A Descriptive Model of Consumer Choice Processes Among Nursing Home Patients

ABSTRACT - This article presents a model describing the processes by which consumers first select and then adjust to nursing homes. The model is based upon data collected through survey research, and it bears implications for both improvement of the consumer decision process, and reorientation of nursing home administration.


Steven A. Baumgarten, Tanniru R. Rao, and L. Winston Ring (1976) ,"A Descriptive Model of Consumer Choice Processes Among Nursing Home Patients", in NA - Advances in Consumer Research Volume 03, eds. Beverlee B. Anderson, Cincinnati, OH : Association for Consumer Research, Pages: 457-462.

Advances in Consumer Research Volume 3, 1976      Pages 457-462


Steven A. Baumgarten, Purdue University

Tanniru R. Rao, University of Wisconsin-Milwaukee

L. Winston Ring, University of Wisconsin-Milwaukee


This article presents a model describing the processes by which consumers first select and then adjust to nursing homes. The model is based upon data collected through survey research, and it bears implications for both improvement of the consumer decision process, and reorientation of nursing home administration.


In the period 1963-1970, the number of nursing homes in the United States increased from approximately 13,000 to over 20,000. During that time period, the number of patients in nursing homes almost doubled. Today, there are over one million patients in U.S. nursing homes. This represents approximately 4% of all persons over the age of 65.

Despite the obvious size and growth of Nursing Homes as an important societal institution, the process by which consumers select and adjust to nursing homes has not been the subject of systematic empirical investigation.

Viewing the relationship between nursing homes and their patients as a marketing system provides a useful conceptual framework for understanding the pre- and post-adoption decision processes of the elderly person faced with the decision of whether to enter a nursing home.

This article presents a descriptive model of consumer choice processes among nursing home patients which is based upon an empirical study sponsored by the U.S. Department of Health, Education and Welfare.


The data upon which this descriptive model is based were obtained from a wide variety of sources. Among these were:

1. Discussion with twenty nursing home administrators, social workers and therapists;

2. Individual depth and structured interviews with eleven elderly persons living in private residences, twelve elderly persons in hospitals, two relatives of nursing home patients, three doctors of nursing home patients, and one lawyer of a nursing home patient;

3. Group depth interviews with a total of eighty patients in three separate nursing homes;

4. Structured field interviews with 121 patients at sixteen area nursing homes, and

5. Structured interviews with floor nurses at each of the sixteen nursing homes.

The data were collected in late 1971 in the Milwaukee metropolitan area.


The model was generated strictly from the data and information collected in the research project, and is intended to be an accurate description of the process by which consumers actually do select and adjust to nursing homes.

The model in Figure 1 presents the process by which consumers select a nursing home. Figure 2 is, in effect, a continuation of Figure 1, and presents the process by which consumers adjust to the nursing home environment.

In both figures, the center column presents the basic model and shows the selection and adjustment processes sequentially, primarily as seen from the (potential) patient's point of view. The left- and right-hand columns contain empirically determined breakdowns of the components of the processes. (To avoid unnecessary verbiage, the elderly person involved in both the selection and adjustment processes will hereafter be referred to as "the patient," with the understanding that he or she is, in fact, only a potential patient until admission to the nursing home.)

Stimulus and Problem Identification

The model begins with a stimulus leading to identification of the problem, "Should a nursing home be entered?' In almost all cases, the stimulus seems internal--self-recognition of the problems of old age, illness, inability to care for oneself, etc. Only 4% of the nursing home patients surveyed indicated that a doctor's recommendation was a major stimulus, and only 6% expressed the stimulus altruistically as a desire not to burden others. The insistence of relatives was a stimulus for only 4% of those surveyed, but as is seen later, relatives' input and/or participation in the decision-making process is a very important element in the model.

Value Conflict

Confrontation of the problem, "should a nursing home be entered?" almost invariably leads to conflict within both the patient and the family, and between the patient and the family.

The family frequently has guilt feelings over "abandoning'' a loved one to the care of an impersonal institution. This guilt is generated both internally, by the felt need to be personally responsible for the care of a loved one, and externally by residual social mores which dictate that people should be personally responsible for the care of loved ones.

The patient desires family togetherness, a sense of belonging and frequent love and attention, as well as peer relationships and (often) more extensive care than can ordinarily be offered by family or friends. At the same time, the physical act (or even the very thought) of entering a nursing home can serve to emphasize the relative imminence of death.

Furthermore, both the patient and the family are very likely to have a negative image of nursing hours generated by unfavorable publicity or interpersonally-received "horror stories."

Alternative Search

Family and patient conflict usually leads to a prolonged and frequently exhaustive search for non-nursing home alternatives. Living with or near relatives or friends, other types of care facilities ("foster homes," retirement homes, etc.), periodic extended "visits" with a number of family members, and paid companions or nurses are alternatives which are usually considered at this stage.

