A Descriptive Model of Consumer Choice Processes Among Nursing Home Patients

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.

IMPLICATIONS

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.

CONCLUSION

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.

FIGURE 1

FIGURE 2

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