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Fulfilled preferences, perceived control, life satisfaction, and loneliness in elderly long-term care residents.

Author: Nathaniel Andrew

Andrew, Nathaniel, and Suzanne Meeks. “Fulfilled Preferences, Perceived Control, Life Satisfaction, and Loneliness in Elderly Long-Term Care Residents.” Aging & Mental Health, vol. 22, no. 2, Feb. 2018, pp. 183–189. EBSCOhost, doi:10.1080/13607863.2016.1244804

Objectives: Person-centered care constructs such as fulfilled preferences, sense of control, and life satisfaction might contribute to loneliness among nursing home residents, but these relationships have not been thoroughly explored. The aim of this study was to examine the relationship between fulfilled preferences and loneliness in nursing home residents with perceived control and life satisfaction as potential mediators. Methods: The study utilized a cross-sectional design, examining the targeted variables with a questionnaire administered by trained research staff. A convenience sample of 65 residents (median age = 71) of eight nursing homes were interviewed. Linear regression analysis was utilized to examine the mediation hypotheses. Results: The relationships between fulfilled preferences and loneliness (β = −.377, p =.002), fulfilled preferences and perceived control (β = −.577, p <.001), and perceived control and loneliness (β =.606, p <.001) were significant, and the relationship between fulfilled preferences and loneliness (β = −.040, p =.744) became non-significant when perceived control was included in the model. The relationships between fulfilled preferences and life satisfaction (β =.420, p <.001) and life satisfaction and loneliness (β = −.598, p <.001) were significant, and the relationship between fulfilled preferences and loneliness (β = −.152, p =.174) became non-significant when life satisfaction was included in the model. Conclusion: The findings suggest an important association between person-centered care, particularly fulfilling personal care and recreation preferences, and social-affective needs of long-term care residents. Fulfilling preferences may be an appropriate intervention target for loneliness.

Keywords: Loneliness; long-term care; perceived control; preferences


Loneliness is a significant clinical issue due to a variety of associated negative quality of life outcomes, and its high prevalence in long-term care settings warrants more attention in current research initiatives. Bridging the gap between research on person-centered care and social need in older adults in long-term care settings can inform policy and procedures to help improve long-term care residents' psychosocial environment. The purpose of this study is to add to the literature on person-centered care and clinical outcomes through exploring important relationships among fulfilled preferences, perceived control, life satisfaction, and loneliness in long-term care residents.

Loneliness is a mental and emotional health construct that describes a deficit in an individual's feelings of social fulfillment. The construct has been defined as the discrepancy between one's desired and actual experience of social satisfaction (Hawkley & Cacioppo, [18]; Perlman & Peplau, [28]; Pinquart & Sorensen, [29]), which occurs when one's desire for social and emotional support does not meet one's expectations. Loneliness has also been conceptualized as a measure of an individual's subjective dissatisfaction with their social relationships (Gierveld, [16]; Perlman & Peplau, [28]). Loneliness is a negative state of emotion that may be experienced by people of all ages (McWhirter, [25]). The experience of loneliness may also include feelings of 'emptiness' and 'abandonment' (Gierveld, [16], p. 74). In sum, loneliness may be defined as low satisfaction with social support, leading to a negative affective state.

