In today's health care environment, the patient-provider relationship has taken a backseat to efficiency and revenue production. Most practices dictate health care providers spend limited time with patients. This time constraint affects the quality of the visit, the amount of information that can be processed, and the outcome of the visit. As a result, researchers need to investigate the patient-provider interaction to address whether patients' expectations for care are met.
Expectations for care have previously been shown to influence both trust in providers and satisfaction with the health care encounter (Hupcey, Penrod, & Morse, 2000). Hupcey et al. (2000) found loss of trust and dissatisfaction during an acute hospitalization were linked to and resulted in patients not cooperating, refusing treatments, and looking for a way out of the situation (i.e., switching providers). In an outpatient setting, unmet expectations and thus, mistrust and dissatisfaction, may lead to noncompliance with the medical regimen and lack of appropriate follow up.
This study sought to determine whether community-dwelling older adults' expectations for care were met by identifying factors that influence trust in health care providers and satisfaction with health care encounters in a primary care setting. Older adults were chosen because in many countries (e.g., United States, Canada, United Kingdom), they represent one of the fast growing segments of the population (BBC News, 2000; Rosenberg & Moore, 1997; U.S. Census Bureau, 1995), and keeping this population healthy would result not only in a better quality of life for older adults but also in significant financial savings.
Older Adult Population
The older adult population is growing rapidly worldwide. In the United Sutes, as of 2000, one in eight Americans (12.4% of all Americans) or 35 million individuals were older than age 65 (Administration on Aging, 2002). Between 1960 and 1994, the U.S. older adult population grew 100% and the oldest of the old grew 274%, while the general U.S. population grew only 45% (U.S. Census Bureau, 1995). In Canada, the older adult population has doubled in the past 25 years, comprising 12.2% of the population in 1996 compared to 8.1% in 1971 (The Daily Statistics Canada, 1997). In the United Kingdom, the growth of the older adult population has demonstrated a similar trend, with a predicted growth of 50% by the year 2030 (BBC News, 2000).
The majority of communitydwelling older adults consider themselves to be in good health, although many require assistance with some activities of daily living (e.g., heavy housework, shopping) (Administration on Aging, 2002; Rosenberg & Moore, 1997). As these older adults age, the number who need assistance increases and their overall health status begins to decline (Rosenberg & Moore, 1997; U.S. Census Bureau, 1995). However, by maintaining a healthy lifestyle and having adequate medical care, elderly individuals can maintain a high quality of life for an extended period of time (BBC News, 2000; Kane, Ouslander, & Abrass, 1999). Thus, one of the primary goals of gerontological care is to maintain older adults' quality of life either by preventing disease or by at least minimizing the impact of disease (Kane et al., 1999).
Health Care Expectations
Patients' expectations for care may influence feelings of trust in health care providers as well as satisfaction with the health care encounter. Hupcey et al. (2000) interviewed 50 patients during an acute hospitalization and found pre-existing expectations for care impacted trust in both health care providers and institutions and also influenced satisfaction with the care received. During interactions with providers, there were behaviors that both facilitated and inhibited patients' perceptions that expectations for care were met. Facilitating behaviors included:
* Treating patients as individuals.
* Connecting on a personal level.
* Being an advocate for patients.
* Going the extra mile.
Inhibiting behaviors included:
* Not knowing patients.
* Being inflexible.
* Not being responsive to needs.
* Not explaining care.
When expectations for care were met, patients trusted providers and often trusted the health care institution as well. When expectations were not met, patients rebuilt trust by changing their expectations; they distrusted with a feeling of no way out; they became angry, vigilant, and refused treatments; or they distrusted but found a way out by changing providers or hospitals.
In outpatient settings, patients also have pre-existing expectations for care. However, older adults' expectations for care and factors within the health care interaction have not been studied and what happens when these expectations go unmet is not known (Beisecker, 1996; Hodes, Ory, and Pruzan, 1995). Many aspects related to the health care interaction may influence older adults' perceptions of the encounter and the feeling that expectations for care were or were not met. Some of these aspects included individual personality characteristics of both the provider and the elderly individual as well as the context and content of the encounter (Beisecker, 1996).
Limited research has examined the influence of provider characteristics such as age, gender, ethnicity, and specialty on the outcome of health care interactions with elderly individuals. Kern (1990) sampled 305 general practice physicians and found that as providers aged (both in chronological years and in practice years), their treatment of older adults also changed. Although these providers spent less time with their patients during routine appointments, they made more nursing home visits, believed older adults needed more prescriptions than younger patients, and thought older adults were more compliant than younger patients.
