subset of variables. Variable selection. A major issue in multiple regression analysis is deciding which variables to include in the model. In this study, PCS and MCS scores were the only measures available for self-reported health status, and these were included as the outcome variable. As explained earlier, the five interRAI Scales developed by Morris et al. (2018) provide different measures of quality of life and were derived from the interRAI SQoL-LTCF instrument; all five scales were considered important to include in the model. A sequential model building approach was used by first identifying sets of variables and then including these as ‘blocks’ in subsequent regression models. First, each potential variable was evaluated for inclusion into the regression model based on the statistical significance (p < .05) of its regression coefficient. For demographic variables, each variable was run independently against each dependent variable. Demographic variables with statistically significant coefficients were then included in Block 1. The two relational interRAI Summary Scales were subsequently examined independently as RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 62 separate regressions with the demographic variables included as covariates. This was done against both PCS and MCS. This method was continued whereby demographics were entered as Block 1, followed by the significant relational scales as Block 2, and examination of the remaining individual relational items as Block 3. These individual relational items were dummy coded, and were included if the coefficient of any one or more of the dummy variables demonstrated statistical significance (p < .05). Once the individual relational questions were determined for Block 3, each non-relational care scale was added individually in the same manner to determine the Block 4 variables. Finally, the regression coefficients for each nonrelational care, individual BC item were evaluated, and those with statistically significant coefficients comprised Block 5. Of note, the individual BC question ’Do you want to live here?’ was evaluated separately as the final block (Block 6) because it was a global question rather than an ‘experience of care’ question. Evaluation of assumptions of linear regression. To ensure the regression results are valid, it is imperative to test whether the assumptions of a hierarchical multiple regression have been met. Eight assumptions are required: (a) continuous dependent variable; (b) two or more independent variables that are either continuous or categorical; (c) independence of observations; (d) linear relationship between dependent variable and predictor variables, both individually and collectively; (e) homoscedasticity of residuals; (f) no multicollinearity; (g) no significant outliers, high leverage points or highly influential points; and (h) normal distribution of residuals (Field, 2013; Laerd Statistics, 2015). The study design met the first two assumptions, but required all ordinal variables (Likert items) and polytomous nominal variables to be dummy coded prior to entry into RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 63 the regression model. The remaining six assumptions were evaluated after running the regression by examining the residual statistics, and are discussed in the results chapter. The regression results were examined to assess these assumptions. The Durbin-Watson statistic and the Tolerance/VIF values were inspected to assess for independence of errors and multicollinearity, respectively (Laerd Statistics, 2015). Casewise diagnostics were reviewed to assess for outliers, leverage, and influential points; and scatterplots, histograms, and Q-Q plots were examined to assess linearity, homoscedasticity, and normality of residuals (Field, 2013; Laerd Statistics, 2015). Ethical Considerations Ethical approval was obtained for a secondary analysis of data obtained in the survey initiative of the British Columbia Office of the Seniors Advocate. Both the Trinity Western Research Ethics Board and Providence Health Care Research Institute provided ethical approval for the current study, as shown in Appendix C. For the OSA’s survey initiative, interviews were voluntary and verbal consent was obtained from every participant by trained interviewers. An imperative of the OSA survey was that direct care providers and family members not be involved in data collection; volunteers with no prior relationship with the care home or its residents conducted the resident interviews and data collection. All data obtained for analysis was de-identified; no results are attributable to identifiable individuals. This author maintained security of all data and used a password protected, encrypted computer for all analysis and storage of files. Data files will be removed from this author’s computer upon completion of the study and after preparation of any publication submissions. Given that this study is a secondary analysis of existing RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 64 data, it is considered minimal risk research (British Columbia Ethics Harmonization Initiative [BCEHI], 2013); review by Dr. Rick Sawatzky (first reader) and Lena Cuthbertson (second reader) was considered sufficient peer review. Chapter Summary In summary, the data from the OSA survey was analyzed using hierarchical, multivariate linear regression to answer the research question. Using hierarchical multivariate linear regression allows a researcher to determine the unique, added variance in the dependent variable attributed to a specific block of the regression equation (Laerd Statistics, 2015). Scientific quality for this study was assured by using reliable and validated measurement instruments, accommodating missing data, addressing statistical assumptions necessary for linear regression analysis, and using data from a survey that provided an opportunity for all residents to participate. The validated, reliable measurement instruments for experiences of care, and mental and physical health outcomes were detailed, and the steps of preparing and analyzing the data explained. Ethical approvals for the study were reviewed. The next chapter will outline the findings of the described analysis. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 65 Chapter Four: Findings This research evolved from a desire to examine relational aspects of care within LTRC environments from the perspective of residents themselves. In particular, it seeks to illuminate associations between relational care and self-perceived health status of residents living in LTRC. In my view, even a small effect size on such a multifactorial outcome as health is worthwhile, and can provide evidence that the way in which we provide care matters to residents’ physical and mental well-being. This study was structured to identify those experiences of care considered relational and to use hierarchical multiple linear regression to examine their contribution to variation in mental and physical health of residents. This chapter will describe the findings of the analysis outlined previously. The sample of residents used in this study is described and the distributions of the dependent variables examined. Next, the findings of bivariate associations and hierarchical multiple linear regressions for each dependent variable are provided. Assumptions necessary for multiple linear regression are verified and discussed. To conclude, the overall findings will be briefly summarized. Sample Description The study sample consisted of 2,108 residents living in LTRC within Providence Health Care or Vancouver Coastal Health Authority. The sample was predominately seniors (92.2%), with a mean age of 82.43 years; this is slightly lower than the provincial average of 85 years (CIHI, 2016). Half (50%) of residents were age 85 years or older, which again is somewhat lower than the provincial average of 59.77% (CIHI, 2016). Highest percentages for resident characteristics included female gender (63.2%), of white ethnicity (71.5%), and widowed (42.6%). The second largest ethnic group comprising RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 66 the residents was Chinese (16.1%), and residents with aboriginal ethnicity made up 2.2% of the sample. Nine additional ethnicities were collapsed into the ‘other’ category. The Cognitive Performance Scale (CPS) scores for residents showed only 8.2% had severe to very severe (CPS ≥ 4) cognitive impairment. Average length of time living in the facility was 3.28 years (SD = 3.83), the lower and upper quartiles were 0.79 and 4.32 years, respectively, and the range was 45.80 years. Refer to Table 2 for complete descriptive statistics of the sample of residents, including missing data percentages. In terms of disease diagnosis, the most frequent diagnosis was hypertension (48.2%). A high percentage of residents suffered from non-Alzheimer’s dementia (40.6%), with another 7.8% suffering Alzheimer’s disease. One in four residents (25.1%) had diagnosed depression. Chronic diseases such as diabetes (23.4%), cardiovascular disease (24.9%), and arthritis (21.2%) were also common. Comorbidity (having > 2 listed conditions) was common (62.5%). While experiencing three concurrent disease conditions was most common, 14.3% of residents suffered six or more of the listed conditions; see Table 3 for prevalence of each disease. Dependent Variable Distributions The dependent variables were measures of self-reported physical and mental health status of the residents. Two separate analyses were completed – one with the adapted VR-12 Physical Component Score (PCS) as the dependent variable, and the other with the Mental Component Score (MCS) as the dependent variable. The distributions of the PCS and MCS scores were reviewed for both the original and the imputed data as recorded in Table 4. As assessed by visual inspection of the histograms and Normal Q-Q RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 67 plots, displayed in Figures 3, 4, 5, and 6, the unimputed PCS and MCS scores were both approximately normally distributed. Table 2 Demographic Characteristics of Resident Sample Characteristic Gender Female Male Age Category Under 65 65 to 74 75 to 84 85 to 94 95 to 104 105 and over Marital Statusa Never married Married Widowed Separated Divorced Self-Reported Ethnicityb White Chinese Aboriginal Other Cognitive Performance Scale (CPS) Score of 0/1 Score of 2 Score of 3 Score of 4 Score of 5/6 Age in years (Mean (SD)) Time in Facility - years (Mean (SD))* N Valid Percent 1234 720 63.2 36.8 152 252 576 780 194 3 7.8 12.9 29.4 39.9 9.9 .2 315 411 801 86 266 16.8 21.9 42.6 4.6 14.2 1326 296 40 187 71.5 16.1 2.2 10.2 733 37.5 535 27.3 530 27.1 52 2.7 108 5.5 82.43 (11.21) 3.28 (3.83) Missing Data 7.3% 7.2% 10.9% 12.9% 7.1% 7.2% 18.8% Note: N = 2,108. a missing includes missing and unknown. bmissing includes missing and prefer not to answer. *from date of admission to survey date. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 68 Table 3 Prevalence of Disease Diagnoses in Resident Sample Disease Diagnosisa Percent of Sample c Hypertension Dementia not ADᵇ Depressionᵇ Diabetesᵇ Cardiovascular diseasec Arthritisc Osteoporosisc CVAᵇ Hypothyroidismc Gastrointestinal diseaseᵇ Emphysema/COPDc Allergiesc Renal failurec Alzheimer’s (AD)c Anxiety disorderc Anemiac Cataractsc Parkinson’sc Cancerc Hip fractureᵇ Hemiplegia/hemiparesisᵇ Note. N = 2,108. ª disease included if present in 5% or more of the sample. ᵇ missing data 7.1%. 9.1%. 