The experience of loneliness is associated with many negative quality of life outcomes such as poor physical health (Luanaigh & Lawlor, [23]), poor mental health (Coyle & Dugan, [ 8]; Fees, Martin, & Poon, [15]; Luo, Hawkley, Waite, & Cacioppo, [24]; McWhirter, [25]; Prieto-Flores, Forjaz, Fernandez-Mayoralas, Rojo-Perez, & Martinez-Martin, [30]), and suicide (Ernst & Cacioppo, [14]; McWhirter, [25]). Several reviews indicate that loneliness may be common among the oldest older adults (Dykstra, [13]; Victor, Scambler, Bond, & Bowling, [38]), and cross-sectional data suggest that loneliness increases in the oldest old age groups (over 80 years old) when compared to younger old groups (between 60 and 80 years old) (Pinquart & Sorensen, [29]). The loss of friends, transitions to care facilities, and declining health conditions are common late-life psychosocial stressors that may lead to an increased risk of loneliness in older adults (Hicks, [19]). Over 45% of a sample of older adults living at home in Sweden and Finland indicated feeling either sometimes or often lonely (Nyqvist, Cattan, Andersson, Forsman, & Gustafson, [26]). Similarly, 40%–41% of Australian and British samples of elderly adults reported being lonely at least sometimes (Victor, Grenade, & Boldy, [37]), and 32% of community-dwelling older adults with 'integrated social networks' (p. 695) in a Dublin sample reported loneliness within the last month (Golden et al., [17]). Loneliness prevalence may be even higher than what is self-reported; older adults may under-report loneliness due to the stigma associated with the experience (Victor et al., [38]).

Loneliness may be more prevalent in long-term care residents as compared to community-dwelling older adults. In a cross-sectional study, 56% of a Norwegian nursing home sample experienced loneliness to some degree (Drageset, Kirkevold, & Espehaug, [12]). Another recent study indicated that 55% of older adults in a nursing home care sample from Sweden and Finland experienced loneliness at least sometimes or often (Nyqvist et al., [26]). Research suggests a greater percentage of older adults in long-term care settings are lonely when compared to community-dwelling older adults (Nyqvist et al., [26]; Pinquart & Sorensen, 2001; Prieto-Flores et al., [30]). Qualitative research also suggests that living in a nursing home can be a lonely experience (e.g. Slettebø, [34]). In general, current literature suggests that loneliness is common in long-term care.

Long-term care residents' preferences and perceived control

Due to the rise of the person-centered care movement, nursing home caregivers are becoming more aware of the importance of recognizing nursing home residents' preferences. The person-centered care movement began as a type of reform urging long-term care facilities to shift from a medical emphasis to an emphasis on providing residents with more control, autonomy, and choices in their daily lives. Preferences, in the context of a nursing home resident's daily activities and care, may take the form of decisions and choices the resident desires. Recognizing and fulfilling residents' preferences in life activities and choices is a main tenet of the person-centered care movement, and recent studies are seeking to better understand older adults' preferences (Bangerter, Van Haitsma, Heid, & Abbott, [ 1]; Carpenter, Van Haitsma, Ruckdeschel, & Lawton, [ 6]; Van Haitsma et al., [36]). In addition, the person-centered care movement focuses on providing nursing home residents with a sense of control over their environment and activities. Kane and colleagues (Kane et al., [20]; Kane & Kane, [21]) have suggested that nursing home residents value the ability to have a degree of control and to be empowered in their life choices. Satisfying residents' preferences and providing a greater range of choices may result in greater quality of life (Koren, [22]). An increased interest in understanding nursing home residents' preferences and choices has led to increased efforts to offer them more control over their lives. For example, the newest version of the Minimum Data Set (MDS version 3.0), required as part of a broader assessment of nursing home resident health care needs, obligates nursing home staff to assess residents' care and activity preferences. However, there are few, if any, studies that explore the relationship of resident preferences, sense of control, and loneliness in elderly nursing home populations.

It may be the case that loneliness is one domain of mental health for which a greater sense of personal preferences and control may be important. Fulfilled resident preferences, perceptions of control, and loneliness may be connected in several ways. For example, residents who have more of their preferences satisfied may subsequently gain a greater sense of control and efficacy in their living situation. According to the person-centered care ideal, nursing home residents' experience involves more individualized care (Brownie & Nancarrow, [ 5]), which may impact residents by providing a greater sense of control and autonomy (Brownie & Horstmanshof, [ 4]). Thus, offering residents choices with their activities and care empowers them and gives them a perception of having more control over their lives.