Sometimes an alternative solution is found and is, in fact, desirable. In many instances, alternative solutions are tried even when both the patient and family recognize that they are "logically" inferior to the nursing home solution. In both of these instances, the problem of entering a nursing home is likely to arise again in the future.

Conflict Resolution

In most cases, conflict is not actually resolved, or even appreciably abated. Tension is reduced somewhat due to the relative comfort of finally being able to make a decision, but guilt feelings remain and a very high level of dissonance is generated among family members. The patient often feels abandoned and remains apprehensive about entering a nursing home.

Frequently, too, doctors, social workers and visits to nursing homes and other care facilities may help to reduce tension and, on a post-decision basis, dissonance.


When the decision is one of entering a nursing home, it is very frequently made by persons other than the ultimate recipient of the services--51% of the nursing home patients indicated that the decision that they would enter a nursing home was made strictly by others. At the same time, only 24% claimed to have made the decision solely by themselves.

Development of Choice Criteria

Once the decision to enter a nursing home is made, selection criteria are usually necessary in order to priorly reduce the number of alternatives to a manageable size. With 121 nursing homes in the Milwaukee area, it would seem necessary to pre-screen on some basis. Despite the seemingly large number of nursing homes available, however, the nature of their offerings is so segmented that for most families, very few homes are suitable. Many homes are affiliated with specific religions and/or church-supported. There are small, medium and large homes; old and new homes; Medicare approved homes, Medical Assistance approved homes and homes with no assistance approval; Skilled care homes, limited care homes and personal care homes, etc.

Generation of Alternative Set

The segmentation of these offerings, taken together with patient and family needs concerning location, facilities, level of care, religious affiliation, reputation, size, etc., typically results in the generation of a highly limited alternative set. In fully 78% of the cases, only one home was considered.

Evaluation of Selected Alternatives

The bases upon which a nursing home is finally selected are also extremely limited. The most frequently mentioned criterion (21%) was "favorable impression of facilities." 13% relied upon the advice of others, 10% selected on the basis of religious affiliation and 7% on the basis of location. Only 3% were concerned with medical care and only 2% with cost. In 36% of the cases, the patient indicated that he or she didn't choose the nursing home or didn't know what the criteria were. Thus the non-participative nature of the decision process continues through to the ultimate selection of the home.

Selection to Admission

Now the nursing home has been selected. The patient may undergo a waiting period--typically less than one month, but in the case of some few of the most highly desired homes the waiting period may exceed one year--and is finally admitted to the nursing home.

As is the case with other consumer products and service% however, the consumer decision process does not end here. Post-purchase reactions, use of the product, etc., are important considerations for the marketer concerned with providing consumer satisfaction. In the case of nursing homes, the extent to which the patient successfully adjusts to the home is a primary determinant of the extent to which the "marketer" is successful.

Figure 2 presents a model of the patient adjustment process which is discussed in the following sections.

Admission--Initial Shock

The initial reaction of a new patient to a nursing home can be, and usually is, traumatic. Suddenly there are rules (many of which, fostered by legislation, seem to have no logical basis), specified eating times, an almost total lack of privacy (very few patients have private rooms), an unfamiliar environment and the faces of only strangers.

Institutional Adjustment Process

The process of adjusting to this new environment is only marginally aided by most institutions. Even a brief orientation program is more 'the exception than the rule. The patient, then, must rely upon other patients or friendly staff members to aid him or her in adjusting. In the absence of formal aids to adjustment, the new patient can also take solace in the improved medical security, improved care and increased number of planned activities now available to him or her.

Internalization of a New Value System

In order to successfully adjust to the nursing home environment, it is often necessary for patients to revise their attitudes, interests and opinions. Thus, the patient who views nursing home life as a form of independence from being a burden to others can generally cope better than the patient who feels abandoned to an institution. Similarly, patients are found to be better adjusted when they develop the spirit of having a home within the nursing home; when, within their physical limitations, they can do useful things (read to fellow patients, write letters, tidy up, etc.); when they generate a social service orientation; and when they become involved, in almost any way, with events in the home and in the community.

The patient who successfully internalizes these values generally becomes more active, demands more from the home and the community, becomes politically involved, becomes a spokesman for the home, and spends little time worrying about death.

The typical profile of the patient who does not successfully internalize these values is that of passivity, a sense of resigned living, substantial bitterness, loneliness, feelings of rejection and high fear of death.

The successfully adjusted patient represents a societal gain. He or she is relatively satisfied and a contributing member of society. The unadjusted patient is unsatisfied, unhappy and a loss to society.


If the model presented above is viewed as one involving the relationship of a marketer and his customers, then two categories of implications may be meaningful: 1) Implications for improved consumer decision-making, and 2) implications for improved marketing and management of nursing homes.