48.2 40.6 25.1 23.4 24.9 21.2 20.9 19.4 14.2 12.6 11.0 8.9 8.9 7.8 7.3 7.2 7.1 6.0 5.6 5.3 5.2 c missing data Although the Shapiro-Wilk test was statistically significant (p < .001) for the unimputed PCS and MCS scores, one would expect this in such a large sample (N = 1,832) (Field, 2013). Histograms for the imputed data appear quite similar to the unimputed data; the imputed PCS and MCS both approximated a normal distribution (see Figures 3, 4, 5 and 6). The imputed PCS statistics suggest moderate kurtosis; however, the histogram and Q-Q plots look to approximate normality. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 69 Table 4 Distributions of Dependent Variables: PCS, MCS, Original and Imputed Statistic Mean (SE) Variance SD Minimum Maximum Skewness (SE) Kurtosis (SE) N PCS Original .01 (.02) .77 .88 -2.63 1.96 -.02 (.06) -.40 (.11) 1,832* PCS Imputed -.00 (.00) .80 .89 -3.51 3.41 -.03 (.01) -.31 (.02) 2,108 MCS Original -.08 (.02) .78 .88 -3.25 2.00 -.05 (.06) -.09 (.11) 1,832* MCS Imputed -.10 (.00) .81 .90 -3.78 3.22 -.06 (.01) -.05 (.02) 2,108 *missing 13.1%. Figure 3. Histograms of physical component score (PCS), original and imputed data. Original data, N = 2,108. Imputed data, N = 42,160. Figure 4. Normal Q-Q plot of physical component score (PCS), original and imputed data. Original data, N = 2,108. Imputed data, N = 42,160. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 70 Figure 5. Histogram of mental component score (MCS), original and imputed data. Original data, N = 2,108. Imputed data, N = 42,160. Figure 6. Normal Q-Q plot of mental component score (MCS), original and imputed data. Original data, N = 2,108. Imputed data, N = 42,160. Bivariate Associations The Pearson’s correlation matrix was examined for statistically significant associations among variables. Correlations were also reviewed for high correlations (r ≥ .7) among independent variables (see Table 5 for results; although all variables were assessed, only summary scales and dependent variables are reported). All of the interRAI Summary Scales showed statistically significant (p < .001, two tailed) associations with mental health (MCS) scores. Moderate correlations (Cohen, 1988) were noted for mental health score with Personal Control (r = .384) and mental health score with Staff RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 71 Responsiveness (r = .343). Likewise, for physical health scores (PCS), all summary scales demonstrated statistically significant associations with physical health. The strongest correlations with physical health were Personal Control (r = .375) and Food (r = .277). Not surprisingly, the interRAI Summary Scales all showed statistically significant associations with each other. The strongest correlation between independent variables was between Caring Staff and Staff Responsiveness Scales (r = .575). Table 5 Pearson’s’ Correlations – Dependent Variables and interRAI Summary Scales Variable MCS Score Caring Staff Staff Responsiveness Personal Control Social Life Scale Food Scale PCS Score .75** .11** .26** .38** .16** .28** MCS Score Caring Staff Staff Responsiveness Personal Control Social Life .16** .34** .38** .17** .26** .58** .39** .53** .34** .57** .32** .43** .35** .36** .30** Note. N = 2,108. **statistically significant (p < .001). Hierarchical Linear Regression Analysis The objective of running a hierarchical linear regression analysis was to determine the proportion of variation in self-reported physical and mental health outcomes explained by relational aspects of care. For this study, prediction of dependent variable scores was not the aim, and therefore the linear regression equations will not be emphasized nor reported. The physical component scores and mental component scores were completed as two separate hierarchical regression analyses, and will be reported separately. As described in the previous chapter, variables were evaluated for inclusion into the regression models based on their regression coefficients. Statistically significant (p < RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 72 .05) demographic variables were the same for PCS and MCS, and included age, time in facility, and marital status; these made up Block 1. Both the Caring Staff and Staff Responsiveness Scales demonstrated statistically significant (p < .05) regression coefficients against each dependent variable, and both were retained as Block 2. When evaluating individual relational questions, two questions were dropped from the PCS and three from the MCS models, due to lack of statistical significance. Remaining relational items were entered as Block 3. All three non-relational care summary scales were statistically significant for both PCS and MCS models, and made up Block 4. Finally, the non-relational care individual BC items were evaluated and entered as Block 5. For PCS, all non-relational care questions were retained except for the final question ’Do you want to live here?’, which lacked statistical significance. Two questions dropped out in the MCS model at this point, whereas the ’Do you want to live here?’ question was statistically significant for MCS. Table 6 lists all potential variables and shows which are included in the final models. Table 6 Variables Included in Final Regression Models Variable Demographic: Age Time in Facility Gender Marital Statusa Ethnicitya PCS Model MCS Model Yes Yes* No Yes* No Yes Yes* No Yes No RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES Table 6 (continued) Variables Included in Final Regression Models Variable Relational Care: Caring Staff Scale Staff Responsiveness Scale I get help to eat when neededa I get help to the toilet when neededa I tell staff when I am not happy about somethinga Problem gets solved when I tell staff I am not happya Staff explains what they are doing when giving carea Staff tries to relieve my physical discomforta Staff tries to understand what I’m feelinga Doctor comes to see me when I am sicka Doctor comes to see me even when I am not sicka Non-relational Care: Personal Control Scale Social Life Scale Food Scale Treated with respect by other residents who live herea Family and friends can visit whenever they choosea Do you know what drugs you are takinga Do you know what you’re taking the drugs fora Were you consulted about taking the drugsa Do you want to live here 73 PCS Model MCS Model Yes Yes* No Yes* Yes Yes No Yes* Yes Yes* No Yes* Yes* No Yes Yes Yes Yes Yes* Yes* Yes* No Yes* Yes* Yes* Yes* Yes* Yes Yes Yes No Yes* Yes Yes* No No Yes Yes Yes Yes* Note. Yes = retained in the model, No = not retained in the model due to non-significant coefficient. a dummy coded variables. *regression coefficient remained statistically significant (p < .05, two tailed) in final model. Physical Component Score (PCS). A hierarchical multiple regression was run to determine the amount of variation in PCS (a measure of self-reported physical health) that could be attributed to relational aspects of care for residents living in LTRC homes. The full model included six demographic covariates entered in Block 1, two relational interRAI Summary Scales in Block 2, 24 relational experience of care responses in Block 3, three non-relational care interRAI Summary Scales in Block 4, and 14 non-relational RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 74 care responses in Block 5, as predictors for PCS. Note that several of these predictors were dummy coded, explaining the total number of predictors. Due to the F-statistics not being pooled for multiply imputed data in SPSS, reporting will include the range of Fstatistics across the 20 imputations. Block 1 consisted of demographic covariates with an R² of .014 (F(6, 2101) = range 4.024 to 6.839, p < .05). The addition of relational summary scales (Block 2) led to a statistically significant increase in R² of .066 (F(2, 2099) = range 57.843 to 90.165, p < .001), and the addition of relational BC ‘experience of care’ items (Block 3) led to a statistically significant increase in R² of .094 (F(24, 2075) = range 7.530 to 13.107, p < .001). Together, the two relational blocks explained an additional 16% of the variance in PCS, which is a moderate effect size, according to Cohen (1988). The remaining nonrelational care summary scales explained another 7.8% of variance in PCS (Block 4), and the non-relational care BC ‘experience of care’ items (Block 5) explained another 2.7%. The final PCS model was statistically significant, with R² = .279 (F(49, 2058) = range 13.906 to 18.111, p < .001). In the PCS model, the relational aspects of care variables had a relative importance (Pratt index) of 34.5%, the non-relational care variables a Pratt value of 62.4%, and the demographic variables was 4.0%. One can see that the Personal Control Scale has the highest relative importance, followed by the Staff Responsiveness Scale. See Table 7 for the PCS pooled model summary and Appendix D, Table D1 for a model summary for all imputations. Refer to Table 8 for full multivariate regression results and relative importance explaining physical health outcomes (PCS). RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 75 Table 7 Hierarchical Multivariate Regression Model Summary – Physical Health Block R R² 0.014 SE Est. (range) 0.878-0.903 0.014 FΔ (range) 4.024-6.839 Sig F Δ (range) 0.000-0.001 1 0.120 2 0.283 0.080 0.848-0.873 0.066 57.843-90.158 0.000-0.000 3 0.417 0.174 0.808-0.842 0.094 7.530-13.107 0.000-0.000 4 0.502 0.252 0.769-0.804 0.078 61.665-82.694 0.000-0.000 5 0.528 0.279 0.756-0.796 0.027 3.806-7.199 0.000-0.000 R²Δ Note. Block 1 – demographics; Block 2 – relational summary scales; Block 3 – relational BC custom, Block 4 – non-relational care summary scales; Block 5 – non-relational care BC custom. Table 8 Multivariable Regression and Relative Importance of Variables Explaining Physical Health Variable Age Time in Facility Marital Status (referent married) never married widowed separated divorced Caring Staff Scale Staff Responsiveness Scale Tell staff when not happy about something (referent Always) Never Rarely Sometimes Most of the time Problem gets solved when tell staff not happy (referent Always) Never Rarely Sometimes Most of the time Staff tries to relieve physical discomfort (referent Always) Never Rarely Sometimes Most of the time β 0.04 -0.06 SE β 0.02 0.02 r 0.08 -0.06 p 0.10 0.01 0.04 0.06 0.02 -0.01 -0.08 0.17 0.03 0.03 0.03 0.03 0.04 0.04 -0.02 0.09 -0.02 -0.04 0.11 0.26 0.14 0.04 0.60 0.82 0.05 0.00 0.03 0.02 -0.02 0.01 0.04 0.03 0.03 0.03 0.07 -0.02 -0.11 -0.01 0.46 0.51 0.53 0.69 -0.03 -0.02 -0.01 -0.04 0.08 0.03 0.02 0.04 0.05 0.05 0.04 0.04 0.03 0.04 0.03 0.03 -0.02 -0.03 -0.08 0.00 0.06 -0.02 -0.10 -0.03 0.53 0.63 0.73 0.23 0.02 0.34 0.46 0.23 d 1.1% 1.4% 1.5% 0 15.3% 1.2% 0.9% 0.4% RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 76 Table 8 (continued) Multivariable Regression and Relative Importance of Variables Explaining Physical Health Variable β SE β r Staff tries to understand what I’m feeling (referent Always) Never 0.03 0.04 0.02 Rarely -0.03 0.04 -0.09 Sometimes 0.01 0.04 -0.09 Most of the time 0.05 0.03 0.07 Get help to toilet when needed (referent Always) Never 0.14 0.04 0.11 Rarely 0.14 0.05 0.10 Sometimes 0.08 0.03 -0.05 Most of the time 0.02 0.03 -0.12 Doctor comes to see me when I am sick (referent Always) Never 0.06 0.03 0.09 Rarely -0.02 0.03 -0.04 Sometimes -0.06 0.03 -0.10 Most of the time -0.09 0.03 -0.07 Food Scale 0.12 0.02 0.28 Personal Control Scale 0.30 0.03 0.38 Social Life Scale 0.06 0.03 0.16 Treated with respect by residents who live here (referent Always) Never 0.02 0.03 -0.05 Rarely 0.03 0.03 -0.05 Sometimes 0.07 0.03 -0.05 Most of the time 0.04 0.03 0.01 Family/ friends