In turn, an increased sense of control may impact an individual's loneliness experience. One of the characteristics of the loneliness construct is a lack of the perception of control. Loneliness may be connected to the feeling that one does not have control over one's situation (Weeks, [39]). Perlman and Peplau ([28]) suggested that perceiving a sense of control over one's situation may influence individuals to find ways to decrease their loneliness. Similarly, the idea of competence, in activities dictated by a resident's preferences, is related to loneliness (Pinquart & Sorensen, [29]); if residents have a sense of competence over decisions of everyday life, they may then feel more in control of their living situation, which may influence social efficacy as well. In one recent review, Hawkley and Cacioppo ([18]) summarize a model of loneliness emphasizing that lonely people may feel unsafe and that the world is dangerous. People who lack social fulfillment may perceive themselves lacking control and may feel insecure in their circumstances. Similarly, Gierveld ([16]) suggests people who are lonely may feel powerless about their situations. Individuals with greater fulfilled preferences may feel more in control of their circumstances, and people who feel more in control of their circumstances may be less likely to feel lonely; therefore, individuals with greater fulfilled preferences may be less likely to feel lonely.

Having fulfilled preferences may also influence loneliness through an increase in positive emotions and greater life satisfaction. Greater life satisfaction has been associated with less loneliness (de Guzman et al., [10]). Nursing home residents who are offered more choices in daily activities may feel more fulfilled, whereas a lack of fulfilling activities may contribute to loneliness (Brownie & Horstmanshof, [ 3]). Facilitating more positive emotions in residents through satisfied preferences may counter those negative emotions. For many older adults, the aging process may involve a loss of stability in various life domains, such as health and living situation (Hicks, [19]), which may lead to sadness or other negative emotions. Expressing choices and preferences for certain life activities and decisions is a way to achieve more positive emotions and satisfaction during such a stressful period of life. Completing activities that are aligned with a resident's preferences is related to less loneliness (Pinquart & Sorensen, [29]); it is possible that activity engagement may help people cope with their loneliness. For these reasons, it would seem that having a higher number of satisfied preferences would increase life satisfaction, which in turn would decrease one's feelings of loneliness.


In this study, we addressed nursing home residents' experience of loneliness in relation to preferences, control, and life satisfaction using the following hypothesized model of their inter-relationship: nursing home residents may gain a greater sense of control of their daily lives through greater fulfillment of their preferences for life activities, schedule, and social life. Greater sense of control, through empowering residents and making them feel competent, may lead to less loneliness. In addition, fulfilled preferences may lead to greater life satisfaction, which may influence loneliness as well. We hypothesized that having more fulfilled preferences would be associated with less loneliness and that this relationship would be mediated by higher levels of perceived control and life satisfaction.


Institutional Review Board approval

This study was approved by the College of Arts and Sciences Institutional Review Board at the University of Louisville (No. 15.0633).


The volunteer sample was comprised of cognitively intact residents in 8 nursing homes in the Louisville metropolitan area and southern Indiana. On average, the 8 facilities held 141 beds, had staffing of 1.65 hours per resident day, had a 3 star Centers for Medicare & Medicaid Services (CMS) rating, and were for-profit businesses. Although age was not an inclusion criterion for the sample, the majority of the sample consisted of older adults; participants ranged in age from 51 to over 90 (Mdn = 71). As the age of individuals over 90 is considered protected health information, participants who reported they were 90 or older were recorded as '90+' in the database so as not to identify them. As such, the specific age of eight residents over 90 was not recorded in the database. Residents who were cognitively unable to consent, unable to articulate answers to interview questions, or who did not explicitly communicate a desire to participate were excluded from the study. Refer to Table 1 for resident demographics.

Table 1. Sample demographics (N = 65).

