Purpose
This study explored tools to measure service experiences for families of older adults living in long-term care facilities, with the goal of suggesting directions for developing service experience measurement indicators for these families in the Korean context.
Methods
In this scoping review, English-language literature on the service experiences of families of older adults in long-term care facilities published in academic journals from January 1990 to December 2021 was reviewed. The CINAHL, Embase, and PubMed databases were searched. The review process involved identifying the research question; searching for relevant published studies; selecting studies; mapping the data; and collating, summarizing, and reporting the results. This method helped identify knowledge gaps, explore, and define key concepts, and obtain an overview of extant studies’ focus by determining the literature scope. Among 118 articles, seven were finally selected according to predetermined criteria.
Results
Through an analysis of the sub-factors of the tools used in the seven selected articles, the following themes were derived: environment, information and family member involvement, tailored care, respect, and responsive workforce. Concept definitions were clarified and examined.
Conclusion
Measuring the service experiences of families serving as surrogates for older adults who are in long-term care facilities and cannot express their opinions is essential for improving service quality. Developing a measurement tool for experiences of facility service experience that accurately reflects the perspectives of family members of older adults in these facilities in the Korean context is a pressing need given South Korea’s rapidly aging population.
,1
and Jui Kim2
This study explored tools to measure service experiences for families of older adults living in long-term care facilities, with the goal of suggesting directions for developing service experience measurement indicators for these families in the Korean context.
In this scoping review, English-language literature on the service experiences of families of older adults in long-term care facilities published in academic journals from January 1990 to December 2021 was reviewed. The CINAHL, Embase, and PubMed databases were searched. The review process involved identifying the research question; searching for relevant published studies; selecting studies; mapping the data; and collating, summarizing, and reporting the results. This method helped identify knowledge gaps, explore, and define key concepts, and obtain an overview of extant studies’ focus by determining the literature scope. Among 118 articles, seven were finally selected according to predetermined criteria.
Through an analysis of the sub-factors of the tools used in the seven selected articles, the following themes were derived: environment, information and family member involvement, tailored care, respect, and responsive workforce. Concept definitions were clarified and examined.
Measuring the service experiences of families serving as surrogates for older adults who are in long-term care facilities and cannot express their opinions is essential for improving service quality. Developing a measurement tool for experiences of facility service experience that accurately reflects the perspectives of family members of older adults in these facilities in the Korean context is a pressing need given South Korea’s rapidly aging population.
According to the 2022 Korean Statistical Office report, adults aged 65 and over in the Republic of Korea (South Korea) comprised 17.5% of the total population, a figure expected to rise to 46.4% (approximately half the total population) by 2070 [1]. With the rapid aging of the population, there has been an increase in chronic diseases such as stroke, cardiovascular disease, and dementia. Simultaneously, the number of families available to support the growing older adult population is declining [2]. In response, South Korea introduced a long-term care insurance system for older adults in July 2008. Fifteen years post-implementation, this social care system has seen some success. However, its core objectives, including “promoting the health and quality of life of older adults” and reducing the burden on their families, have not been fully met, indicating that there is still room for improvement [3]. In particular, families utilizing long-term care facility services frequently express concerns about the loss of autonomy and privacy for their older family members, as well as disruptions to their social relationships due to the impersonal and standardized approaches of these facilities [4, 5].
To address these issues in long-term care facilities, Western countries, which introduced long-term care systems much earlier than South Korea, have developed the concepts of person-centered care and patient experience to enhance the quality of life for residents. These countries require that patient experience surveys be conducted regularly [6, 7]. In this paper, the term “long-term care” specifically refers to nursing homes. This distinction is made because, although patient experience surveys are common in hospitals focused on treatment, similar research in long-term care settings, which focus on nursing, is lacking. Therefore, we propose that a patient experience survey encompassing both care and quality of life within long-term care systems is needed.
Person-centered care emerged as an alternative to the traditional disease-centered model in the 1980s, in response to recognized quality issues in long-term care facilities in the United States. It involves the perception and practice of delivering care that aligns with the individual’s preferences and needs, while respecting their self-esteem, independence, and autonomy [6, 8]. Patient experience encompasses both the objective reporting of events during the care process and the subjective evaluations provided by the patient [9]. Wolf et al. [10] highlighted the importance of patient-centeredness by defining patient experience as an activity that identifies the patient’s needs, delivers the desired services, actively fosters trusting relationships, and inspires.