can visit whenever they choose (referent Always) Never 0.02 0.03 0.00 Rarely 0.00 0.03 -0.04 Sometimes 0.03 0.02 -0.04 Most of the time 0.05 0.02 -0.01 Know what drugs I am taking (referent Not taking drugs) Yes -0.08 0.05 -0.11 No -0.03 0.05 0.03 Know what taking the drugs for (referent Not taking drugs) Yes -0.09 0.06 -0.10 No -0.03 0.06 0.01 Consulted about taking the drugs (referent Not taking drugs) Yes -0.05 0.04 -0.05 No -0.04 0.04 -0.02 Note. r = bivariate correlation with PCS, N = 2,108, d = Pratt index. R² = 28%. p 0.53 0.40 0.73 0.12 0.00 0.01 0.01 0.50 0.05 0.61 0.04 0.00 0.00 0.00 0.05 0.50 0.36 0.02 0.14 0.51 0.92 0.23 0.03 0.16 0.56 0.16 0.63 0.21 0.31 d 1.9% 7.9% 6.9% 11.6% 40.5% 3.4% 0 0 2.7% 2.9% 1.3% RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 77 Mental Component Score (MCS) A separate hierarchical multiple regression was run to determine the amount of variation in MCS (a measure of self-reported mental health) attributed to relational aspects of care for residents living in LTRC homes. The full model for MCS included six demographic covariates entered in Block 1, two relational interRAI Summary Scales in Block 2, 28 relational experience of care items in Block 3, three non-relational care interRAI Summary Scales in Block 4, six nonrelational care items in Block 5, and one global question in Block 6. The demographic covariates (Block 1) contributed to an R² of .015 (F(6, 2101) = range 4.056 to 6.227, p < .001). The addition of relational summary scales (Block 2) led to a statistically significant increase in R² of .116 (F(2, 2099) = range 114.536 to 167.622, p < .001), and the addition of relational BC ‘experience of care’ items (Block 3) led to a statistically significant increase in R² of .080 (F(28, 2071) = range 5.512 to 9.857, p < .001). Thus, relational aspects of care explained 19.6% of the variance in self-reported mental health, when controlling for demographic variables. The three additional non-relational care interRAI Summary Scales (Block 4) accounted for an additional 4.6% of variance in MCS and the non-relational care BC ‘experience of care’ items (Block 5) contributed another 1.4%. For the mental health outcome (MCS), the final item asking ‘Do you want to live here’ was included and demonstrated a statistically significant addition to the model R² of .003 (F(1, 2061) = range 3.214 to 16.214; p ranging from < .001 to .073). The final MCS model was statistically significant, with R² = .274 (F(46, 2061) = range 15.533 to 18.572, p < .001). See Table 9 for a summary of the final pooled MCS model and Appendix D, Table D2 for model summary for all imputations. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 78 For the measures of mental health, relational aspects of care showed a total relative importance (Pratt index) of 48.3%, whereas the non-relational care experiences’ relative importance was 45.3%. The demographic variables’ Pratt index was 4.1%, and the question ‘Do you want to live here?’ had a Pratt score of 3.4%. Similar to the PCS model, the MCS regression revealed Personal Control as having the highest relative importance. The variable of next highest importance was Staff Responsiveness; it appears to hold even higher importance for mental health than physical health outcomes. See Table 10 for full multivariate regression results and relative importance explaining mental health outcomes (MCS). Table 9 Hierarchical Multivariate Regression Model Summary - Mental Health Block R R² 0.015 SE Est. (range) 0.993-0.996 0.015 FΔ (range) 4.056-6.227 Sig F Δ (range) 0.000-0.000 1 0.122 2 0.361 0.130 0.924-0.945 0.115 114.536-167.622 0.000-0.000 3 0.459 0.211 0.887-0.908 0.081 5.512-9.857 0.000-0.000 4 0.507 0.257 0.858-0.882 0.046 34.437-50.134 0.000-0.000 5 0.520 0.271 0.851-0.874 0.014 3.477-8.642 0.000-0.002 6 0.523 0.274 0.850-0.871 0.003 3.214-16.21 0.000-0.073 R²Δ Note. Block 1 – demographics; Block 2 – relational summary scales; Block 3 – relational BC custom, Block 4 – non-relational care summary scales; Block 5 – non-relational care BC custom; Block 6 – ‘Do you want to live here?’ RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 79 Table 10 Multivariable Regression and Relative Importance of Variables Explaining Mental Health Variable Age Time in Facility Marital Status (referent married) never married widowed separated divorced Caring Staff Scale Staff Responsiveness Scale Tell staff when not happy about something (referent Always) Never Rarely Sometimes Most of the time Problem gets solved when tell staff not happy (referent Always) Never Rarely Sometimes Most of the time Staff explains what they are doing (referent Always) Never Rarely Sometimes Most of the time Staff tries to relieve physical discomfort (referent Always) Never Rarely Sometimes Most of the time Staff tries to understand what I’m feeling (referent Always) Never Rarely Sometimes Most of the time Get help to toilet when needed (referent Always) Never Rarely Sometimes Most of the time β SE β r p d 0.03 -0.07 0.03 0.02 0.07 -0.07 0.32 0.00 0.02 0.04 -0.01 -0.01 -0.09 0.22 0.03 0.03 0.03 0.03 0.04 0.04 -0.03 0.09 -0.04 -0.04 0.16 0.34 0.46 0.15 0.70 0.65 0.02 0.00 0.7% 1.9% 1.5% 0.01 -0.04 -0.04 -0.02 0.04 0.03 0.03 0.03 0.07 -0.08 -0.11 -0.03 0.84 0.19 0.21 0.38 0.01 0.00 0.02 -0.01 0.05 0.04 0.04 0.03 -0.01 -0.06 -0.09 0.01 0.83 0.91 0.57 0.71 -0.01 0.00 -0.01 -0.05 0.04 0.04 0.03 0.03 -0.02 -0.06 -0.10 -0.03 0.87 1.00 0.87 0.12 0.08 0.01 0.01 0.01 0.03 0.04 0.03 0.03 0.06 -0.07 -0.12 -0.05 0.02 0.34 0.46 0.23 -0.01 -0.08 0.01 0.06 0.04 0.04 0.04 0.04 -0.02 -0.15 -0.09 0.11 0.53 0.40 0.73 0.12 0.07 0.08 0.03 0.01 0.04 0.04 0.03 0.03 0.06 0.05 -0.08 -0.11 0.10 0.07 0.26 0.83 0 28.2% 3.3% 0 0.8% 1.1% 6.4% 2.0% RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 80 Table 10 (continued) Multivariable Regression and Relative Importance of Variables Explaining Mental Health Variable β SE β r Doctor comes to see me when I am sick (referent Always) Never 0.05 0.03 0.06 Rarely -0.02 0.03 -0.06 Sometimes -0.08 0.03 -0.12 Most of the time -0.08 0.03 -0.05 Food Scale 0.06 0.02 0.26 Personal Control Scale 0.25 0.03 0.38 Social Life Scale 0.02 0.03 0.17 Know what drugs I am taking (referent Not taking drugs) Yes -0.09 0.05 -0.08 No -0.02 0.05 0.02 Know what taking the drugs for (referent Not taking drugs) Yes -0.05 0.06 -0.04 No -0.02 0.06 -0.02 Consulted about taking the drugs (referent Not taking drugs) Yes -0.02 0.05 0.00 No -0.03 0.05 -0.05 Wants to live in this care home -0.06 0.02 -0.15 Note. r = bivariate correlation with MCS, N = 2,108, d = Pratt index. R² = 27%. p 0.15 0.45 0.02 0.01 0.02 0.00 0.50 d 6.5% 5.3% 34.7% 1.3% 0.10 0.63 0.35 0.67 0.63 0.49 0.01 2.4% 1.0% 0.6% 3.4% Evaluation of Assumptions for Multiple Linear Regression Independence of Observations. The Durbin-Watson statistic tests for 1st-order autocorrelation, which is a lack of independence in adjacent observations (Laerd Statistics, 2015). The Durbin-Watson statistics for the PCS imputations ranged from 1.951 to 2.047, thereby confirming independence of residuals. Likewise, the DurbinWatson statistics for the MCS imputations ranged from 1.906 to 2.020, so independence of observations was confirmed. Homoscedasticity, Linearity, and Multicollinearity. Scatter plots of standardized predicted versus standardized residuals across imputations were visually inspected, and demonstrated homoscedasticity for both PCS and MCS regression models. These plots also established linearity between the dependent variable and collective RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 81 independent variables; both PCS and MCS models demonstrated an overall flat, linear relationship. Additionally, examination of scatter plots of the dependent variable against each individual, continuous predictor was completed. In both PCS and MCS models, all individual predictors showed linearity with the dependent variable. Although no substantial relationships were evident, all interRAI Summary Scale scores demonstrated small, positive relationships in each model. There was no evidence of multicollinearity in either PCS or MCS models, as assessed by Variance Inflation Factors (VIF) less than 10 across all imputations. The highest correlation between predictors was .575 for both models, further supporting lack of multicollinearity. Outliers, High Leverage, or Highly Influential Points. In terms of the MSC and PCS distributions, only the MCS varied from a truly normal distribution. MCS regression. The number of outliers (data points ≥ 3 SD) is somewhat greater than one would expect in a truly normal distribution. For the MCS regression with imputed data (N = 42,160), there were 159 (0.38% of sample size) studentized deleted residuals greater than ± 3.29. This would coincide with the large negative kurtosis value seen in the imputed MCS statistics, indicative of heavier tails than expected in a truly normal distribution. There were no leverage values greater than 0.2, nor were there any values for Cook’s distance above 1. Given the very large sample size, and lack of high leverage or highly influential points, it is reasonable to consider these assumptions were met. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 82 PCS regression. For the PCS regression, there were fewer extreme outliers than seen in the MCS regression; the number of outliers was close to expected for a normal distribution. For the PCS regression with imputed data (N = 42,160), there were 53 (0.13% of sample size) studentized deleted residuals greater than ± 3.29. There were no leverage values above 0.2 and no values for Cook’s distance greater than 1. Normality of Residuals. The assumption of normality of residuals was met for both PCS and MCS multiple linear regressions as assessed by histograms of the standardized residuals and P-P plots, shown in Appendix E, Figures E1, E2, E3, and E4. Chapter Summary This analysis examined resident reports of care experiences within LTRC and their associations with self-reported physical and mental health outcomes. The aim of this study was to describe the extent that relational aspects of care explain variation in self-reported mental and physical health outcomes; this was accomplished by conducting multivariate linear regressions with both physical health (PCS) and mental health (MCS) as dependent variables. The ‘experience of care’ questions on the OSA survey were grouped into those that involved the relationship between care provider and resident (relational aspects of care) and all other aspects of care such as food, social life with coresidents, sense of personal control, medications, etc. The complete model, which included all experiences of care items from the survey, accounted for a total 27.9% of the variation in the PCS health outcome and 27.4% of the variation in self-reported mental health outcomes. Both of these equate to a moderate effect size, according to Cohen (1988). Despite the complex and multifactorial nature of health, the PCS model demonstrated that relational aspects of care explained 16.0% of the variation in self- RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 83 reported physical health outcomes and 19.6% of the variation in self-reported mental health, when controlling for demographic variables. What is clear from this analysis is that relational aspects of care do contribute in a statistically significant manner to both physical and mental health outcomes of residents living in LTRC homes. Therefore, relational aspects of care matter to the physical and emotional well-being of residents living in LTRC homes. The Pratt indices reveal the relative importance of relational aspects of care compared with all measured experiences and demographics on the survey. As expected, relational aspects of care appear to be even more important to mental health (Pratt = 48.3%) than their substantial importance (Pratt = 34.5%) to physical health outcomes. The following discussion chapter will summarize the findings and examine them in light of the research question and current literature. Further exploration of study findings will be done with interpretation regarding how this study can impact our approach to the provision of care in LTC settings. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 84 Chapter Five: Discussion With data analysis complete, the discussion chapter allows the findings to be considered in the context of previous research. The specific research question addressed in this study was: To what extent do relational aspects of care explain variation in selfreported mental and physical health of residents living in long-term residential care? I will compare and contrast the study’s results with existing literature, and consider how these results relate to theoretical literature on a relational approach to care. Summary of Findings The hierarchical regression analyses showed relational aspects of care explained 16.0% of variation in physical health (PCS), when controlling for demographic differences. For the PCS model, ‘experience of care’ questions not designated as relational explained another 10.5% of variance, while demographics explained 1.4%. These results demonstrate that relational aspects of care are significantly associated with residents’ self-reported physical health outcomes. Similarly, relational aspects of care were significantly related to self-reported mental health. For mental health outcomes, relational care explained an even greater percentage of variation (19.6%), when controlling for demographic differences. All other experiences (non-relational care) explained 6.0% of the variation in MCS, demographics explained 1.5%, and whether they want to live there another 0.3%. When one considers the experience of care items overall, those with a relational focus are clearly substantiated as relevant, particularly with respect to mental health outcomes. Because the order of entry into the model can affect these variance percentages, it is helpful to consider the Pratt index of relative variable importance. In the case of RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 85 physical health outcomes, relational aspects of care have a relative importance of 34.5%, whereas all other non-relational care experiences (Social Life, Personal Control, Food, respect by residents, medications, etc.) have a relative importance index of 62.4%. The single variable that demonstrates the most importance to physical health outcomes is the non-relational Personal Control Scale, which has a Pratt index of 40.5%. What is striking is that of all experience items on the OSA survey, relational aspects combined with personal control show a relative importance of 75% with respect to PCS outcomes. Both relational aspects of care and personal control are considered integral to PCC. With respect to mental health (MCS) outcomes, the Pratt index shows relational aspects of care have a relative importance of 48.3%, compared to all other variables. All remaining non-relational care experiences had a relative importance of 45.3%, demographics had an index of 4.1%, and whether the resident wants to live there was 3.4%. This suggests that even though relational aspects of care are important to physical health, they are even more important to residents’ mental health, relative to other care experiences. The two single variables of highest relative importance to mental health outcomes were the non-relational Personal Control Scale (34.7%), and the relational Staff Responsiveness Scale (28.2%). The relational care items together with personal control show a high relative importance of 83% with respect to MCS outcomes. The interRAI Caring Staff Scale showed a statistically significant, positive association with both physical and mental health when entered individually into the model. However, somewhat surprisingly, once Caring Staff was entered together with the Staff Responsiveness Scale, its regression coefficient became negative. It is possible that an interaction between the two predictors led to this result. Positive associations RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 86 between Caring Staff and health outcomes are supported by the positive and statistically significant correlations and regression coefficients when only Caring Staff and demographic covariates were included in the regression model. Variables that remained statistically significant in both PCS and MCS final models included: (a) length of time in facility; (b) staff responsiveness, personal control, and food summary scales; (c) ‘doctor comes to visit when I am sick’ item; and (d) ‘staff tries to relieve my physical discomfort’ item. The three statistically significant interRAI Summary Scales (Staff Responsiveness, Personal Control, and Food) all demonstrated a positive relationship with both physical and mental health. From a relational care perspective, this suggests higher levels of staff responsiveness are associated with higher levels of physical and mental health. Likewise, from a non-relational care perspective, higher levels of personal control and positive food experiences are each associated with higher levels of physical and mental health. As a resident’s time in facility increased, levels of both physical and mental health decreased. Interpretation of dummy coded variables in regression is a challenge. Nonetheless, there were individual items on the survey where at least one response option showed a significant association with physical and mental health outcomes. Interestingly, the mean responses for the two statistically significant items, (‘doctor comes to visit when I am sick’ and ‘staff tries to relieve my physical discomfort’), showed those with higher health outcomes experience more extremes (response of always or never), whereas inconsistency (response of sometimes) is associated with lower health scores. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 87 There were some differences between physical and mental health outcomes in terms of which variables remained statistically significant in the final models. For the physical health (PCS) model, additional statistically significant variables were marital status, the Social Life scale, and three individual questions including: (a) ‘I get help to the toilet when needed’, (b) ‘I am treated with respect by other residents who live here’, and (c) ‘family and friends can visit whenever they choose’. Analysis of these OSA survey results suggests that Social Life and relationships with co-residents, friends, and family appear to be more pertinent to physical health than to mental health. Getting help to the toilet when needed is associated with increased levels of physical health, and yet was not associated with mental health outcomes. This is somewhat surprising given the research by Donnelly and MacEntee (2016), who reported resident expressions of indignity when they were not helped to the bathroom. Variables that were statistically significant only in the MCS model included the Caring Staff Scale and two individual questions: (a) ‘staff tries to understand what I’m feeling’, and (b) ‘do you want to live here’. These results suggest that caring behaviours and empathy from staff are associated with better mental health outcomes. When considering whether residents want to live in the care home, it was found that when added as the final block after all other experiences of care, that it contributed in a statistically significant manner to mental health outcomes. Wanting to live in the care home is associated with higher mental health scores. Relationship to the Literature Prior studies. Much of the research in this area has examined resident outcomes in culture change models or person-centred care, rather than focusing specifically on RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 88 relational aspects of care, as in this study. Because relational aspects of care are integral to PCC principles, one can find overlap among study results. In their review of eleven culture change studies on health outcomes, Hill et al. (2011) found some evidence “support[s] the positive influence of culture change models on aspects of psychosocial health” (p. 32). This was not the case, however, for physical health outcomes in their review, which were largely inconclusive. In their reviewed studies (Hill et al., 2011), psychosocial outcomes were largely obtained via resident self-ratings, whereas most physical health outcomes were objective measures such as rates of infection, medication use, incontinence, falls, or measures of cognition, nutritional status, etc. Similarly, the review of 24 studies by Li and Porock (2014) found inconclusive evidence with respect to physical health outcomes. They did find implementation of culture change models provided some beneficial effects on psychological well-being, namely, decreased depression, loneliness, and boredom in some of the Eden Alternative homes. In the current study, relational aspects of care demonstrated a statistically significant, moderate (Cohen, 1988) association with resident reported physical health outcomes; there was a somewhat stronger association with resident reported mental health than physical health outcomes. It is plausible to surmise that resident perceptions of their physical health (as studied here) may not equate to clinician observed and reported measures of physical health. No studies were found in the review of the literature that correlated relational aspects of care with residents’ self-reported mental or physical health. However, two studies (Burack et al., 2012; Yeung & Rodgers, 2017) examined variables relevant to QoL, such as those found in the interRAI survey, and their associations with overall RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 89 satisfaction or sense of QoL. Burack et al. (2012) found residents’ experience of dignity was the only significant predictor for satisfaction with staff, while dignity, spiritual wellbeing, and food enjoyment were significant predictors of overall satisfaction with the nursing home. Yeung and Rodgers (2017) found experiences of being treated with dignity and caring relationships to be the most important elements associated with a sense of QoL. Both of these studies (Burack et al., 2012; Yeung & Rodgers, 2017) used the Quality of Life Scales for Nursing Home Residents instrument (Kane et al., 2003), which includes a resident reported measure of dignity. In the current study, questions regarding dignity are found in the Staff Responsiveness Scale. Consequently, the importance of dignity as an indicator (or predictor) of positive mental and physical health status in these studies is consistent with the current research, which showed high relative importance for Staff Responsiveness on both PCS and MCS. Dignity conserving care has been described by Chochinov (2007) as care that affirms a patient’s value; when a healthcare provider can see the person behind the illness, this upholds a patient’s sense of dignity. This type of care is central to personcentred care and involves kindness, respect, dignity and embodies our sense of humanity. Chochinov (2007) emphasizes a framework for providing dignity conserving care that includes examining one’s attitudes and behaviours while