N Percentage
 Male 23 35.4
 Female 42 64.6
 White 51 78.5
 African-American 14 21.5
Marital status
 Single 16 24.6
 Married 14 21.5
 Divorced 18 27.7
 Widowed 17 26.2


The study utilized a cross-sectional design, examining the targeted variables with a questionnaire administered by trained research staff. Measures of participant demographics, preferences, life satisfaction, sense of control, and loneliness were administered via one face-to-face interview. Approximately 15–20 minutes were needed to complete the interview. Fourteen nursing homes in the Louisville metropolitan area and southern Indiana were contacted for permission to recruit residents within their facility. Only facilities who had given the research group permission to recruit for previous studies were contacted. Eight facilities gave permission to recruit, and a convenience sample of residents was recruited in all eight facilities. An a-priori power analysis was conducted to determine how many participants would be needed to achieve sufficient power. It was calculated that 68 participants would be needed assuming a medium effect size of.15, power of.8, and alpha of.05. We approached approximately 200 residents to ask about their interest in participating. Seventy-five residents were consented for the interview, and 10 were excluded from the analysis after consenting. Of these 10 excluded participants, four of them never began the interview either because they changed their mind about participating or because it was deemed after the consent process that they were not cognitively capable of responding reliably. Of the 10 excluded participants, six were excluded from the analysis after beginning the interview. Of these six, five participants were excluded from the analysis because they either voluntarily withdrew or their responses were deemed unreliable due to confusion or a lack of understanding of the questions. One participant was excluded from the analysis after they began the interview because the interviewer failed to use a complete interview packet. As a result, 65 participants were included in the final analysis. Residents were recruited only in the long-term care sections of each facility, and efforts were made to avoid recruiting residents in short-term rehabilitation. Residents were not compensated for participation.

Residents were recruited by interviewers walking through each facility and approaching those who appeared generally alert. Residents who were sleeping or clearly unaware of their surroundings were not approached for recruiting. In addition, nursing staff were occasionally asked whether any of their residents may be interested and cognitively capable of participating in a brief interview. Some residents were approached based on staff members' response in the affirmative. Alert residents were asked by the interviewer if they were interested in participating in a research study. If general interest was expressed, the interviewer read the study consent form to the resident and inquired if they had any questions. If there was any uncertainty as to whether the resident may be either more than mildly cognitively impaired or unable to consent due to confusion about the nature of the study, the interviewer would ask one or more questions to confirm the resident's level of awareness (e.g. 'In your own words, could you tell me what I am asking you to do if you decide to participate?') . Based on the resident's response, if the determination was made that the resident did not have capacity to participate, the interview would not be commenced; otherwise, the interview protocol was administered.


Demographic variables (age, gender, race/ethnicity, and marital status) were assessed via self-report during the interview.


Residents' preferences were assessed with the Preferences for Everyday Living Inventory (PELI), originally developed to measure the psychosocial needs of community-dwelling older adults (Carpenter et al., [ 6]; Van Haitsma et al., [36]). The measure has been modified for use in nursing home populations (e.g. Curyto, Van Haitsma, & Towsley, [ 9]). The original measure includes 55 items from domains including 'Social Contact', 'Growth Activities', 'Diversionary Activities', 'Self Dominion', and 'Enlisting Others in Care' (Van Haitsma et al., [36]). In order to minimize the burden on participants in this study, we selected 12 preferences appropriate to nursing home settings based on our experience working in nursing homes. Preferences from the domains with the three highest Cronbach's alpha values from a previous study (Van Haitsma et al., [36]) were chosen in order to facilitate the selection of domains with the highest internal consistency: growth activities (α =.664), social contact (α =.581), and self-dominion (α =.552). For each item, participants were asked how important each preference was to them, with response options of not important at all, not very important, somewhat important, and very important. In a previous study, nursing home residents also rated PELI items with responses of either 'not at all satisfied', 'somewhat satisfied', or 'completely satisfied' (Van Haitsma et al., [35]) with respect to whether their preferences were honored. In this study, for items rated 'somewhat important' and 'very important', participants rated whether those preferences were fulfilled using a scale from 1 (not satisfied at all) to 10 (completely satisfied). These values were averaged to create a total preferences average variable with a range from 1 to 10. The intent of this modified measure was to assess the fulfillment of preferences that were at least somewhat important to the resident. For this scale in this study, α =.856.


