Author: Morgan Pankhurst
Pankhurst, Morgan, 2022 Measuring consumer food service satisfaction in residential aged care homes, Flinders University, College of Nursing and Health Sciences
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Residential Aged Care Homes (RACHs), commonly known as nursing homes, are group living environments where older adults who can no longer live independently in the community can receive full-time care and support. In Australia there are over 2,700 RACHs housing more than 245,000 residents who are entirely dependent upon the food service for their daily nutrition and hydration requirements. The prevalence of malnutrition in RACHs is alarmingly high, with studies suggesting approximately 50% of residents are malnourished. Despite extensive research into strategies to prevent or reduce malnutrition, the prevalence has remained persistently high for decades.
Although many factors contribute to diminished appetite and reduced food consumption among older adults, the risk of malnutrition increases significantly when residents are dissatisfied with the meals and dining. Research suggests that when residents are dissatisfied with the food and food services, this can lead to unintentional weight loss, diminished nutritional status, and poor quality of life. This thesis explores how food service satisfaction can be measured in RACHs and presents a questionnaire that can be used by food services and dietary managers to measure resident food service satisfaction.
The methodology of scale design is described in Chapter Two, this was positioned at the beginning to familiarise the reader with the terminology and concepts used to describe and discuss psychometric testing. The construct of food service satisfaction is explored in more depth to include the unique conditions of institutionalised care. Additionally, item generation and appropriate response scales are discussed, and the steps required to establish content and face validity are explained. Lastly, the chapter also describes the statistical tests required to establish construct validity and measures of reliability.
The literature review and critical appraisal in Chapter Three present a summary of the ways RACHs measure food service satisfaction among organisational (staff) stakeholders and consumers (residents and family members). In short, there are a small number of existing Food Service Satisfaction Questionnaires (FSSQs) available. However, some are more than a decade old, and others exhibit flaws in the psychometric testing processes, meaning they may not be valid or reliable. Additionally, no questionnaires were identified to measure family member satisfaction with the food services. Thus, the gap that this thesis addresses is the design and development of FSSQs for consumers.
The development of any new scale hinges on the assumption that it will be useful to the intended population. Consequently, Chapter Four discusses the results of a unique Aged Care Home Food Service Satisfaction Questionnaire that was completed by RACH food service managers (n=20). This study was undertaken to explore how RACHs gather satisfaction data from residents and how they share that information with other stakeholders. The findings suggest that RACHs routinely gather resident satisfaction data and use the intelligence for quality improvement and accreditation purposes. Unfortunately, most questionnaires used were created in-house or at a corporate level and therefore may not be valid or reliable. This demonstrated the need for quality questionnaires to be developed to measure food service satisfaction.
The design and development of the resident FSSQ is described in Chapter Five. The process of item generation is described, including data derived from qualitative interviews conducted with residents (n=13) together with a synthesis of qualitative and quantitative research identified during the literature review. The resulting 35-item FSSQ was reviewed by an expert panel and underwent preliminary testing to establish content and face value before being administered to residents.
The administration and psychometric testing of the resident FSSQ is described in Chapters Six and Seven. The newly developed FSSQ was interviewer administered to residents (n=387) living in RACHs (n=20) across South Australia. Chapter Six examines the participant responses and compares those to the examples of actions and evidence contained within the Aged Care Quality Standards. The comparison suggests RACHs perform consistently well in areas of staff assistance and politeness; however, they are inconsistent in providing residents with choice and variety. Most RACHs were not providing flexible mealtimes or enabling resident participation in the food service.
Chapter Seven reports the results of psychometric testing of the FSSQ. Principal Components Analysis identified a 25-item questionnaire that met or exceeded tests for validity (structural validity, convergence validity) and reliability (internal consistency, temporal stability, intra-rater reliability). The result is a FSSQ that is simple to use and interpret, providing RACHs with an accurate and reliable measure that can be used for benchmarking, quality improvement, and accreditation.
The exploration of consumer perspectives continues in Chapter Eight with the design of a FSSQ intended for family members or proxies. Although residents are the primary consumers of the food service system, there are multiple reasons why residents may not be able to provide feedback directly to the home, thereby situating family members as proxies. The literature review demonstrated there were no questionnaires available to measure family member food service satisfaction highlighting another key gap this thesis addresses. Item generation is described using data obtained from interviews conducted with family members (n=10) and qualitative peer-reviewed literature exploring family members’ experiences with the food services in RACHs. The result was a 35-item FSSQ that is ready to present to an expert panel for consideration.
The key findings, strengths and limitations, implications for practice, and areas for future research are summarised in Chapter Nine. In brief, this thesis presents a newly developed 25-item FSSQ that is a valid and reliable tool for measuring resident satisfaction with the food and food service in RACHs. The FSSQ is quick to administer, simple to use, and can provide food services managers in RACHs with accurate and effective measures of resident satisfaction with the meals and dining. This thesis also presents a newly developed 35-item FSSQ intended to measure family member satisfaction with the food services.
The Aged Care Quality Standards require RACHs to implement accessible and confidential methods of gathering stakeholder feedback as part of their accreditation process and to inform quality improvement activities. The two questionnaires are original contributions to knowledge and fill important gaps in the field of consumer satisfaction with the food services in RACHs.
Future directions for the resident questionnaire include working collaboratively with aged care partners to translate the resident questionnaire into a digital platform. This will allow the questionnaire to be freely distributed into RACHs across Australia as a benchmarking platform and quality performance index. Future directions for the family questionnaire include establishing content and face validity before pilot testing among family members who have a loved one living in a RACH and using the data to conduct psychometric testing.
Keywords: residential aged care, nursing home, older adults, food service satisfaction, psychometric, questionnaire
Subject: Nutrition and Dietetics thesis
Thesis type: Doctor of Philosophy
Completed: 2022
School: College of Nursing and Health Sciences
Supervisor: Professor Michelle Miller