providing compassion and dialogue. An interesting contradiction with the current study is Burack et al.’s (2012) lack of statistical significance on measures of autonomy. Note that Yeung and Rodgers (2017) did not measure autonomy in their study. Much of the literature on PCC (Custers et al., 2010; Donnelly & MacEntee, 2016; Moyle et al., 2011; Nakrem et al., 2011) RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 90 supports choice and personal control as being important to residents’ QoL. This study further supported these literature findings. The Personal Control Scale demonstrated the highest single variable importance for both physical (40.5%) and mental (34.7%) health, relative to all areas on the survey. An existing body of qualitative research examining care home life suggests both connectedness and caring practices may positively influence a resident’s QoL (Bradshaw et al., 2012; Dragaset, Haugen, & Tranvag, 2017). Connectedness was achieved through relationships with peer residents, staff, and family (Bradshaw et al., 2012). Caring practices were described as meeting a resident’s needs, taking time with and getting to know residents, having a caring attitude, providing staff continuity, and providing a sense of safety for residents (Bradshaw et al., 2012). Within the current study, connectedness with staff is captured in relational aspects of care, connectedness with peers in the Social Life Scale, and caring practices in both the Caring Staff and Staff Responsiveness Scales. Interactions between staff and residents (relational aspects of care) showed positive associations with physical and mental health outcomes in the current research, however, interactions with other residents (measured in the Social Life Scale) were only significant for physical health. Furthermore, the Pratt index of relative variable importance suggests the Social Life Scale did not hold as much importance for residents participating in the OSA survey as one might expect, given the findings in the literature. The Pratt index for the Social Life Scale was 3.4% for PCS and 1.3% for MCS. Further research is needed to discern the degree that interactions with co-residents matter to the perceived physical and mental health of residents, as well as the impact of other factors, such as cultural and linguistic diversity, communication barriers, availability of activities, etc. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 91 Very little quantitative research exists that primarily examines relationships between health care provider and resident. Only two quantitative studies (Custers et al., 2010; Haugan, 2014) were located that focused on interactions between nursing staff and residents of LTRC homes. Custers et al.’s (2010) questions on need fulfillment in the caring relationship closely align with those in the Staff Responsiveness section of the current research, and could be considered relational aspects of care. Custers et al. (2010) found significant associations between need fulfillment in the caring relationship and less depressive feelings and increased life satisfaction. This supports the findings of the current research that showed relational aspects of care are significantly, positively associated with mental health outcomes. Haugan (2014) found high quality nurse-patient interactions were positively and significantly associated with meaning-in-life. Additional explicit research on relational aspects of care and self-reported health outcomes is needed to support the findings of the current study. As only a subset of the data from the OSA’s survey was available for analysis for this study, replication of this study using the statistical model with the larger data set would be worthwhile to determine if the findings remain consistent. Theoretical literature. Relationships are crucial to the approach researchers take, and indeed to the very core of nursing. A relational imperative. In their article on a relational approach to care for older people, Wasserman and McNamee (2010) discuss how social constructionist theory explains our existing emphasis on problems in healthcare. Our focus on problem identification and diagnosis, dysfunction, and disease, with its emphasis on the healthcare provider’s role of expert may ultimately limit us. They suggest “meaning is created in RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 92 relational interchange” (Wasserman & McNamee, 2010, p. 310) and promote dialogue in which the healthcare provider’s “role as expert is not central” (p. 310). Wasserman and McNamee (2010) stress the importance of creating discussions around “values, strengths and possibilities…[to] create and live within a reality of potential” (p. 310). When considering the experience of living in LTRC for residents, as examined in this study, two primary areas of importance were revealed. These are a sense of personal control and relational aspects of care. While taking a relational approach has merit on its own, it also can ultimately assist staff and residents to explore ways to increase personal control for residents. According to Wasserman and McNamee (2010): A relational approach is one of knowing how to be attentive to the process of opening viable possibilities and potentials for those with whom we work. This requires focus on what professionals and clients do together in the healthcare conversation. It shifts the conversation from diagnosis and problem solving to exploring: What can we accomplish (i.e., create) in our conversations together? (p. 310) In my own experience, I have often observed seniors who loathe ‘making waves’ and willingly relinquish their ‘personhood’ in deference to the expert physician or nurse. Too often, we tell a resident the way things are, rather than exploring with them how things could be. If we can build relationships and get to know seniors in our care, we can encourage agency for our residents by exploring possibilities that hold meaning for them. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 93 A relational inquiry approach. Implementation of a relational care approach in LTRC homes requires an understanding of relational practice. As described by Doane and Varcoe (2015), what is needed is a relational inquiry approach, which is ultimately “oriented toward enhancing the capacity and power of people to live meaningful lives” (p. 12). They suggest “five particular ways of being” in order to practice relational inquiry effectively; these include “being compassionate, curious, committed, competent, and corresponding” (Doane & Varcoe, 2015, p. 103). Being compassionate requires an intention to relate “human being to human being – to share something of ourselves and what it means to be human” (Doane & Varcoe, 2015, p. 103). Many residents living in LTRC homes have chronic illnesses; they have learned to carry on and find ways to live with their limitations. Doane and Varcoe (2015) describe compassion as the ability to be with others where they are, at a particular moment in time. “Being compassionate therefore means being in solidarity with patients and families while enabling them to retain their independence and dignity (vonDietze & Orb, as cited in Doane & Varcoe, 2015, p. 107). Being curious involves being interested and inquisitive while also being able to tolerate the uncertainties inherent in illness or disease (Doane & Varcoe, 2015). To be corresponding is to be in tune to the needs of your patient and to be in step, or in harmony, with the overall situation – it requires sensitivity to the moment and what that patient needs at that time. Doane and Varcoe (2015) explain it as “relating to and with people in a way that is meaningful to them” (p. 129). To commit to a relational approach to care, one has to be intentional and consistently apply these principles during interactions with residents. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 94 The relational core of nursing. Jonsdottir, Litchfield, and Pharris (2004) discuss the medicalization of nursing and a “rational and linear thinking approach to solving problems in a standardized, prescriptive manner” as the force driving nursing practice (p. 243). In their opinion, this problem focused approach “obscures the humanness of the health experience and diminishes, even inhibits, the caring relational aspect that is essential to assist people to live life with intricate health predicaments” (Jonsdottir et al., 2004, p. 242). Jonsdottir et al. (2004) describe their view of partnership where: the nurse is fully present to the patient and relates to the patient with open attentiveness. The nurse holds the patient in unconditional warm regard as a fellow human being. This has its expression in a mutually responsive and nondirective dialogue between them, where the nurse’s sole intent lies in an effort to understand the patient’s experience. (p. 243) Though the focus of this study is on understanding the relationships between relational aspects of care and mental and physical health outcomes, irrespective of this, relational care is viewed as important in its own right. As care providers, what we may intuitively believe is a sound approach to care provision (i.e., relational practice) can carry more weight if it demonstrates improved health outcomes. Chapter Summary This study demonstrated that relational aspects of care do contribute significantly and positively to physical and mental health outcomes for residents living in LTRC homes. In the two hierarchical regression models, it was found that relational aspects of care explained 16.0% of the variation in PCS and 19.6% of the variation in MCS, both of which equate to a moderate effect size (Cohen, 1988). When one considers the RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 95 multifactorial nature of health outcomes including the effects of disease, these numbers suggest a reasonable and worthwhile effect. Although no studies specifically examined relational aspects of care and their influence on health outcomes, the existing literature on PCC approaches and culture change models were used to inform the current research findings. This study’s results regarding mental health outcomes are consistent with those found in the literature. However, because the current findings demonstrating a significant association with physical health outcomes have not been supported in the literature, further research is necessary to consolidate the findings. Although PCC is broader than relational aspects of care, this research adds to the current body of literature regarding PCC and its impact on health outcomes. The provision of relational care may positively influence residents’ physical and mental health outcomes. The next and final chapter will review the study limitations and will make recommendations for nursing practice, education, and research to support relational care approaches within LTRC. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 96 Chapter Six – Conclusions and Recommendations The quality of relationships needs to be given as much attention as the quality of science and the quality of clinical competence (Bergrum, 2013, pp. 139-140). This research project, from development of the research question, to examination of the literature review, to outlining the methodology and conducting the analysis, now culminates in the synthesis of my findings. It is hoped this research can lead not just to an extension of knowledge, but to tangible recommendations for actions that can enhance residents’ overall health, quality of life, and can ‘add life to years’. This chapter will briefly summarize the research study and its conclusions, provide recommendations for practice, education, and research, and review the study limitations. Summary of Study This study began through a sincere belief that individual caregivers have the opportunity to make a difference for residents living in LTRC through the manner in which we provide care, particularly by ensuring a relational approach to residents that fosters their sense of personhood, respect, and dignity. I have observed care provision from the perspectives of nurse, manager, educator, and now family member of someone living in a LTRC home. When the opportunity to analyze the data from the BC Office of the Seniors Advocate’s 2016/17 Residential Care Sector Survey presented itself, I understood this was a unique opportunity to study what really matters from the perspective of those living in LTRC in BC. The OSA survey was wholly based on a resident’s point of view – they shared their perceptions of the experience of living in LTRC while also sharing their thoughts about their physical and mental health status. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 97 Over the last few decades in LTRC, there has been a widespread goal to shift away from a ‘disease - based medical model’ of care to a less institutionalized approach that reinforces each resident’s personhood. Although strides have been made in some facilities that adhere to a non-institutional, more home-like setting, many traditional care homes continue to seek methods to become more person-centred. I would argue that an effective strategy for enhancing person-centredness is to commit on a professional, organizational, and individual level to the practice of relational care. There has been a tremendous movement within LTRC to become more person-centred and to shift the environment to be more like a home, rather than an institution. However, we have not yet achieved true person-centredness in many LTC settings. We continue to be based on a primarily liberal political ideology that often views the healthcare provider as the expert who is responsible for making decisions aimed at achieving health outcomes (Zou, 2016). Committing to operationalizing person-centredness through relational practice is within all of our reach. PCC involves authenticity, genuineness, respect, dignity, empathy, and a desire to know residents and what matters to them (McCormack, 2004). Where this occurs is in the relationships that exist between resident and care provider. The goal of this research was to look closely at interactional experiences between residents and care providers, and to ascertain how much these interactions matter to residents and their health. This was accomplished by first identifying those areas of the OSA survey that involved relational aspects of care or those day to day experiences of care where care providers engage with residents. Bivariate analysis was used to examine associations between these relational aspects of care and resident reported physical and mental health. Hierarchical regression analysis was utilized to determine if relational RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 98 aspects of care explain a statistically significant amount of variation in mental and physical health outcomes after controlling for all other variables (demographics and nonrelational care experiences). The results of this study demonstrated that relational aspects of care do matter – they are significantly and positively associated with measures of both physical and mental health, as perceived by residents. Other care experiences that contributed significantly to measures of mental and physical health included personal control, food experiences, and length of time in the facility. Experiences around social life and relationships with others (non-staff) may be more important to physical health than mental health. The findings of this study suggest that providing relational care may positively influence a resident’s physical and mental health and subsequent quality of life. Recommendations for Practice Professional development activities for practicing nurses and other care providers should offer “ongoing conversations that explore highpoints in patient care. These conversations help professionals notice and focus on these experiences, amplify these experiences, and thus, strengthen their skills, capacities and frequencies of such moments” (Wasserman & McNamee, 2010, p. 311). Discussion of the specific attributes of relational care - authenticity, respect, empathy, connection, and being fully present (Koloroutis & Trout, 2012), and the importance these can have to residents is crucial. Ideally, managers and nursing leadership commit to a person-centred philosophy and work with their staff and residents to facilitate it. PCC has been receiving attention for several years, and yet, I believe individual care providers still find themselves uncertain RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 99 of how to transform their environments to a truly person-centred approach. Staff may need to discuss concrete ways to implement change; many may worry these approaches are too time consuming, so they defer to the normal routines of the unit. All too often in healthcare, limited resources impair our ability to effect change. Provision of relational care can be initiated without budget approvals or structural modifications – but it does require commitment and dedication from care providers at all levels. An area that deserves attention is that of context and how it influences the provision of relational care and the ability to provide a responsive, caring, and truly person centred approach. Doane and Varcoe (2013) discuss the dilemma nurses sometimes encounter when faced with conflicting obligations – both obligated to a resident and their organization, but in conflicting ways. A barrier that seems to exist within LTRC is that of health promotion sometimes being at odds with resident choice. Consider the following situations in which a health care provider might want to support a resident’s personal choice as part of person centred care, but the choice is at odds with the ‘medical’ goal of promoting healthy behaviours: (a) resident does not want to walk the hall…but she needs to walk the hall daily or she will lose the ability; (b) a resident wants to eat his meal in his room while watching television…but he needs to eat in the common dining room in case he chokes; (c) a resident wants to sleep in…but she needs to be up early because that is when additional staff are available to bathe and dress residents; and, (d) a resident asks for the brownie his family brought him…but he needs to stop eating refined sugars because his A1c is high. These very real issues care providers face when trying to facilitate personal choice for residents can cause distress for the caregiver. Staff require conversations around what to do in these situations. Staff RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 100 may feel moral distress because they know the resident has the right to selfdetermination…yet the paternalistic approach of physicians and nurses causes conflict in these situations and ultimately removes control from residents. By truly getting to know our residents, we can discern what matters to them, and find ways to facilitate their living as they choose. Much of the literature on relational care approaches (Doane & Varcoe, 2013; Wasserman & McNamee, 2010; Zou, 2016), speaks to dialogue with residents. Dialogue can always serve as a starting point for providing relational care. In addition, intentionality is necessary to promote relational care, and it requires: a conscious intent to act toward the espoused values and goals of nursing, attention to the particularities of people and situations, a critical consideration of one’s own and others’ interpretations, and very often a reconstruction of decisions, actions, and norms that may be at odds with the values and goals of nursing. (Doane & Varcoe, 2013) Relational practice returns us to the roots of nursing…sharing our humanity in a caring, authentic, engagement with another. Getting to know a resident is so important in this regard, as so often an astute care provider can watch for clues and learn what is important to a particular individual. The care provider can then dialogue with the resident to confirm their impressions. Resident and care provider can find possibilities for making the facility more like a home for the resident. Staff and residents alike need permission to bend the rigid structures of the organization in order to individualize care. Unless we build relationships with our residents and get to know what possibilities exist RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 101 for them to live their fullest life, we will continue to provide the same institutional approach of the past. Recommendations for Education The education of healthcare providers should emphasize the importance that staff responsiveness, caring staff, having personal control, and experiences around food hold for residents living in LTRC. By understanding that these areas hold the most importance for residents, care providers from all disciplines can find ways to facilitate person centredness by prioritizing these areas. Nursing has a long history of being task oriented. While instrumental aspects of care will always be present and necessary, nursing educators should emphasize relational aspects of care throughout the curriculum in classroom, laboratory, and clinical settings. As an educator, I am very aware of learners’ focus on ‘skills’, often to the detriment of softer skills that are so crucial to relational care. Educators can demonstrate the difference between mechanistic communication techniques or ‘skills’ and development of a true sense of engagement and dialogue with a resident – not from a place of authority or expertise, but from a place of humanity. How are educators to demonstrate this? Stories are an effective way to encourage new thinking and to allow learners to consider how they might react in a particular situation. Curriculum designers can develop scenarios of relational practice, similar to the emergent scenarios practiced in simulation labs, while placing emphasis on engaging authentically, listening, and encouraging a resident’s ideas as to how they might ‘live better’. These scenarios could then be discussed in classrooms and laboratory settings. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 102 Educators can teach learners how to foster continuous open-ended conversations with residents and how to use reflective practice to review interactions to foster a relational lens or sensitivity. Educators should explain there will be no prescriptive answers for each situation, but that practicing from a relational perspective requires a willingness and capacity to be “in relation” with another (Doane & Varcoe, 2013). We can explain that in order to effectively engage with another, we must be willing to not have all the answers, but nonetheless be willing to ‘be’ together, to share in the uncertainty (Doane & Varcoe, 2013). In curriculum development, educators should emphasize relational ethics when students are learning about bioethical principles, while explaining that both ethical approaches are necessary for high quality care. Zou (2016) recommends including critical social theory in nursing education and suggests that an emphasis on cultural diversity and the social determinants of health is important to the development of a relational sensitivity. Recommendations for Research Although there is a significant body of research on PCC approaches in LTRC, there is very little research identified that looks specifically at relational aspects of care. Ideally, nurse researchers and others can conduct more research that examines relational care approaches within LTRC, including their associations with health outcomes. As explained in the previous chapter, the findings of significant associations with physical health outcomes are not supported in the literature and require further study. In addition, further research is needed to examine potential interactions or mediation between the Caring Staff and Staff Responsiveness Scales within the interRAI SQoL-LTCF instrument; the current study results suggest a possible interaction exists. Furthermore, RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 103 replication of the current study using the available larger dataset is important to lend credence to the conclusions. Intervention studies on relational approaches could examine the extent that various approaches are meaningful and effective. The literature suggests social relationships are important to residents’ quality of life; studies that consider the importance of relationships with co-residents could assist further in defining how differing relationships may hold different meaning for residents. This study considered interactions and relationships with healthcare providers; a future study examining the relative importance of relationships with specific groups of healthcare providers (i.e., RNs, LPNs, care aides, etc.) could also be valuable. Additionally, studies of relationships with co-residents and family or friends could lend understanding regarding the benefits of non-staff relationships to residents’ QoL. Certainly, more qualitative inquiry with a particular focus on relational aspects of care within LTC facilities is important to truly understand residents’ lived experience. Interpretive description is recommended by Zou (2016) as particularly suited to research on relationships. Research comparing those with varying levels of cognition could assist in outlining particularly effective care strategies for different populations of residents. Another area suited to a qualitative approach would be to study nurses and other health care providers to ascertain perceptions of barriers to the implementation of relational care approaches. Limitations of this Research As a secondary analysis, this research was limited to the OSA survey data available. Because there was no ability to structure the questions to address the research RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 104 question, this was a limitation. The cross-sectional nature of the design naturally limits inferences about causality between variables. Worth mentioning is a potentially reciprocal relationship whereby physical or mental health may influence experiences of care or vice versa – it is important to emphasize that associations do not infer cause and effect. A future longitudinal design study could provide clues to the directionality of relationships among variables. In addition, a limitation of the interRAI SQoL-LTCF instrument itself is its lack of questions around spiritual meaning or importance for residents, which I believe would have added to the study. Also, the fact that participants were asked to report on their physical and mental health only over the past week could have introduced confounding factors such as acute illness or exacerbations of disease. The interRAI Self-Reported QoL Survey for LTC Facilities measures resident perceptions of residential care experiences, yet is referred to as a QoL survey. Readers might be tempted to misinterpret the scores as a direct measure of QoL. Another limitation exists as it relates to experiences of staff versus physician care; physicians are not present on a regular basis in LTRC. It is possible that residents’ answers may relate to physicians rather than other staff for some questions. For example, when considering a question such as ‘staff tries to relieve my physical discomfort’, some residents may answer by considering their physician rather than non-medical staff. Finally, the adapted VR-12 scores (MCS and PCS) were calculated based on standardized factor scores from a confirmatory factor analysis model corresponding with the measurement structure of the VR-12 (Wilson et al., 2017). Although this allows comparisons of self-reported health status within the sample, and is adequate for this analysis, it creates challenges in interpreting health status for this sample compared to other seniors’ populations. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 105 Additionally, it is important to recognize that the sample is not representative of those with higher cognitive impairment, compared to the population of residents living in LTRC across BC. According to CIHI (n.d.b), the percentage of LTRC residents across BC with severe to very severe cognitive impairment (CPS ≥4) was 31.0% in 2017-2018. The study sample had only 8.2% of respondents with severe to very severe cognitive impairment. Even though the OSA survey did not exclude those with severe cognitive impairment, data collection was done via patient interview and it is possible that selfselection and the requirement for informed consent precluded those with higher cognitive impairment. Conclusion Every individual’s life matters. To be given a voice…to be asked for one’s opinion about one’s day to day lived experience in long term residential care empowers the individual and by extension the population of residents in a care home. With the ambitious undertaking by the OSA to seek out residents’ viewpoints across an entire province, we as clinicians, policy makers, care providers, researchers, and family members must now listen. We are entrusted with a rich source of information and have an opportunity to utilize it in the best way possible to improve the quality of LTRC residents’ lives. We can work toward a system of residential care that, as BC’s Seniors Advocate states, “we can be very proud of” (OSA, 2017, p. 44). By examining the opinions of residents living in residential care homes in BC, this study has shown that relational aspects of care can make a difference to the health and wellbeing of residents. We are now challenged to use this knowledge to inform residential care practices, directions for education and research, and quality improvements for years to come. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 106 References Anderberg, P., & Berglund, A. L. (2010). Elderly persons’ experiences of striving to receive care on their own terms in nursing homes. International Journal of Nursing Practice, 16(1), 64–68. doi:10.1111/j.1440-172X.2009.01808.x Andrew, N., & Meeks, S. (2018). 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RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 118 Appendix A Search Terms for Literature Review: Patient Satisfaction “patient satisfaction” OR “person satisfaction” OR “resident satisfaction” OR “client satisfaction” OR "PROM" OR "PREM" OR “patient-reported outcome*” OR "person-reported outcome*" OR “resident-reported outcome*” OR “client-reported outcome*” OR "patient-reported experience*" OR "person-reported experience*" OR "resident-reported experience*" OR "client-reported experience*" OR “patient* perception*” OR “resident* perception*” OR “client* perception*” OR “person perception*” OR “patient perceive* physical health” OR “resident perceive* physical health” OR “person perceive* physical health” OR “client perceive* physical health” OR “patient perceive* mental health” OR “resident perceive* mental health” OR “person perceive* mental health” OR “client perceive* mental health” patient* n3 satisf* OR person* n3 satisf* OR resident* n3 satisf* OR client* n3 satisf* OR “resident* perce*” OR "patient* perce*" OR "person* perce*" OR "PROM" OR "PREM" OR “patient-reported outcome*” OR "person-reported outcome*" OR “resident-reported outcome*” OR “client-reported outcome*” OR "patient-reported experience*" OR "person-reported experience*" OR "resident-reported experience*" OR "client-reported experience*" Person Centred Care "person centered" OR "person centred" OR “patient centered” OR “patient centred” OR “resident centered” OR “resident centred” AND Type of Care Facility ltc OR “long term care” OR “resident* care” OR “care home*” OR “nursing home*” OR (MH “Nursing Homes+”) OR (MH “Residential Care+”) AND Population elder* OR "older adult*" OR geriatric* OR gerontolo* OR senior* OR MH "Aged+" OR MH "Geriatrics" RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES Appendix B Literature Search Flowchart 119 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 120 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES Appendix C Certificates of Approval for Research 121 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 122 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 123 Appendix D Hierarchical Multivariate Regression Model Summaries: PCS and MCS Table D1 Hierarchical Multivariate Regression Model Summary - Physical Component Score (PCS) Imputation Number Imputation 1 Block R R² Adjusted R² SE R²Δ FΔ Sig FΔ 1 2 3 4 5 0.113 0.279 0.415 0.506 0.539 0.013 0.078 0.172 0.256 0.291 0.010 0.075 0.159 0.243 0.274 0.882679 0.853341 0.813340 0.771555 0.755888 0.013 0.065 0.094 0.084 0.035 4.501 74.475 9.814 77.947 7.199 0.000 0.000 0.000 0.000 0.000 1 2 3 4 5 0.131 0.308 0.424 0.509 0.541 0.017 0.095 0.180 0.259 0.292 0.014 0.091 0.167 0.246 0.275 0.884034 0.848750 0.812593 0.772923 0.757940 0.017 0.078 0.085 0.079 0.033 6.085 90.158 8.956 73.822 6.909 0.000 0.000 0.000 0.000 0.000 1 2 3 4 5 0.125 0.305 0.421 0.496 0.524 0.016 0.093 0.177 0.246 0.274 0.013 0.090 0.164 0.233 0.257 0.882073 0.847066 0.811556 0.777392 0.765158 0.016 0.077 0.084 0.069 0.028 5.577 89.624 8.821 63.130 5.770 0.000 0.000 0.000 0.000 0.000 1 2 3 4 5 0.126 0.287 0.413 0.509 0.539 0.016 0.083 0.171 0.259 0.290 0.013 0.079 0.158 0.247 0.273 0.898561 0.867998 0.830109 0.785041 0.770977 0.016 0.067 0.088 0.089 0.031 5.679 76.280 9.166 82.694 6.449 0.000 0.000 0.000 0.000 0.000 1 2 3 4 5 0.119 0.290 0.409 0.502 0.525 0.014 0.084 0.167 0.252 0.276 0.011 0.081 0.155 0.239 0.259 0.882857 0.851298 0.816395 0.774634 0.764423 0.014 0.070 0.083 0.084 0.025 5.032 80.333 8.638 77.587 4.980 0.000 0.000 0.000 0.000 0.000 Imputation 2 Imputation 3 Imputation 4 Imputation 5 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 124 Table D1 (continued) Hierarchical Multivariate Regression Model Summary - PCS Imputation Number Imputation 6 Block R R² Adjusted R² SE R²Δ FΔ Sig FΔ 1 2 3 4 5 0.107 0.278 0.427 0.509 0.535 0.011 0.077 0.182 0.260 0.286 0.009 0.074 0.169 0.247 0.269 0.884647 0.854972 0.809725 0.770937 0.759525 0.011 0.066 0.105 0.078 0.027 4.024 75.190 11.047 72.349 5.481 0.001 0.000 0.000 0.000 0.000 1 2 3 4 5 0.125 0.276 0.394 0.482 0.510 0.016 0.076 0.155 0.232 0.261 0.013 0.073 0.142 0.219 0.243 0.882032 0.854842 0.822301 0.784503 0.772454 0.016 0.061 0.079 0.077 0.028 5.601 68.890 8.059 69.256 5.653 0.000 0.000 0.000 0.000 0.000 1 2 3 4 5 0.109 0.284 0.413 0.505 0.527 0.012 0.081 0.171 0.255 0.278 0.009 0.077 0.158 0.242 0.261 0.887732 0.856627 0.818232 0.776285 0.766857 0.012 0.069 0.090 0.084 0.023 4.228 78.673 9.400 77.768 4.662 0.000 0.000 0.000 0.000 0.000 1 2 3 4 5 0.123 0.271 0.401 0.493 0.517 0.015 0.074 0.161 0.243 0.267 0.012 0.070 0.148 0.230 0.250 0.892243 0.865713 0.828849 0.787787 0.777446 0.015 0.059 0.087 0.082 0.025 5.349 66.372 8.953 74.982 4.963 0.000 0.000 0.000 0.000 0.000 1 2 3 4 5 0.127 0.298 0.408 0.494 0.514 