Loneliness was assessed using the 20-item UCLA Loneliness Scale version 3 (α =.89) (Russell, [31]). Higher overall scores on the scale equates to greater loneliness. Scaled response options for each question range from 1 (never) to 4 (often). Several items are reverse-coded. Scores on the 20 items were summed for a total loneliness score.

Perceived control

Three items created specifically for this study assessed residents' sense of control over daily life activities, routine/schedule, and social life: 'Do you perceive that you have control over your daily life activities?', 'Do you perceive that you have control over your daily routine?', and 'Do you perceive that you have control over your social life?' The three questions were intended to reflect the construct of 'perceived control' and to approximately correspond to the PELI domains of growth activities (corresponding to daily life activities), self-dominion (corresponding to routine/schedule), and social contact (corresponding to social life). Cronbach's alpha for the 3-item perceived control scale was.859 in the present sample. Responses on the scale range from 1 (no control) to 10 (complete control). Scores for the three items were averaged for a perceived control score.

Life satisfaction

The 5-item Satisfaction with Life Scale (α =.87) (Diener, Emmons, Larsen, & Griffin, [11]) was utilized to measure the life satisfaction construct. The scale has previously been utilized in the nursing home setting with good internal consistency (α =.81) (e.g. O'Connor & Vallerand, [27]). Responses for each question ranged from 1 (strongly disagree) to 7 (strongly agree), with higher overall scores indicating greater life satisfaction. The responses were summed for a total life satisfaction score.


Simple and multiple linear regression was used to examine the mediational analyses according to Baron and Kenny's four step method (1986). According to Baron and Kenny, a hypothesis of mediation is supported if the following conditions are met: ( 1) the causal variable is associated with the outcome variable, ( 2) the causal variable is related to the potential mediating variable, ( 3) the potential mediating variable is associated with the outcome variable, and ( 4) the relationship between the causal variable and the outcome variable is no longer significant when the potential mediator is included in the model. The analyses were conducted with IBM SPSS Statistics for Windows (Version 22.0).


Descriptive statistics for average preferences satisfaction, average perceived control, total loneliness, and total life satisfaction are listed in Table 2. On average, residents reported their preferences were mostly satisfied or fulfilled (M = 8.02, SD = 1.58), and they perceived they had much control across domains of their daily life (M = 7.20, SD = 2.33). On average, participants reported high levels of loneliness (M = 41.43, SD = 12.40) relative to other elderly samples (e.g. Russell, [31]; Winningham & Pike, [40]). On average, residents felt neutral in regard to their life satisfaction (M = 22.85, SD = 8.28).

Table 2. Descriptive statistics for loneliness, life satisfaction, and perceived control measures (N = 65).

Average preferences fulfillment Total loneliness Total life satisfaction Average perceived control
Mean 8.02 41.43 22.85 7.20
SD 1.58 12.40 8.28 2.33
Maximum 10 67 35 10
Minimum 4.20 20 5 1
Scale range 1–10 20–80 5–35 1–10

Utilizing a median split, levels of loneliness were examined for residents with high preference satisfaction and low preference satisfaction as well as high and low perceived control. An independent samples t-test indicated that the low preference satisfaction group (M = 46.12, SD = 9.92) reported significantly greater loneliness than the high preference satisfaction group (M = 36.59, SD = 13.09); t(62) = 3.283, p =.002. Similarly, the low perceived control group (M = 48.16, SD = 9.58) reported significantly greater loneliness than the high perceived control group (M = 34.84, SD = 11.55); t(62) = 5.018, p <.001.

