Interview Protocol
Learn how to design and conduct quality-of-life assessment interviews with nursing home residents that not only elicit information useful for improvement efforts but also are flexible and feasible to implement given the time- and cost-constraints in most facilities.
Click one of the following topics to skip to that section:
Protocol Purpose
“The question now is not, ‘Should we improve the quality assessment process by interviewing more residents? But rather, ‘How do we interview more residents within the cost constraints of the quality assessment process?’”
--John F. Schnelle. (2003). Improving Nursing Home Quality Assessment: Capturing the Voice of Cognitively Impaired Elders. J of Geron, Med Sci, 58A(3): 238-239.
In this section we present a protocol for conducting quality-of-life assessment interviews with nursing home residents that not only elicits information useful for improvement efforts but also is feasible to implement given the time- and cost-constraints in most facilities. In addition to quality improvement efforts, these assessments also allow for the identification of resident’s individual care preferences for care planning and more resident-centered care provision.
Based on research we conducted over the past eight years (see Related Studies), the protocol provides instructions on how to design and implement an assessment strategy that aims to achieve any one or all three of the below goals:
In keeping with a fundamental tenet of both resident-centered care and quality improvement (see Fundamentals for a New Assessment Strategy), it recognizes resident self-reports as the gold standard for assessing care preferences and quality of life.
The protocol is flexible, so it allows you to develop an assessment strategy that takes into account your resident population and facility resources. It presents general guidelines to work within, but leaves most of the decision-making to you: Do you want to interview all residents or a sub-group? Do you want to assess current residents or only new admissions? Do you want to evaluate quality of care across a broad range of domains or narrow the focus to a single care process? Though it is now common practice to assess consumer satisfaction in the managed care and hospital industries, such assessment is a relatively new practice in the long-term-care business. Often with new practices, the hardest part is just getting started. This protocol can help you clear that obstacle.
The protocol, presented below, is organized around commonly asked questions.
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When Should Quality Improvement Interviews with Residents be Conducted?
If your facility, like most nursing facilities, does not routinely interview residents to assess their care preferences and quality of life, then we recommend that you start small, focusing first on a subset of residents, such as new admissions, or on a single care process or other activity you want to improve, such as walking assistance or shower/bathing process. With this in mind, here are two suggestions for when to conduct resident interviews:
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Who Should be Interviewed?
As a general rule, you should interview residents who score 2 or more on the Minimum Data Set (MDS) Recall subscale. Our research shows that these residents consistently provide reliable information useful for quality improvement efforts (1, 2). Ideally, the four MDS items that comprise the recall scale should be completed by nursing home staff familiar with the resident based on the most recent seven-day period, as opposed to relying on the most recent MDS assessment data, which may be three months or more old at any one point in time.
If your questions ask about services or care processes that occur daily, as opposed to less frequently, or subjective aspects of care (e.g., food preferences) then you should also interview residents who score 1 (or more) on the MDS Recall subscale. Our research shows that the majority of these residents can reliably self-report pain and depression, express meaningful preferences for daily care (they can tell you, for example, what activities they like, what food they want for breakfast and where they like to eat their meals).
If you are assessing quality of care for a specific activity of daily living (ADL), interview residents (with appropriate MDS Recall scores) who require any level of staff assistance (supervision to total dependence) for that ADL, excluding only residents who are either completely independent or completely unable to do the activity (e.g., unable to walk, even with assistance). You can use MDS ADL ratings to identify appropriate interview candidates:
Residents should be asked questions about only the care activities that are relevant to them. Do not, for example, ask a bed-bound resident questions about getting in and out of bed or ask a resident completely incapable of walking questions about walking assistance.
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Who Should Conduct the Interviews?
Interviews should always be conducted in-person with residents. This enables a range of cognitively and physically impaired residents to participate. In-person interviews also provide an opportunity to clarify questions, which can lead to more accurate responses.
Because most daily care is provided by certified nursing assistants, a different staff member should conduct the interviews so that residents feel sure their reports are confidential. Ideally, a social worker or licensed nurse should conduct the interviews.
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Where Should Interviews be Conducted?
Interview each resident in a private room to ensure confidentiality. The room should be quiet (turn off television, radio) so that the resident is not distracted and can hear you more easily.
Is There Anything I Need to do Before Conducting the Interview?