Other researchers reported female physicians generally spent more time with all of their patients (although not statistically significant in all studies), spent more time talking with their patients, and believed patients should have greater input into medical decisions (Beisecker, Murden, Moore, Graham, & Nelmig, 1996; Bertakis, Helms, Callahan, Azari, & Robbins, 1995; Meeuwesen, Schaap, & van der Staak, 1991; Roter, Lip kin, & Korsgaard, 1991). Thus, while there may be some differences in approach to older adults based on provider characteristics, such as gender, the effect on patient outcomes has not been explicated.
Patient characteristics such as age, gender, ethnicity, socioeconomic status, and health status are important factors that may impact health care encounters and outcomes. Patient age has been shown to influence time spent during a medical visit, with physicians spending less time with older patients (Keeler, Solomon, Beck, Mendenhall, & Kane, 1982; Radecki, Kane, Solomon, Mendenhall, & Beck, 1988).
Patient characteristics also influence the encounter from patients' perspectives in terms of what they want out of a health care visit and in relation to providers as to what they will offer older patients. With advancing age and co-existing medical problems, older adults may decide not to pursue major workups and treatments for their conditions (Resnick, 1998). It also has been shown that providers tend to limit preventive services and treatment options for individuals as they get older (Bergman-Evans & Walker, 1996; Fox, Murata, & Stein, 1991; Samet, Hunt, Kay, & Goodwin, 1986; Silliman, Troyan, Guadagnoli, Kaplan, & Greenfield, 1997).
Context of the Health Care Encounter
The context of a health care interaction includes such things as the reason for the visit, length of the visit, prior interaction with the provider, and length of the relationship with the provider. These factors influence the outcome of a health care encounter more than patient and provider characteristics (Beisecker, 1996). Beisecker and Beisecker (1996) sampled 106 adult rehabilitation patients and found both the time providers spent during an encounter and having prior interaction with a patient influenced the content, which then impacted the outcome of the encounter. Also, as the length of the visit increased, so did the use of information-seeking behaviors.
In terms of relationships with providers, Weiss and Blustein (1996) examined the length of patients' ties to a particular physician in relation to health care use, healthy behaviors, and cost. Among the more than 8,000 elderly individuals in the study, decreased cost was the only outcome factor positively associated with longstanding ties with a physician.
Focus group methodology was used for this study. Focus groups are an appropriate method when information related to attitudes and opinions are to be investigated and when group interaction may produce insights that might not have otherwise been generated (Morgan, 1997). Within a focus group, a large number of participants can be interviewed simultaneously, and differences and similarities in experiences can be brought forth.
The number of focus groups within a project varies with the complexity of the topic of interest and diversity of the sample (Morgan, 1997). The important consideration with focus groups is theoretical saturation, which occurs when no new information is revealed with additional focus groups (Morgan, 1997). For this study, saturation occurred by the sixth focus group; however, two additional groups were completed as originally planned.
Individuals age 59 or older were recruited from senior centers and a senior housing complex. Specific centers were targeted to include older adults residing in cities, suburban (small communties outside of the city), and rural areas. A total of 39 older adults from a variety of ethnic and socioeconomic backgrounds participated in 8 focus groups.
Data were collected using a demographic questionnaire and focus group discussions. The demographic questionnaire included information such as age, gender, géographie location, ethnicity, financial and insurance status, duration of participants' relationship with their primary health care provider, and medical history.
Focus groups consisting of three to seven participants were conducted. Focus groups were audiotaped and videotaped, and lasted between 45 and 90 minutes. The focus groups were videotaped to enable identification of individual speakers and to observe any unspoken communication that may have influenced group responses.
CATEGORIES INFLUENCING MEETING OF OLDER ADULTS' HEALTH CARE EXPECTATIONS
The focus groups were conducted by a moderator whose role was to ask questions and facilitate discussion. Eye contact and other signals were used to keep the discussion on track and ensure that all members participated. A funnel strategy was used in which less structured questions were followed by more structured questions (Morgan, 1997), thereby ensuring the group explored all questions.
Directors at three senior centers and one housing complex were contacted and asked if they would be willing to participate in the study. If the directors agreed to participate, a flyer about the study was sent to the center, and a date was set for the researchers to meet with potential participants, discuss the project, and schedule the focus groups. Although sign-up sheets originally were planned to allow the researchers to assign participants to groups, thereby enabling each group to include older adults with a variety of experiences, this did not prove feasible and was not needed as the naturally formed groups were able to provide this mix.
Focus groups were conducted in a private room, and three researchers were present for each focus group. One researcher was in charge of the audiotaping and videotaping equipment and the second researcher moderated the session, with the third researcher assisting.