Perceived control

To examine whether perceived control mediated a relationship between preferences and loneliness, we conducted a mediation analysis by following the four step method proposed by Baron and Kenny ([ 2]). As the total control variable was initially negatively skewed (skewness statistic = −.660, SE =.297), the data were reflected and transformed using a square root transformation (transformed skewness statistic =.146, SE =.297). The reflected and transformed values were used in the regression analyses and are represented in the regression table; higher values represent lower perceived control, and lower values equal higher perceived control after the reflection. There was a significant correlation between fulfilled preferences and perceived control, r(63) =−.58, p <.001, fulfilling the second condition for mediation, that the mediator and 'predictor' variable be correlated. We used a hierarchical linear regression to test Baron and Kenny's conditions 1, 3, and 4 (see Table 3). Fulfilled preferences, entered in Step 1, explained a significant proportion of variance in loneliness scores; R2 =.142, F( 1, 63) = 10.409, p =.002. Greater fulfilled preferences was associated with less total loneliness, β = −.377, t(63) = −3.226, p =.002. When perceived control was entered in Step 2, perceived control was significantly associated with less total loneliness, β =.583, t(63) = 4.713, p <.001, and the relationship between fulfilled preferences and total loneliness was no longer significant (β = −.040, t(62) = −.327, p =.744), supporting the mediation hypothesis.

Table 3. Results of hierarchical linear regression analyses testing the mediation of perceived control and life satisfaction on the relationship between fulfilled preferences and loneliness (N = 65).

Analysis for perceived control as a mediator of loneliness
Step Variables entered B ( SE ) B R


(1) Fulfilled preferences −2.949(.914) −.377** .142
(2) Fulfilled preferences −.317(.968) −.040 .368
Perceived control 11.891(2.523) .583**
Analysis for life satisfaction as a mediator of loneliness
(2) Fulfilled preferences −1.191(.865) −.152 .377
Life satisfaction −.800(.165) −.535**

2 ** p<.01.

The analysis indicated that perceived control mediated the relationship between fulfilled preferences and loneliness. The standardized indirect effect was (−.577)(.583) = −.336. The significance of the indirect effect was tested using bootstrapping estimation procedures utilizing 1000 bootstrapped samples. The unstandardized indirect effect was −2.632, and the 95% confidence interval ranged from −4.655 to −1.365. Thus, the indirect effect was statistically significant.

Life satisfaction

We examined the mediation hypothesis for life satisfaction in the same way as for perceived control. The results are also shown in Table 3. There was a significant correlation between fulfilled preferences and life satisfaction, r(63) =.42, p <.001, fulfilling the second condition for mediation, that the mediator and 'predictor' variable be correlated. We used a hierarchical linear regression to test Baron and Kenny's conditions 1, 3, and 4 (see Table 3). Step 1 was identical to the previously described mediation analysis. In Step 2, life satisfaction was significantly associated with less total loneliness, β = −.535, t(63) = −4.839, p <.001, and the relationship between fulfilled preferences and total loneliness was no longer significant (β = −.152, t(62) = −1.376, p =.174), supporting the mediation hypothesis.

The analysis indicated that life satisfaction mediated the relationship between fulfilled preferences and loneliness. The standardized indirect effect was (.420)(−.535) = −.225 The significance of the indirect effect was tested using bootstrapping estimation procedures utilizing 1000 samples. The unstandardized indirect effect was −1.759, and the 95% confidence interval ranged from −3.344 to −.786. Thus, the indirect effect was statistically significant.


The overall purpose of the study was to examine a number of interesting conceptual relationships associated with the psychosocial experience of older adults in long-term care. The first primary hypothesis, that perceived control mediates the relationship between fulfilled preferences and loneliness, was supported by the linear regression analysis. The second primary hypothesis, that life satisfaction mediates the relationship between fulfilled preferences and loneliness, was also supported by the linear regression analysis. The effect sizes as reflected in the data were bigger than anticipated based on the a-priori analyses, which suggested that the study was sufficiently well-powered despite the modest sample size. The evidence for mediation effects suggests perceived control and life satisfaction are potentially important explanatory variables in the relationship between residents' care preferences and feelings of loneliness.