Determine whether the resident you are about to interview needs a hearing device and if so, whether the device is available. When we conduct interviews, we arrive prepared to offer residents the use of amplifying earphones (inexpensive and available from most electronic stores). Also, find out whether the resident has any particular needs (e.g., has difficulty speaking) that might affect participation in the interview. Review the resident’s most recent MDS assessment so that you are aware of which ADL care activities the resident requires assistance to perform and which aspects of the interview may not be applicable to the resident due to complete independence or inability.
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How Should Interviews be Conducted?
Introduce yourself and spend a few minutes establishing rapport with each resident or simply socially interacting with the resident.
Follow good interviewing techniques: Your mouth should be clearly visible to the resident; you can help the resident focus his or her attention by using the person’s name and by using touch. Situate yourself so that you are as level as possible with the resident’s eyes.
Make sure the resident can hear you and understands each question, to the greatest extent possible. You may need to check the person’s hearing aide.
Reassure the resident that his or her responses will be kept confidential. Feel free to adopt the preface we often use: “Everything you tell me will be kept private. I will not tell the staff (the people who work here) what you say. Some of these questions are personal, so if there are any questions you feel uncomfortable answering, you don’t have to answer. Also, some of my questions may seem silly but please try to answer as many as you can. You may discontinue this interview at any time and it will in no way affect the care you receive. (Our state) law requires that I report abuse. If this occurs, I will tell you exactly what I plan to tell the social worker here, and you will be protected from any further harm from staff.”
Avoid awakening residents or interrupting social visits, meals, or activities to conduct an interview.
Back to Top
What Types of Questions are Most Useful for Improvement Purposes?
You can develop interview questions that specifically address the care areas and aspects of quality of life that are the focus of your facility’s improvement efforts and/or resident-centered care delivery program. In general, interview questions should:
Question sets that meet all these criteria are available in this training module for the following care areas:
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What Types of Questions Should be Avoided?
Avoid using these types of questions:
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How do I Analyze Responses?
For many, perhaps most, interview questions it is sufficient to simply calculate the frequency of the various responses to each question: What percentage of the residents interviewed responded “yes” to the question? What percentage responded “no”?
If the question asks for a number in response (e.g., How many times during the day does someone who works here help you to use the bathroom?), then in addition to response frequencies, you may want to calculate an overall average for the question. This single number helps outline the big picture.
Consider creating an excel database that can quickly calculate frequencies and averages for you.
Responses to some questions require special handling:
The method follows three steps:
Our best advice is simply this: Let common sense guide you.
Bear in mind that you are collecting two types of data: 1) individual data, or the responses from each person who answers your questions, and 2) group data, as represented by the Big Picture you derive from considering all responses together. Conclusions drawn from the individual data may be very different from conclusions drawn from group data. Moreover, one data type may be more useful than the other type in guiding your improvement efforts. For example, the individual data is useful for care preference assessment and related care planning, as required by the MDS, to allow for resident-centered care; where as, the group data is useful for determining aspects of care in need of improvement for most residents in your facility. For example, if you want to offer social activities that most residents will enjoy, examine resident responses as a group.
More frequently, improvement efforts in nursing homes are intended to enhance care and daily life for the individual. If one resident prefers to get out of bed in the morning at 6am but his roommate prefers 8am, you meet neither one’s preference if you decide to split the difference and help them both to get up at 7am. When the goal is to individualize care and services to meet personal needs and preferences, resident-centered care provision, then your improvement efforts must be driven by the individual responses of each resident you interview.
You can use group data to set and measure performance goals, however. For example, an intervention designed to improve toileting assistance may aim to earn an average discrepancy score of 0, meaning that on average, residents who require toileting assistance receive as much of this assistance as each person wants.
Back to Top
Try This Assignment
Find out whether residents on one hallway or unit are getting helped out of bed in the morning at the times they prefer.
Back to Top or proceed to Resident-Centered Care
Click one of the following topics to skip to that section:
- Protocol Purpose
- When Should Quality Improvement Interviews with Residents be Conducted?
- Who Should be Interviewed?
- Who Should Conduct the Interviews?
- Where Should Interviews be Conducted?
- Is There Anything I Need to do Before Conducting the Interview?
- How Should Interviews be Conducted?
- What Types of Questions are Most Useful for Improvement Purposes?
- What Types of Questions Should be Avoided?
- How do I Analyze Responses?
- How do we Interpret our Findings?
- Try This Assignment
Protocol Purpose
“The question now is not, ‘Should we improve the quality assessment process by interviewing more residents? But rather, ‘How do we interview more residents within the cost constraints of the quality assessment process?’”
--John F. Schnelle. (2003). Improving Nursing Home Quality Assessment: Capturing the Voice of Cognitively Impaired Elders. J of Geron, Med Sci, 58A(3): 238-239.