In self-reported surveys on the service experiences of older adult residents in long-term care facilities, the residents' perspectives are considered the most accurate measure [11]. However, many of these residents have varying degrees of cognitive impairment, and in cases of severe cognitive decline, it becomes challenging or impossible for them to accurately convey their views on the quality of care they receive. Therefore, it is crucial to include the perceptions of their families or care providers to fully assess their service experiences [12]. A previous survey that explored the experiences of families of older adults in long-term care facilities—including their views on staff performance and the autonomy of residents—revealed a statistically significant negative correlation with key quantitative indicators of long-term care quality, such as the incidence of pressure ulcers, hospitalization rates, and mortality rates. This suggests that evaluations of experience by family members play a vital role in assessing the quality of long-term care facilities [8]. Additionally, a study conducted outside of Korea examined patient experience surveys focusing on non-quantitative aspects of long-term care facilities, such as attention to recipients, personal hygiene, regular medical services, the physical environment, cleanliness, social relationships, food quality, communication with family, and physical therapy. The findings showed a moderate correlation with the 5-star quality index, a prominent quantitative quality index in the United States that includes data on falls, pressure ulcers, urinary tract infections, improvements in daily living abilities, and emergency room visits. When older adults themselves were surveyed on the same items, the results demonstrated a significant negative correlation, confirming that patient experience surveys of older residents and their families are valuable tools for complementing quantitative quality indicators and assessing the quality of long-term care facilities [13].
Recent studies on the service experiences of long-term care facility residents have primarily been qualitative in nature. Examples include a study examining the relationship between caregiver image and trust and the burden of care, another exploring key factors that enhance residents' quality of life, and research focusing on the families of older adult residents. However, empirical studies addressing the service experiences of these families are limited [14, 15, 16]. Given South Korea's rapidly aging population, there is an urgent need to develop a measurement tool for service experiences. This tool should accurately reflect the perspectives of family members of older adults in long-term care facilities and serve as a benchmark for improving service performance and quality within the Korean context.
In this study, we utilized a scoping review method to analyze and summarize published English-language studies concerning tools developed for measuring the service experience of family members of older adults in long-term care facilities outside of South Korea. This approach was chosen because no such tool has been specifically developed for use in South Korea. A scoping review is typically conducted prior to a systematic literature review as it encompasses a broad spectrum of related literature and provides an overview without conducting an extensive quantitative synthesis or evaluating the quality of the research. Using the findings from this review, we identified the components necessary for a service experience measurement tool tailored for families of older adults in long-term care facilities within the Korean context. Additionally, we conducted a systematic review of research papers on the development and psychological assessment of tools to measure service experiences for this demographic, focusing on studies published in non-Korean journals from the 1990s to the present. As a result, we identified various sub-factors (domains) essential for developing a tool to measure service experiences for families of older adults in long-term care facilities in South Korea.
This study used a scoping review methodology to explore the service experiences of families with older adults in long-term care facilities. The goal was to guide the development of a tool for assessing these service experiences within the Korean context. Our scoping review followed the guidelines previously established by the Joanna Briggs Institute (JBI) [17], which are grounded in the research methodologies of Arksey and O’Malley [18]. The scoping review process involved five main steps: identifying the research question (step 1), locating relevant studies (step 2), selecting appropriate studies (step 3), charting the data (step 4), and synthesizing and reporting the findings (step 5). Steps 1~4 are described in the Methods section, and step 5 is described in the Results section.
Scoping reviews are guided by research questions that define the scope of the analysis; therefore, these questions must be specific and clear [19]. The research questions were formulated in accordance with the JBI scoping review guidelines, which encompass population, context, and concept [20]. The defined population was “families of older adults who use long-term care facilities,” the context was “long-term care facilities,” and the concept was “service experiences.” The research questions posed were: “What tools have been used to measure the service experiences of families of older adults in long-term care facilities?” and “What domains are used in tools to measure the service experiences of families of older adults in long-term care facilities?”.
This study conducted a review of the literature concerning the service experiences of families with older adults in long-term care facilities, focusing on articles published in academic journals from January 1990 to December 2021. The databases utilized for the search were CINAHL, Embase, and PubMed, and the search was restricted to articles written in English. The literature search was primarily conducted online, taking into consideration the constraints of time and available research resources. Initially, a librarian with expertise provided a list of potential articles. Subsequently, two nursing professors, who are experts in the content area, collaborated to manually search and identify relevant studies, ensuring the successful completion of the research. The search terms used were “caregivers” OR “family” AND “nursing homes” OR “nursing home” AND “psychometric properties” OR “psychometrics.”
Our study's inclusion and exclusion criteria for literature selection adhered to the recommendations outlined by Levac et al. [21]. Two reviewers, the first and corresponding authors, independently assessed the abstracts. Given the consistency in the literature selections made by the two reviewers, the involvement of a third reviewer was deemed unnecessary. Of the 171 articles initially searched, 53 duplicates were removed. After evaluating the abstracts of the remaining 118 articles, seven articles were chosen for the scoping review. This selection process excluded articles that were unrelated to the target or topic of the research questions established for this study (Figure 1).