Prior to starting the focus group, the study was explained and informed written consent was obtained from all participants. Participants then completed a questionnaire that included demographic information, and ground rules were explained, such as confidentiality of the information discussed in the group and only one person talking at a time. Participants were encouraged not to talk in sequence, but to speak freely if the discussion reminded them of something they wished to discuss.
Although a total of 10 questions were planned for each group, this number varied slightly by group responses. Some groups answered the more structured questions as part of the initial discussion and thus these questions were not asked.
Each focus group began with introductions of group members and a brief general discussion of activities the members participated in at the center. Members then were asked to think about a visit with one of their health care providers that was positive and what it was about the experience that made it positive. This was followed by a similar question related to a negative experience. Participants then were asked whether their expectations for care were met and why.
Members were asked more structured questions that related to satisfaction with and trust in providers. Participants were asked to identify what made them satisfied or dissatisfied with providers and what they did when they were dissatisfied. Similarly, participants were asked to identify what made them trust or not trust providers and what they did when they did not trust providers.
CATEGORIES RESULTING IN UNMET HEALTH CARE EXPECTATIONS OF OLDER ADULTS
All members were encouraged to participate in the discussion. If some of the members did not participate, they were specifically asked their opinion, or if a member appeared to be dominating the group, the moderator would look at other participants and specifically ask them questions. The moderator also used probes (e.g., "go on," "could you give us an example") to stimulate responses.
Once the moderator finished asking questions, participants were asked if there was other information they would like to share and were asked to summarize the discussion. At the end of each focus group, light refreshments were offered and an honorarium of $10 was given to each participant.
The audiotapes were used to transcribe each focus group discussion verbatim. Transcripts included notation of all pauses and emotional expressions such as laughing. The videotapes then were used to verify the accuracy of the transcripts, to fill in gaps, and to identify speakers.
Each researcher individually read and coded the transcripts. Transcripts initially were read multiple times to grasp the whole context of the data set. Participants' responses were analyzed line by line, then significant phrases, facts, and incidents were highlighted and codes were placed in the margins. From this, significant themes were pulled out from each individual group and then across all eight groups, and categories then were developed around the themes.
The 39 participants (35 women and 4 men) ranged in age from 59 to 93 (mean age, 73 [SD = 10] years). Thirty-two participants were White, 4 were American Indian, and 3 were Black. Three participants were married, 24 were widowed, and 12 were separated or divorced; the majority (n = 33) of the sample lived alone. Thirty-two of the participants resided in an suburban area, 4 resided in a city, and 3 resided in a rural area.
Of the 36 participants who responded to the question regarding financial status, 21 said their finances were adequate or more than adequate, while 15 said they were just getting by or considered themselves as poor. All of the participants had Medicare, and all but 7 had supplemental insurance or were part of a health maintenance organization. The number of medical conditions participants had ranged from none to five, with the majority having arthritis (n = 24), hypertension (w = 22), or both.
The length of time participants had been going to their current primary health care provider ranged from months to 43 years (mean, 9 [SD - 7] years). The majority of participants (n = 31) said their insurance allowed them to pick their health care provider. Of the eight participants who had no choice of providers, only one was truly unhappy with the provider, whom she had been seeing for 7 years.
Seven participants said their expectations for care were not being met by their present provider; six of these seven participants indicated they could switch providers or practices but did not. The length of time these participants had been going to their present providers ranged between 2 and 20 years.
Themes related to expectations for care fell into three categories (Tables 1 and 2):
* Sense of personal touch so participants felt the provider cared for them.
* Technical proficiency.
* Environmental factors, such as time spent with participants.
These categories related either to the provider as an individual or to the environment associated with the practice where the provider was employed. When providers and practice settings met participants' expectations for care within the three categories, participants felt satisfied with the care received. If all of the expectations were not met, then participants were not satisfied; however, the degree of dissatisfaction related to which categories of expectations were not met.
In terms of trust, having expectations met also influenced trust; however, participants said they could be satisfied with the care they received but not have all of their care expectations met. Thus, there were instances in which participants said they were satisfied with their provider but for some reason still did not trust their provider. Conversely, there were participants who said they definitely trusted their provider but were not satisfied with the care they received from their provider. This dissatisfaction came either from feeling a lack of personal touch or from one of the environmental factors (e.g., not being able to get an appointment) and not necessarily from unmet expectations on the part of the provider.
Personal touch and caring. A sense of personal touch and the feeling that providers cared for them as an individual enhanced participants' degree of satisfaction with providers. One participant described her expectation for care as needing "to know that somebody cares what is going on." This feeling made participants relax at their appointment and enhanced their ability to talk to their provider about their medical concerns.