In this section we present a protocol for conducting quality-of-life assessment interviews with nursing home residents that not only elicits information useful for improvement efforts but also is feasible to implement given the time- and cost-constraints in most facilities. In addition to quality improvement efforts, these assessments also allow for the identification of resident’s individual care preferences for care planning and more resident-centered care provision.
Based on research we conducted over the past eight years (see Related Studies), the protocol provides instructions on how to design and implement an assessment strategy that aims to achieve any one or all three of the below goals:
- Identifying resident’s individual preferences for care planning and resident-centered care delivery;
- Identifying nursing home care processes in need of improvement, and
- Designing and evaluating quality improvement interventions.
In keeping with a fundamental tenet of both resident-centered care and quality improvement (see Fundamentals for a New Assessment Strategy), it recognizes resident self-reports as the gold standard for assessing care preferences and quality of life.
The protocol is flexible, so it allows you to develop an assessment strategy that takes into account your resident population and facility resources. It presents general guidelines to work within, but leaves most of the decision-making to you: Do you want to interview all residents or a sub-group? Do you want to assess current residents or only new admissions? Do you want to evaluate quality of care across a broad range of domains or narrow the focus to a single care process? Though it is now common practice to assess consumer satisfaction in the managed care and hospital industries, such assessment is a relatively new practice in the long-term-care business. Often with new practices, the hardest part is just getting started. This protocol can help you clear that obstacle.
The protocol, presented below, is organized around commonly asked questions.
Back to Top
When Should Quality Improvement Interviews with Residents be Conducted?
If your facility, like most nursing facilities, does not routinely interview residents to assess their care preferences and quality of life, then we recommend that you start small, focusing first on a subset of residents, such as new admissions, or on a single care process or other activity you want to improve, such as walking assistance or shower/bathing process. With this in mind, here are two suggestions for when to conduct resident interviews:
- At admission, when you are required to assess, as part of the Minimum Data Set (MDS), a new resident’s care preferences, and again two weeks later, during the mandated reassessment for new residents. If completing the MDS plus a quality improvement (QI) interview takes too long for one sitting, then schedule the QI interview for the next day or as close to the MDS as possible. Tying your quality care assessment to the MDS will help ensure that it is completed in a time-efficient manner. In addition, using more structured interview questions, such as those in our protocol, to assess resident’s care preferences will allow for more complete and accurate information for care planning and resident-centered care delivery purposes.
- Just before an improvement intervention or a change in care practice is implemented, and then again after sufficient time has passed for residents to have registered the change in routine. You need interview only those residents who are the target of your improvement effort (e.g., residents on a given unit or floor). You can compare residents’ self-report from the before and after assessments to determine whether your change in practice is noticeable to the residents and making a positive difference in their daily life quality.
Back to Top
Who Should be Interviewed?
As a general rule, you should interview residents who score 2 or more on the Minimum Data Set (MDS) Recall subscale. Our research shows that these residents consistently provide reliable information useful for quality improvement efforts (1, 2). Ideally, the four MDS items that comprise the recall scale should be completed by nursing home staff familiar with the resident based on the most recent seven-day period, as opposed to relying on the most recent MDS assessment data, which may be three months or more old at any one point in time.
If your questions ask about services or care processes that occur daily, as opposed to less frequently, or subjective aspects of care (e.g., food preferences) then you should also interview residents who score 1 (or more) on the MDS Recall subscale. Our research shows that the majority of these residents can reliably self-report pain and depression, express meaningful preferences for daily care (they can tell you, for example, what activities they like, what food they want for breakfast and where they like to eat their meals).
If you are assessing quality of care for a specific activity of daily living (ADL), interview residents (with appropriate MDS Recall scores) who require any level of staff assistance (supervision to total dependence) for that ADL, excluding only residents who are either completely independent or completely unable to do the activity (e.g., unable to walk, even with assistance). You can use MDS ADL ratings to identify appropriate interview candidates:
Residents should be asked questions about only the care activities that are relevant to them. Do not, for example, ask a bed-bound resident questions about getting in and out of bed or ask a resident completely incapable of walking questions about walking assistance.
Back to Top
Who Should Conduct the Interviews?
Interviews should always be conducted in-person with residents. This enables a range of cognitively and physically impaired residents to participate. In-person interviews also provide an opportunity to clarify questions, which can lead to more accurate responses.
Because most daily care is provided by certified nursing assistants, a different staff member should conduct the interviews so that residents feel sure their reports are confidential. Ideally, a social worker or licensed nurse should conduct the interviews.