Figure 1
Flow chart of the literature search process.
According to the recommendations for scoping reviews [19], we extracted data in tables that outlined topics, commonalities, and differences in the selected literature. Armstrong et al. [22] classified the criteria for scoping reviews into several categories, including author, publication year, research region, intervention format, number of research participants, research purpose, overview of methods, measurement of results, and conclusion. Based on these categories, we analyzed the data using two distinct methods. The first method involved a quantitative analysis, which considered the tools used to measure the service experiences of family members of older adults in long-term care facilities. This analysis took into account the research year, research design, research country, research subjects, and the topic reported in this study. The second method was a thematic analysis. Initially, two reviewers (the first and corresponding authors) independently examined the domains of the final seven papers to identify themes. Subsequently, these reviewers discussed the identified themes and reached a consensus on the final themes. The final themes, derived from the content of the tools used to measure the service experiences of the care providers of older adults in long-term care facilities, included environment, information and family member involvement, tailored care, respect, and a responsive workforce.
Because this study was a literature review and researchers had no access to study participants or their personal information, there were no ethical concerns. Therefore, this study was deemed exempt from review by the A University ethics committee (2022-10-0001).
The detailed results of the quantitative analysis are presented in Table 1.
Table 1
Results of the Quantitative Analysis of Selected Articles
Of the seven articles selected, one (14.3%) was published in the 1990s, one (14.3%) in the 2000s, one (14.3%) in the 2010s, and four (57.1%) in the 2020s.
All seven articles were quantitative studies. Three (42.9%) were methodological tool development studies, and four (57.1%) were tool validity studies.
The countries of research were the United States (3; 42.9%), the Netherlands (2; 28.5%), Canada (1; 14.3%), and South Korea (1; 14.3%).
All seven studies included family members of older adults in long-term care facilities. Four (57.1%) studies were conducted only with family members, two (28.6%) with family members and resident older adults, and one (14.3%) with family members and caregivers. The number of respondents to the tool surveys ranged from 91 to 32,424.
Table 1 lists the tools used in the included studies. There were seven tools, with a minimum of one domain and a maximum of eight domains. The number of items included in the tools ranged from 9 to 65. The scales of the research tools also varied, including binary scales of yes/no, picture scales, 3- to 4-point scales, and 5- to 10-point Likert scales.
The domains and the number of items in each domain used to measure the service experiences of care providers for older adults in long-term care facilities are presented in Table 2. In this study, these domains were organized into five themes: environment, information and family member involvement, tailored care, respect, and a responsive workforce (refer to Table 3). After identifying and merging similar domains from each tool, they were categorized into themes. Under the environment theme, seven domains were analyzed, covering both the physical aspects of the long-term care facility (such as facilities, food, laundry, and safety) and the psychological aspects (such as creating a safe, home-like environment). The information and family member involvement theme included seven domains, encompassing topics like administrative procedures and family participation in care provision. The tailored care theme consisted of five domains, which involved providing opportunities for meaningful and joyful experiences, professional care and support, and various services and activities within the facility. The respect theme included four domains, focusing on privacy protection, resident autonomy, and promoting kindness and respect. Lastly, the responsive workforce theme comprised two domains that addressed human resource responses, including appropriate staffing and meeting basic needs.
Table 2
Domain Analysis Results from Selected Articles
Table 3
Results of the Thematic Analysis of Research Instruments
This scoping review analyzed seven studies that focused on the development and psychological assessment of tools to measure service experiences for family members of older adults in long-term care facilities, designed for non-Korean contexts. The scope and domains of these tools varied according to the objectives of the research. Upon analyzing the themes addressed by the tools, five key themes emerged: environment, information and family member involvement, tailored care, respect, and a responsive workforce.
Tools to measure service experiences were employed to assess whether patient-centered care was being delivered from the perspective of the subject. It was determined that patient experience was evaluated from various viewpoints, including solely family; family and older adults; family and staff; as well as family, older adults, and staff. This finding contrasts with a previous study that analyzed the concept of patient-centered care in Korean nursing publications. That study reported that the majority of the 31 studies reviewed either mentioned or assessed patient-centered care primarily from the perspective of medical or facility staff, with only one study evaluating it from the perspective of the subject [23]. In the Korean context, it is essential to measure the service experience in long-term care facilities from the perspectives of not only facility staff, but also older adults and their families.