Improved Consumer Decision-Making

One of the more disturbing features of the model is the general lack of patient participation in the decision-making process. It is interesting that our society has a great appreciation for the value of participative decision-making in family relationships, personnel management and school situations, to name just a few. Yet, in the decision to radically alter the life style of an elderly person, that person is denied participation more than half the time! (It should be noted that all of the 121 patients surveyed were lucid and capable of relatively sophisticated interaction.) If participation in decision-making does, in fact, lead to greater commitment to the decision, then certainly families considering nursing home care should be encouraged to involve the potential patient in the decision.

Once the decision to join a nursing home has been made, the vast majority do not, as one might expect, shop extensively. On the contrary, fully 78% of those surveyed considered no home other than the one they ultimately selected. We would be remiss if we didn't point out that the average teenager at a candy counter generates a more extensive alternative set!

In addition to this highly limited generation of alternatives, the evaluative criteria ultimately selected leave a great deal to be desired. "Favorable impression of facilities" (21%) and "Advice of others" (13%) represent the primary bases upon which the nursing home is selected. Returning to the consumer goods arena for another damning analogy, it is obvious that most people generate more thorough evaluative criteria for the purchase of a washing machine!

If the consumer is to make a reasoned choice in this very important decision process, he or she will have to first recognize the importance of the decision and then be provided the information necessary to more thoroughly evaluate the alternatives. What is needed is massive consumer education. Nursing home trade associations as well as individual nursing homes are in an excellent position to provide useful information to potential consumers. Additionally, Social Security Administration Offices and any other agencies which have frequent contact with the elderly are prime outlets for information dissemination and counseling.

In, roved Management of Nursing Homes

one critical stage in the selection process is that of "Conflict Resolution." As pointed out earlier, conflict is usually not truly resolved at this stage, and it is here that nursing home administrators can begin to undertake marketing effort. It should be noted that nursing homes are frequently enjoined from competitive advertising by either industry association or legislative regulations. Most nursing homes and associations can, however, engage in generic promotion of the nursing home concept. Any form of reassuring and/or educational promotion is likely to reduce tension at the conflict resolution stage and may well result in: 1) a more comfortable decision process for the patient and family, 2) a greater likelihood of the nursing home alternative being selected, and 3) a generally improved image of nursing homes among the population. It is probable that strong industry association activity will be necessary to accomplish this task.

If such promotion is undertaken, it is also likely to improve the subsequent stages of the selection decision process, particularly if the promotion is educational in nature (i.e., messages which explain nursing home procedures and provide a reasoned basis for consumer selection). Thus, evaluative criteria might be improved, thereby leading to better selection.

As an additional benefit, if consumers are more comfortable in their decision, they will likely be more positive in their attitudes toward the nursing home and likely to adjust more easily. Currently, 56% of the patients surveyed stated that they would have preferred not to come to a nursing home at all. It is perhaps not surprising that many fail to adjust successfully, given such a high negative predisposition.

In terms of the adjustment process, the initial shock of institutional life probably represents the greatest deterrent to rapid adjustment. The lack of privacy, lack of freedom, routinization and disruption of previous social activities are aspects of nursing home life which may be easily changed. Certainly, nursing home administrators should explore the possibilities of such changes as revised (more informal) scheduling of events and activities, providing of mOTe private rooms, relaxing some non-legislated rules, and continuing (in some fashion) some of the previous social activities of the patients.

It is almost too obvious to point out that a simple orientation program and/or small-scale social event should accompany the admission of a new patient. Yet many nursing homes do little more than show a new patient his or her room. Certainly a welcoming "party" and/or orientation program would make the patient feel more "at home."

Finally, planned events and activities which encouraged interaction outside of the home could help to alleviate patient's feelings of isolation and uselessness. Instead of (or, in addition to) a bus trip to the zoo, some patients might benefit more from an opportunity to help work on a political campaign or charitable drive, by doing envelope stuffing, telephoning, etc. Similarly, events which bring the public to the nursing home, such as art shows and open houses, can also help alleviate feelings of isolation.


A better understanding of the processes by which patients select and adjust to nursing homes can provide insights into developing procedures for improved consumer decision-making. At the same time, it highlights areas in which administrative reorientation can provide increased customer satisfaction.

The presentation of survey research results in a descriptive model format is seen as desirable in that it: 1) Conceptualizes what might otherwise appear to be a loose collection of findings, and 2) helps to highlight empirically testable issues and thereby provides future researchers with a stronger conceptual framework for constructing data collection instruments and/or experimental procedures.

The model presented in this article focuses upon the the decision-making process as seen from the patients point of view. This is a necessary first step toward understanding this complex process. It should be emphasize, however, that detailed investigation of the role of the patient's family in this decision process is a necessary next step for the development of a more comprehensive model.





Steven A. Baumgarten, Purdue University
Tanniru R. Rao, University of Wisconsin-Milwaukee
L. Winston Ring, University of Wisconsin-Milwaukee


NA - Advances in Consumer Research Volume 03 | 1976

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