Back to Top
Where Should Interviews be Conducted?
Interview each resident in a private room to ensure confidentiality. The room should be quiet (turn off television, radio) so that the resident is not distracted and can hear you more easily.
Is There Anything I Need to do Before Conducting the Interview?
Determine whether the resident you are about to interview needs a hearing device and if so, whether the device is available. When we conduct interviews, we arrive prepared to offer residents the use of amplifying earphones (inexpensive and available from most electronic stores). Also, find out whether the resident has any particular needs (e.g., has difficulty speaking) that might affect participation in the interview. Review the resident’s most recent MDS assessment so that you are aware of which ADL care activities the resident requires assistance to perform and which aspects of the interview may not be applicable to the resident due to complete independence or inability.
Back to Top
How Should Interviews be Conducted?
Introduce yourself and spend a few minutes establishing rapport with each resident or simply socially interacting with the resident.
Follow good interviewing techniques: Your mouth should be clearly visible to the resident; you can help the resident focus his or her attention by using the person’s name and by using touch. Situate yourself so that you are as level as possible with the resident’s eyes.
Make sure the resident can hear you and understands each question, to the greatest extent possible. You may need to check the person’s hearing aide.
Reassure the resident that his or her responses will be kept confidential. Feel free to adopt the preface we often use: “Everything you tell me will be kept private. I will not tell the staff (the people who work here) what you say. Some of these questions are personal, so if there are any questions you feel uncomfortable answering, you don’t have to answer. Also, some of my questions may seem silly but please try to answer as many as you can. You may discontinue this interview at any time and it will in no way affect the care you receive. (Our state) law requires that I report abuse. If this occurs, I will tell you exactly what I plan to tell the social worker here, and you will be protected from any further harm from staff.”
Avoid awakening residents or interrupting social visits, meals, or activities to conduct an interview.
Back to Top
What Types of Questions are Most Useful for Improvement Purposes?
You can develop interview questions that specifically address the care areas and aspects of quality of life that are the focus of your facility’s improvement efforts and/or resident-centered care delivery program. In general, interview questions should:
- Require a simple yes/no response.
- Be direct, specific and concrete.
- Focus on daily occurrences, because these are most recent and tangible in the resident’s memory. Ideally, questions should be posed shortly after the occurrence of the care or other activity in question.
- Should include discrepancy questions that compare residents' preferences for care to their perceptions of the care they actually receive (e.g., “How many times during the day would you like the staff to help you to the bathroom?” vs. “How many times during the day do the staff help you to the bathroom?”). You can score such questions by subtracting the second answer from the first. For example, if a resident says he is provided toileting assistance once a day but he prefers to receive assistance three times a day, then the discrepancy score is -2 (i.e., 1-3 = -2). The negative difference signals unmet needs. Although discrepancy questions are most appropriate for evaluating care frequency preferences, they can also be used to evaluate other aspects of care, such as dining location (“Where do you like to have breakfast? versus “Where do you have breakfast?”), or timeliness of care (e.g., “What time do staff help you out of bed in the morning?” versus “What time would you like for staff to help you out of bed in the morning?”)
- Should include some structured open-ended questions (e.g., “If you could change something about the toileting schedule or the way staff help you to use the toilet, what would it be?”).
Question sets that meet all these criteria are available in this training module for the following care areas:
- Toileting assistance
- Walking assistance
- Dressing and personal hygiene assistance
- Getting in and out of bed
- Social activity participation
- All of the above care areas
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What Types of Questions Should be Avoided?
Avoid using these types of questions:
- Direct satisfaction questions (e.g., “Are you satisfied with the nursing care?”). They are not very informative from a quality improvement standpoint and tend to elicit an acquiescent response bias among residents (see Fundamentals of a New Assessment Strategy).
- Questions that use abstract constructs (e.g., “Do the staff treat you with dignity and respect?”). A better way to assess “dignity and respect” within care delivery is to ask about concrete staff behaviors, such as:
- “Do the people who work here knock on your door before entering the room?"
- ”pull your curtain before helping you to get dressed?”
- "address you by name when they see you?"
- ”tell you when they will be back to check on you again?” - Questions that require residents to rate their satisfaction along any type of rating scale (e.g., a three- or five-point scale or along a scale with responses such as, very satisfied, moderately satisfied, unsure, moderately dissatisfied, very dissatisfied). Many residents are simply unable to use these complex multiple point scales.