Turning to the results of the thematic analysis, the first theme identified was “environment," which included seven domains. This theme was derived from five of the seven selected articles. As the number of long-term care facilities increases and the role of social care becomes more prevalent, both family members of older adults in these facilities and other stakeholders are increasingly concerned about the quality of care and the quality of life of the residents [24]. Since older adults reside in these facilities, it is crucial to consider their quality of care and quality of life concurrently [4, 25]. The transition from their homes to long-term care facilities necessitates ongoing efforts to enhance their quality of life and quality of care through approaches like “resident-centered care” and “creating a home-like environment.” Previous research, including a study conducted in South Korea, has demonstrated improvements in the quality of life and the creation of a more human-centered environment in long-term care facilities due to this cultural shift [4, 26]. In this study, the environment theme included not only the physical aspects but also the psychological aspects, such as culture. Notably, domains like well-being, food and meals, physical environment, and safety were mentioned in more than three articles and should be considered when developing tools for use in the Korean context.
The second theme, “information and family member involvement,” encompassed seven domains and was derived from five of the seven selected articles. This theme aligns with the findings of a qualitative study examining the experiences of family members whose elderly parents transitioned from their homes to long-term care facilities. The study revealed that although the respondents believed the care in the facilities was superior to that at home, they still felt a profound sense of sadness and regret [16]. Similarly, another study that conducted in-depth interviews with 13 family members of older adults in long-term care facilities found that residents desired their family members to have a voice in the services provided and to participate in decision-making processes [5]. Therefore, it is crucial to provide timely information and actively involve family members of older residents in the decision-making processes at long-term care facilities to improve the quality of service experiences.
The third theme, “tailored care,” included five domains and was derived from five of the selected articles. Older adult residents in long-term care facilities should not be perceived merely as patients with diseases, but rather as individuals leading ordinary lives within these settings. Therefore, “tailored care” plays a crucial role, significantly influencing the quality of life for these older adults [23, 27]. Furthermore, research on the factors affecting service quality in long-term care facilities, conducted with nursing facility staff, revealed that aspects of “tailored care"—such as individualized care and organizational support—were strongly positively associated with the quality of care services. This underscores the high value placed on “tailored care” by not only the older adults and their families but also by facility employees, highlighting its importance in enhancing service experiences in long-term care settings [28].
The fourth theme, “respect,” encompassed four domains and was derived from three of the seven articles reviewed. These domains are autonomy, dignity, privacy protection, and the staff’s kindness and respect toward family members. These elements are crucial to the concept of patient-centeredness, which is a significant aspect of patients' experiences [9, 10]. Additionally, the concept of a positive service experience for older adult residents in long-term care facilities within the Korean context aligns with the “respect” domains identified as key factors in this study. This alignment indicates that both older adult residents and their family members place a high value on respect [29].
The fifth theme, “a responsive workforce,” included only two domains but was derived from five of the seven selected articles. The World Health Organization proposes that “responsiveness” could be another term for measuring patient experience. This suggestion stems from the definition of “responsiveness” as “satisfaction with the health system from the perspective of the patient experience,” which is considered a crucial aspect of patient experience, surpassing mere patient satisfaction [30]. The theme of “immediate response of staff” is similarly reflected in this study [29]. Addressing the needs of older residents and their families promptly, however, necessitates policy measures such as recruiting adequate care staff, enhancing standards for care staff deployment, and enforcing strict supervision by facility directors to ensure staff compliance [5].
This study is significant because it provides foundational data and policy implications for creating a service experience measurement tool tailored for family members of older adults in long-term care facilities in South Korea. With the population aging rapidly and the consequent rise in the utilization of long-term care services, ensuring the quality of care and the quality of life for older adult residents in these facilities has become a critical societal concern.
This study had certain limitations. We did not include gray literature or articles in languages other than English in our search due to time constraints. Additionally, the scope of the topic and the literature review protocol were not registered before the commencement of the study.
This scoping review analyzed the literature on tools to measure the service experiences of family members of older adults in long-term care facilities, focusing on studies published in non-Korean academic journals. It identified and confirmed the domains and items of the tools employed. The analysis yielded five major themes: environment, information and family member involvement, tailored care, respect, and a responsive workforce.
Based on the findings, we propose the following suggestions for future research. First, our study identified the main domains of the service experience of family members of older adults in long-term care facilities through non-Korean literature; future qualitative studies should explore these components within the Korean context. Second, we recommend the development and implementation of intervention programs aimed at enhancing the quality of care and life for older adult residents in long-term care facilities, drawing on the main domains of the service experience identified in this study. Third, future research should focus on creating a reliable measurement tool for assessing the service experience of older adults in long-term care facilities in South Korea, which can be directly evaluated by family members to ensure their experiences are accurately reflected in efforts to improve facility quality. Lastly, since our study was limited to literature in English and did not include gray literature, future research should consider a broader range of literature sources.
CONFLICTS OF INTEREST:The authors declared no conflict of interest.
AUTHORSHIP:
Study conception and design acquisition - CHS.
Analysis and interpretation of the data - KJ.
Drafting and critical revision of the manuscript - CHS and KJ.
This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) (No. RS-2022-00166186).
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