0.016 0.089 0.166 0.244 0.264 0.013 0.085 0.154 0.232 0.246 0.883311 0.850454 0.818059 0.779480 0.771919 0.016 0.073 0.078 0.078 0.020 5.705 83.739 8.064 71.159 3.913 0.000 0.000 0.000 0.000 0.000 1 2 3 4 5 0.110 0.287 0.435 0.510 0.535 0.012 0.082 0.189 0.260 0.286 0.009 0.079 0.176 0.248 0.269 0.887356 0.855772 0.809133 0.773212 0.762292 0.012 0.070 0.107 0.071 0.026 4.308 79.973 11.373 66.759 5.271 0.000 0.000 0.000 0.000 0.000 Imputation 7 Imputation 8 Imputation 9 Imputation 10 Imputation 11 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 125 Table D1 (continued) Hierarchical Multivariate Regression Model Summary - PCS Imputation Number Imputation 12 Block R R² Adjusted R² SE R²Δ FΔ Sig FΔ 1 2 3 4 5 0.133 0.288 0.418 0.500 0.524 0.018 0.083 0.175 0.250 0.274 0.015 0.080 0.162 0.237 0.257 0.877883 0.848512 0.809489 0.772499 0.762367 0.018 0.066 0.092 0.075 0.024 6.275 74.985 9.635 68.825 4.960 0.000 0.000 0.000 0.000 0.000 1 2 3 4 5 0.112 0.277 0.445 0.525 0.549 0.012 0.077 0.198 0.275 0.301 0.010 0.073 0.186 0.263 0.285 0.900718 0.871423 0.816726 0.777000 0.765509 0.012 0.064 0.122 0.077 0.026 4.418 72.817 13.107 73.533 5.477 0.000 0.000 0.000 0.000 0.000 1 2 3 4 5 0.110 0.283 0.442 0.522 0.545 0.012 0.080 0.195 0.272 0.297 0.009 0.076 0.183 0.260 0.280 0.889695 0.858967 0.808012 0.768777 0.758427 0.012 0.068 0.115 0.077 0.024 4.255 77.504 12.378 73.400 5.067 0.000 0.000 0.000 0.000 0.000 1 2 3 4 5 0.122 0.271 0.404 0.493 0.525 0.015 0.074 0.163 0.243 0.276 0.012 0.070 0.151 0.231 0.258 0.884329 0.857993 0.820018 0.780381 0.766223 0.015 0.059 0.090 0.080 0.032 5.295 66.481 9.288 73.045 6.520 0.000 0.000 0.000 0.000 0.000 1 2 3 4 5 0.115 0.281 0.392 0.479 0.499 0.013 0.079 0.154 0.229 0.249 0.010 0.075 0.141 0.216 0.231 0.903155 0.873045 0.841540 0.803767 0.796255 0.013 0.066 0.075 0.075 0.019 4.713 74.708 7.671 67.538 3.806 0.000 0.000 0.000 0.000 0.000 1 2 3 4 5 0.123 0.261 0.436 0.506 0.527 0.015 0.068 0.190 0.256 0.277 0.012 0.065 0.177 0.244 0.260 0.885168 0.861269 0.807879 0.774623 0.766008 0.015 0.053 0.121 0.066 0.021 5.336 60.109 12.941 61.665 4.347 0.000 0.000 0.000 0.000 0.000 Imputation 13 Imputation 14 Imputation 15 Imputation 16 Imputation 17 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 126 Table D1 (continued) Hierarchical Multivariate Regression Model Summary - PCS Imputation Number Imputation 18 Imputation 19 Block R R² Adjusted R² SE R²Δ FΔ Sig FΔ 1 2 3 4 5 0.116 0.296 0.401 0.498 0.523 0.014 0.088 0.161 0.248 0.274 0.011 0.084 0.148 0.235 0.256 0.895656 0.861700 0.831228 0.787546 0.776462 0.014 0.074 0.073 0.087 0.026 4.795 85.425 7.530 79.856 5.255 0.000 0.000 0.000 0.000 0.000 1 2 3 4 5 0.138 0.285 0.418 0.504 0.533 0.019 0.081 0.174 0.254 0.284 0.016 0.078 0.162 0.241 0.267 0.893149 0.864730 0.824583 0.784436 0.771149 0.019 0.062 0.093 0.080 0.030 6.839 71.183 9.724 73.610 6.144 0.000 0.000 0.000 0.000 0.000 1 2 3 4 5 0.112 0.253 0.418 0.500 0.530 0.013 0.064 0.175 0.250 0.281 0.010 0.061 0.162 0.238 0.264 0.891980 0.868785 0.820565 0.782691 0.768890 0.013 0.052 0.111 0.076 0.031 4.478 57.843 11.581 69.559 6.361 0.000 0.000 0.000 0.000 0.000 Imputation 20 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 127 Table D2 Hierarchical Multivariate Regression Model Summary – Mental Component Score (MCS) Imputation Number Imputation 1 Block R R² Adjusted R² SE R²Δ FΔ Sig FΔ 1 2 3 4 5 6 .117 .378 .474 .523 .539 .541 0.014 0.143 0.225 0.273 0.291 0.293 0.011 0.140 0.211 0.260 0.276 0.277 0.994595 0.927550 0.888096 0.860376 0.851139 0.850249 0.014 0.129 0.082 0.049 0.018 0.002 4.827 158.352 7.809 46.200 8.521 5.318 0.000 0.000 0.000 0.000 0.000 0.021 1 2 3 4 5 6 .131 .386 .475 .519 .533 .536 0.017 0.149 0.226 0.269 0.284 0.287 0.014 0.146 0.212 0.255 0.268 0.271 0.992838 0.924150 0.887473 0.862895 0.855316 0.853664 0.017 0.132 0.077 0.043 0.015 0.003 6.085 162.961 7.324 40.887 7.135 8.987 0.000 0.000 0.000 0.000 0.000 0.003 1 2 3 4 5 6 .132 .385 .455 .505 .513 .518 0.017 0.148 0.207 0.255 0.263 0.269 0.015 0.145 0.194 0.241 0.247 0.252 0.992640 0.924614 0.897983 0.870947 0.867834 0.864720 0.017 0.131 0.059 0.048 0.007 0.006 6.227 161.263 5.512 44.523 3.477 15.881 0.000 0.000 0.000 0.000 0.002 0.000 1 2 3 4 5 6 .124 .367 .453 .500 .512 .514 0.015 0.135 0.205 0.250 0.262 0.264 0.012 0.131 0.191 0.236 0.246 0.248 0.993758 0.931962 0.899302 0.874274 0.868118 0.867166 0.015 0.119 0.070 0.045 0.013 0.002 5.426 144.930 6.544 41.089 5.905 5.534 0.000 0.000 0.000 0.000 0.000 0.019 1 2 3 4 5 6 .130 .379 .468 .520 .535 .537 0.017 0.144 0.219 0.270 0.286 0.289 0.014 0.140 0.205 0.256 0.271 0.273 0.992928 0.927230 0.891454 0.862269 0.854049 0.852804 0.017 0.127 0.075 0.051 0.016 0.002 6.020 155.138 7.138 48.522 7.666 7.027 0.000 0.000 0.000 0.000 0.000 0.008 Imputation 2 Imputation 3 Imputation 4 Imputation 5 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 128 Table D2 (continued) Hierarchical Multivariate Regression Model Summary - MCS Imputation Number Imputation 6 Block R R² Adjusted R² SE R²Δ FΔ Sig FΔ 1 2 3 4 5 6 .118 .357 .459 .511 .524 .527 0.014 0.127 0.211 0.261 0.275 0.278 0.011 0.124 0.197 0.247 0.259 0.262 0.994383 0.935868 0.895938 0.867756 0.860770 0.859158 0.014 0.113 0.084 0.050 0.014 0.003 4.978 136.472 7.831 46.569 6.617 8.747 0.000 0.000 0.000 0.000 0.000 0.003 1 2 3 4 5 6 .124 .342 .435 .487 .503 .508 0.015 0.117 0.189 0.237 0.253 0.258 0.012 0.114 0.175 0.222 0.236 0.241 0.993755 0.941480 0.908411 0.881767 0.873826 0.870993 0.015 0.102 0.072 0.048 0.016 0.005 5.428 120.896 6.557 43.350 7.293 14.435 0.000 0.000 0.000 0.000 0.000 0.000 1 2 3 4 5 6 .113 .331 .463 .511 .524 .526 0.013 0.110 0.215 0.261 0.274 0.277 0.010 0.106 0.201 0.247 0.258 0.260 0.995050 0.945278 0.893945 0.867520 0.861179 0.859963 0.013 0.097 0.105 0.047 0.013 0.002 4.502 114.536 9.857 43.695 6.094 6.837 0.000 0.000 0.000 0.000 0.000 0.009 1 2 3 4 5 6 .125 .351 .452 .506 .518 .519 0.016 0.123 0.205 0.256 0.269 0.270 0.013 0.120 0.191 0.242 0.253 0.253 0.993635 0.938279 0.899501 0.870644 0.864496 0.864032 0.016 0.107 0.082 0.051 0.013 0.001 5.514 128.609 7.603 47.519 5.920 3.214 0.000 0.000 0.000 0.000 0.000 0.073 1 2 3 4 5 6 .125 .385 .474 .526 .537 .541 0.016 0.148 0.224 0.277 0.288 0.293 0.013 0.145 0.211 0.263 0.273 0.277 0.993522 0.924660 0.888340 0.858320 0.852728 0.850138 0.016 0.133 0.076 0.053 0.011 0.005 5.594 163.294 7.255 50.134 5.535 13.583 0.000 0.000 0.000 0.000 0.000 0.000 1 2 3 4 5 6 .118 .356 .454 .499 .517 .519 0.014 0.127 0.206 0.249 0.267 0.269 0.011 0.123 0.192 0.235 0.251 0.253 0.994411 0.936275 0.898709 0.874731 0.865268 0.864391 0.014 0.113 0.079 0.043 0.018 0.002 4.959 135.507 7.398 39.365 8.580 5.188 0.000 0.000 0.000 0.000 0.000 0.023 Imputation 7 Imputation 8 Imputation 9 Imputation 10 Imputation 11 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 129 Table D2 (continued) Hierarchical Multivariate Regression Model Summary - MCS Imputation Number Imputation 12 Block R R² Adjusted R² SE R²Δ FΔ Sig FΔ 1 2 3 4 5 6 .121 .363 .459 .501 .519 .522 0.015 0.132 0.211 0.251 0.269 0.272 0.012 0.128 0.197 0.237 0.253 0.256 0.994071 0.933632 0.896030 0.873562 0.864037 0.862532 0.015 0.117 0.079 0.040 0.018 0.003 5.201 141.413 7.424 36.967 8.642 8.200 0.000 0.000 0.000 0.000 0.000 0.004 1 2 3 4 5 6 .121 .357 .470 .516 .526 .531 0.015 0.127 0.221 0.266 0.277 0.282 0.012 0.124 0.208 0.252 0.261 0.266 0.994008 0.935868 0.890216 0.864651 0.859700 0.856546 0.015 0.113 0.094 0.045 0.010 0.006 5.246 135.577 8.886 42.425 4.982 16.214 0.000 0.000 0.000 0.000 0.000 0.000 1 2 3 4 5 6 .126 .368 .465 .515 .530 .532 0.016 0.135 0.217 0.266 0.281 0.283 0.013 0.132 0.203 0.252 0.265 0.267 0.993442 0.931646 0.892783 0.865052 0.857347 0.856009 0.016 0.119 0.081 0.049 0.015 0.003 5.651 144.981 7.668 45.970 7.223 7.451 0.000 0.000 0.000 0.000 0.000 0.006 1 2 3 4 5 6 .129 .342 .445 .494 .505 .507 0.017 0.117 0.198 0.244 0.255 0.257 0.014 0.113 0.184 0.229 0.239 0.241 0.993046 0.941596 0.903067 0.877875 0.872586 0.871285 0.017 0.100 0.082 0.045 0.011 0.003 5.936 118.936 7.533 41.188 5.191 7.165 0.000 0.000 0.000 0.000 0.000 0.007 1 2 3 4 5 6 .120 .370 .451 .495 .504 .509 0.014 0.137 0.203 0.245 0.254 0.259 0.012 0.134 0.189 0.230 0.238 0.243 0.994212 0.930815 0.900422 0.877301 0.873073 0.870341 0.014 0.123 0.066 0.041 0.009 0.005 5.101 148.971 6.146 37.868 4.346 13.963 0.000 0.000 0.000 0.000 0.000 0.000 1 2 3 4 5 6 .126 .338 .463 .501 .513 .517 0.016 0.114 0.214 0.251 0.263 0.267 0.013 0.111 0.200 0.237 0.247 0.250 0.993442 0.943054 0.894224 0.873303 0.867650 0.865772 0.016 0.098 0.100 0.037 0.012 0.004 5.652 116.257 9.410 34.473 5.506 9.956 0.000 0.000 0.000 0.000 0.000 0.002 Imputation 13 Imputation 14 Imputation 15 Imputation 16 Imputation 17 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 130 Table D2 (continued) Hierarchical Multivariate Regression Model Summary - MCS Imputation Number Imputation 18 Imputation 19 Block R R² Adjusted R² SE R²Δ FΔ Sig FΔ 1 2 3 4 5 6 .107 .384 .463 .512 .524 .527 0.011 0.148 0.215 0.263 0.275 0.278 0.009 0.144 0.201 0.249 0.259 0.262 0.995678 0.925017 0.893801 0.866766 0.860765 0.859326 0.011 0.136 0.067 0.048 0.012 0.003 4.056 167.622 6.328 44.736 5.822 7.914 0.000 0.000 0.000 0.000 0.000 0.005 1 2 3 4 5 6 .129 .341 .447 .495 .512 .515 0.017 0.116 0.200 0.245 0.262 0.265 0.014 0.113 0.186 0.230 0.246 0.249 0.993080 0.941843 0.902411 0.877224 0.868492 0.866593 0.017 0.100 0.083 0.045 0.017 0.004 5.911 118.405 7.694 41.212 7.965 10.050 0.000 0.000 0.000 0.000 0.000 0.002 1 2 3 4 5 6 .110 .343 .452 .497 .511 .513 0.012 0.117 0.204 0.247 0.261 0.263 0.009 0.114 0.191 0.233 0.245 0.247 0.995390 0.941294 0.899637 0.875756 0.868924 0.867989 0.012 0.105 0.087 0.043 0.014 0.002 4.260 125.215 8.103 39.163 6.442 5.441 0.000 0.000 0.000 0.000 0.000 0.020 Imputation 20 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES Appendix E PCS and MCS Standardized Residuals: Histograms and P-P Plots Figure E1. Histograms of standardized residuals – dependent variable PCS. 131 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES Figure E1 (continued). Histograms of standardized residuals – dependent variable PCS. 132 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES Figure E1 (continued). Histograms of standardized residuals – dependent variable PCS. 133 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES Figure E2. P-P plots of standardized residuals – dependent variable PCS. 134 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 135 Figure E2 (continued). P-P plots of standardized residuals – dependent variable PCS. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 136 Figure E2 (continued). P-P plots of standardized residuals – dependent variable PCS. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 137 Figure E2 (continued). P-P plots of standardized residuals – dependent variable PCS. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES Figure E3. Histograms of standardized residuals – dependent variable MCS. 138 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 139 Figure E3 (continued). Histograms of standardized residuals – dependent variable MCS. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES Figure E4. P-P plots of standardized residuals – dependent variable MCS. 140 RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 141 Figure E4 (continued). P-P plots of standardized residuals – dependent variable MCS. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 142 Figure E4 (continued). P-P plots of standardized residuals – dependent variable MCS. RELATIONAL ASPECTS OF CARE AND HEALTH OUTCOMES 143 Figure E4 (continued). P-P plots of standardized residuals – dependent variable MCS.