Most of the participants who felt their provider cared about them as a person also said they trusted their provider. However, a few participants said their provider was a caring individual but had missed a diagnosis; these participants noted that although they were satisfied with the provider as a person and believed the provider cared about them, they did not totally trust the provider.
Participants described providers who spent time with them, listened to them, and actually got to know them as having a personal touch. Certain gestures, such as bringing up a mutually favorite sports team, were considered very positive (Table 1). The following quote illustrates the personal touch:
I think it helps if you're feeling dreadful and you're scared to know that the doctor is concerned and that he's going to be right there if you need him... He was wonderful because he said, "We're going to straighten out. I can do this, you know." But he keeps working to find things that will help me. I think it's what keeps you going if you know somebody who's going to care about you that much.
A feeling that their provider did not care about them resulted in dissatisfaction as well as a lack of trust for many participants. In terms of dissatisfaction, some participants said they felt their provider did not address problems fully due to their age and attributed many of their complaints to "old age." Others described their provider as being rude, limiting questions, failing to listen fully to their problems, and treating them like tliey did not know anything (Table 2). One participant noted, "I always figure that they think, oh, you're too old, forget it." Another participant said:
They don't want to take their time with the older person because you have many ailments and maybe a short life span, so they don't take their time with you and they don't have that caring feeling toward you.
In terms of trust, the participants felt this lack of caring made the provider untrustworthy because the provider was not looking out for their best interest. The lack of a personal touch made participants believe the provider would not care enough to find the source of a problem or follow up appropriately. When participants were asked if they trusted their providers, one participant said:
Not that much... I wanted him to give me a test, when I'm telling him about this thyroid, he wouldn't believe me. He said, "How do you know?" Well, you know, that's up to him to find out if I have it.
Another participant noted:
When you feel like you lost touch with him, sometimes when you are only allotted 15 minutes, and he's late, and you get in there and you feel rushed. And you almost feel like, "I'm taking up his time." When I feel rushed, or you've mentioned a symptom that you're having, and he gets the darn book out for the prescriptions... and he's writing out the prescription, I know he's not listening.
Technical proficiency. Satisfaction was positively influenced by the perception that providers were technically proficient. The perception of proficiency also had a positive impact on trust. The feeling that providers were technically proficient was greatest when participants did not feel rushed during their appointments and believed providers were being thorough in their care including following up on areas of concern (Table 1). One participant noted:
I am very satisfied with him...He's very thorough. When I go in for an exam, he'll say maybe once a year you should have another thorough blood exam. When I go back to see him, he'U give me all the results and go over them with me.
Dissatisfaction occurred when participants felt their providers had poor technical skills. Misdiagnosis or polypharmacy promoted the perception of poor skills and consequently resulted in mistrust. Other feelings of technical incompetence were related to poor interpersonal skills or communication style (Table 2). Some participants noted providers were not thorough in checking their chart:
He asked me about a tetanus shot. I said, "You gave me one last year." His disrespect - he doesn't go back and check like he should.
Another participant described the following encounter:
I had to insist on the x-rays for my lungs to find out I had pneumonia and then to find this thing...It was cancer; it was a bronchial alveolar, which is a rare form of cancer.
Environmental factors. Environmental factors had both positive and negative influences on satisfaction. Although environmental factors did not influence participants' trust in individual providers, negative environmental factors may have caused participants to leave a practice even if they were satisfied with and trusted their providers. More negative environmental factors were identified than positive ones, and most were related to the practice itself (Tables 1 and 2). Some participants did not blame their provider for problems with the practice, but others felt their provider had some control over these problems. For example, most of the participants realized their provider was on a tight schedule, but they felt the provider's interpersonal skills could compensate for this time limitation (e.g., not acting rushed).
One participant described the following example of a positive environmental factor:
The girls there have always worked me in, like if on a Tuesday morning and I know that his schedule is full, the nurse there knows me... she checks over his schedule and then she says, "Well, can you come in at so and so?" and I'll say I'll be there.
Several participants described the following examples of negative environmental factors. One participant commented:
They might take you for your appointment... and the nurse is like, "We'll take your blood pressure," and then you sit in that little room for another hour, and sometimes you feel like they've completely forgot about you.
Another participant said:
They move you through like cattle or something in a slaughterhouse. You know what I mean with the HMOs - they really don't take an interest in you. You're just part of the pack.
Although the majority (n = 23) of older adults in this study were completely satisfied with and trusted their health care providers, most were able to identify areas in which their expectations for care were not met. For example, participants would say they were completely satisfied and trusted their provider, yet they would add a comment such as, "But don't get sick on a Tuesday."