- Questions that require residents to remember details about infrequent events (e.g., a monthly visit from a primary care physician that occurred several weeks prior to the interview).
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How do I Analyze Responses?
For many, perhaps most, interview questions it is sufficient to simply calculate the frequency of the various responses to each question: What percentage of the residents interviewed responded “yes” to the question? What percentage responded “no”?
If the question asks for a number in response (e.g., How many times during the day does someone who works here help you to use the bathroom?), then in addition to response frequencies, you may want to calculate an overall average for the question. This single number helps outline the big picture.
Consider creating an excel database that can quickly calculate frequencies and averages for you.
Responses to some questions require special handling:
- Discrepancy questions: As noted earlier, these come in sets of two and compare residents' preferences for care to their perceptions of the care they actually receive. If, for example, the first question asks, “How many times during the day would you like the staff to help you to the bathroom?” then its companion question will ask, “How many times during the day do the staff help you to the bathroom?” To make full use of these questions, you should calculate a “discrepancy score” for each individual by subtracting the second answer from the first. For example, if a resident says he receives toileting assistance once a day but he prefers toileting assistance three times a day, then the discrepancy score is -2 (i.e., 1-3 = -2). The negative difference signals unmet needs. You can use the discrepancy scores for all residents interviewed to calculate an overall average discrepancy score.
- Open-ended questions: Responses to these questions, as well as spontaneous comments to other types of questions, provide valuable information for individualizing care that forced-choice questions by their very nature cannot capture. For starters, then, you should make it a point to simply listen carefully and take into consideration what your residents have to say. If you go one step further and codify their comments, you can analyze this data quantitatively, adding it to the Big Picture of care quality in your facility. In a recent study, we evaluated a simple, reliable method for coding residents’ comments (9).
The method follows three steps:
- Ask whether each comment indicates a desire for change, that is, for something other than the status quo (e.g., “I would like to walk more often”). Code as yes or no.
- If a change is desired, then ask whether interaction with staff is needed to bring about the change (e.g., “I would like more encouragement to walk”). Code as yes or no.
- If interaction with staff is required, then ask whether the comment refers to the manner of care delivery (e.g., “When they dress you they are rough, not kind.”). Also ask whether it refers to technical aspects of care, such as frequency or timeliness (e.g., “I would like a shower every day”). Code as either one or the other (manner of care versus technical care) or both.
Our best advice is simply this: Let common sense guide you.
Bear in mind that you are collecting two types of data: 1) individual data, or the responses from each person who answers your questions, and 2) group data, as represented by the Big Picture you derive from considering all responses together. Conclusions drawn from the individual data may be very different from conclusions drawn from group data. Moreover, one data type may be more useful than the other type in guiding your improvement efforts. For example, the individual data is useful for care preference assessment and related care planning, as required by the MDS, to allow for resident-centered care; where as, the group data is useful for determining aspects of care in need of improvement for most residents in your facility. For example, if you want to offer social activities that most residents will enjoy, examine resident responses as a group.
More frequently, improvement efforts in nursing homes are intended to enhance care and daily life for the individual. If one resident prefers to get out of bed in the morning at 6am but his roommate prefers 8am, you meet neither one’s preference if you decide to split the difference and help them both to get up at 7am. When the goal is to individualize care and services to meet personal needs and preferences, resident-centered care provision, then your improvement efforts must be driven by the individual responses of each resident you interview.
You can use group data to set and measure performance goals, however. For example, an intervention designed to improve toileting assistance may aim to earn an average discrepancy score of 0, meaning that on average, residents who require toileting assistance receive as much of this assistance as each person wants.
Back to Top
Try This Assignment
Find out whether residents on one hallway or unit are getting helped out of bed in the morning at the times they prefer.
- Use our In and Out of Bed Schedule assessment.
- Interview the residents. For this assignment, after introducing yourself, you need only ask residents questions 1 and 3 on the form:
- Q1: About what time do you get out of bed in the morning?
- Q3: About what time do you like to get out of bed in the morning?
Note: If residents have difficulty providing a specific time, an alternative way to ask these questions is:
- Q1: Do you get out of bed before breakfast or after breakfast?
- Q3: Would you like to get out of bed before breakfast or after breakfast? - Analyze results. Identify those residents who say they would like to get up at a time different from when they say they do get up.
- Create a checklist of these “dissatisfied” residents’ names and the time of morning each would like to get up from bed.
- The next day, check it out: Stroll down the hallway in the morning and make a note of who’s out of bed at the preferred time and who’s not.
- What can the staff do to improve results?
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