It is also interesting to note that many participants who said their expectations for care were met felt they shaped their health care interactions to meet their expectations. For example, some participants said they brought lists of concerns with them to the visit and would not leave until all of their concerns were addressed. Others said they told their providers their needs and made sure they were met.
Some participants noted they were satisfied because they had switched providers and found ones who met their expectations for care. Two participants noted they left providers they had been seeing for 10 years or longer because they felt their care was deteriorating. Six participants who were dissatisfied or did not trust their provider indicated they continued the relationship because they did not know where to go or did not want to expend the energy finding and getting to know a new provider.
This study, as with an earlier study by Hupcey et al. (2000), found the personal touch or being treated as an individual was important to both satisfaction and trust. The results diverge in relation to technical proficiency. In this study, technical proficiency was important for both trust and satisfaction, while in the earlier study (Hupcey et al., 2000), competence or technical proficiency was assumed and only became an issue when someone distrusted.
Environmental factors played a role in satisfaction in this study, but did not influence trust, so although the participants expected offices would run efficiently and offer easy access to providers and appointments, these factors did not influence trust. This was also found to be true in the earlier study by Hupcey et al. (2000), who reported patients may be dissatisfied with how an institution is run, but found mistrust of the institution did not come to the fore unless patients mistrusted the health care providers employed by the institution.
In terms of factors identified in the literature that influence the health care interaction, patient age (BergmanEvans & Walker, 1996; Keeler et al., 1982; Fox et al., 1991; Radecki et al., 1988; Resnick, 1998; Samet et al., 1986; Silliman et al., 1997) was also a concern among some of the participants in this study. As in earlier work, there was the feeling that with patients of increasing age, some providers were not as thorough and did not offer them all possible treatment options.
Providers' gender was another factor that was seen in prior research to positively affect a health care interaction (Beisecker et al., 1996; Bertakis et al., 1995; Meeuwesen et al., 1991; Roter et al., 1991). A small number of participants in this study expressed a similar view, stating that female providers were more caring and attentive to their needs. Because of the small sample size and limited diversity of the sample in this study, other factors such as gender, socioeconomic status, and ethnicity of the participants did not seem to influence expectations for care or satisfaction with and trust in providers.
IMPLICATIONS FOR PRACTICE
Older adults' expectations for care are fairly basic: they want to be treated as an individual by providers who care about them and who are technically proficient. Environmental factors may influence satisfaction, but may not be essential if providers' interpersonal and technical skills meet expectations. Health care providers need to treat elderly individuals with respect and take time to address their concerns.
Some specific areas addressed by the participants were to avoid the use of complicated telephone answering systems with multiple options and to allow them to talk to a "live" person. The easy availability of a nurse or other office personnel made a positive impression on these older adults and sometimes compensated for a lack of accessibility of physicians.
Gerontological nurses can spearhead programs to help older adults' navigate through the health care system. For example, although most of the participants were savvy about their health insurance plans, many needed to be guided through the system. Some participants were unsure about which preventive services they should be requesting even though brochures were available at all of the participating centers. Others did not aggressively pursue questions with their provider. Programs run by gerontological nurses may prove more beneficial for all of these situations. In such programs, not only could general information be presented, but individual questions also could be addressed.
LIMITATIONS AND FUTURE DIRECTIONS
This study was limited by the small sample; however, saturation was reached, as additional groups did not provide new information. The study also may have been limited by the fact that all participants had health care coverage (i.e., Medicare) and were fortunate in the availability of health care providers. Therefore, most of the participants did not report feeling trapped in a bad health care situation. Another potential limitation was related to the use of focus groups as a method of data collection because there is a potential in focus groups for participants to withhold information and be swayed by group opinion.
The older adults in this study appeared to respond freely in the focus groups and held firm in their original opinions about their experiences with their health care providers. The only piece that set the tone for an individual group was the willingness to verbally disclose past medical problems or in mixed gender groups, "female" problems. Interestingly, if participants discussed their medical history in specifics (e.g., "my breast cancer treatment") during the first portion of the session, others did the same. Conversely, if specific medical problems were not mentioned, other participants would follow suit and not mention theirs.
Expanding this project to examine health expectations and perceptions of health care interactions with younger groups and groups without adequate health insurance may provide additional insights into ways to approach time-limited health care systems. Another area for future research would be the relationship between older adults' trust in providers and compliance with medical regimens and preventative health care services.
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CATEGORIES INFLUENCING MEETING OF OLDER ADULTS' HEALTH CARE EXPECTATIONS
CATEGORIES RESULTING IN UNMET HEALTH CARE EXPECTATIONS OF OLDER ADULTS