The findings suggest residents' sense of control over daily life is strongly related to feelings of loneliness. The results of the current study, confirming an association between having one's preferences fulfilled and loneliness, identify perceived control as significant to that relationship. It may be that meeting the psychosocial needs of long-term care residents enables them to feel more autonomy and more influential in maintaining a desirable personal care environment. In contrast to long-term care residents who have learned to be helpless because of a perceived lack of control over their daily lives, residents who have their preferences met may be given influence in their own life decisions, leading them to feel empowered. Residents who feel they have choices regarding their activities, their schedule, and their social interactions may be better able to cope with potential feelings of loneliness. Since this is a cross-sectional study, an alternative interpretation is that people who are high in perceived control are better at getting their preferences met. Either way, the findings support the notion that control and preferences, together, are important for mitigating loneliness.

In addition, the findings indicate the importance of life satisfaction in relation to loneliness. As the data indicate, the significant relationship between fulfilled preferences and loneliness disappears when life satisfaction is added to the equation, suggesting life satisfaction is strongly related to residents' psychosocial needs. Implementing a person-centered care approach by increasing positive events, activities, and social interactions may lead to greater satisfaction in residents' aging experience, which may help fill the emptiness that accompanies deficiencies in social support and unfulfilled social needs. Previous studies have found that loneliness interventions emphasizing various activities may have a positive impact on older adults' mental health (Cohen-Mansfield & Perach, [ 7]). It may be the case that activities interventions targeting specific resident preferences may help alleviate resident loneliness through increased life satisfaction.


The study utilized a convenience sample of residents in facilities that had previously worked with the research team, and residents were volunteers. The sample may not be representative of a typical nursing home population, as the study excluded residents who were so cognitively impaired that they were unable to respond to interview prompts, and thus may represent only the younger and higher functioning residents. Also, residents who were open to or available for a brief interview may differ systematically from other residents, which could lead to lonelier residents being excluded from the sample. The opposite effect could also occur in that lonelier residents might be more likely to agree to an interview because they desired the interpersonal contact. Staff members' recommendations could also have been biased towards more open, verbal, or socially engaging residents as well as residents who were already more satisfied with their care.

The three items used to measure sense of control were developed for the current study. No established, valid measure of perceived control for nursing home residents was found for use in this study, which could have limited the measurement of that construct. Our items were worded to correspond to residents' perception of their control of activities, schedule, and social environment, but to be certain that the items were not confounded with other constructs (e.g. depression), more research on those items would be needed. In addition, because of considerations of time and resident endurance, the PELI section of the interview was limited to only 12 items. Although we selected the items that we felt would be most representative of each area of care, it is possible that a different sample could have altered the results. It may be that participants had more difficulty responding to the 10-point perceived control and preference satisfaction scales than they would have in responding to scales with fewer scale choice points, although the variability and good reliability of their responses suggests this was likely not the case. In addition, this study did not utilize a standardized measure of cognitive status or depression, and it is possible that these variables may have had a confounding influence on residents' self-report of life satisfaction and loneliness. Finally, as the study is cross-sectional, we are unable to infer causal relationships from our results. Because the data were collected at only one time point, it is possible that fulfilled preferences served as a mediator in the relationship between perceived control and loneliness instead of the other way around. Despite these limitations, our planned analyses were consistent in supporting our hypotheses; replication of the finding with an additional nursing home sample will also be important.

Implications and conclusions

Data from this study suggest an important relationship between person-centered care and social needs. To better understand the long-term significance of these relationships, the findings could be further tested with a longitudinal design or by implementing an intervention targeting fulfillment of resident preferences in an experimental design, which could help determine whether fulfilling preferences leads to increased control, increased life satisfaction, or reduced loneliness. Future research may also seek to identify ways to increase residents' perceived control and life satisfaction, given the strong correlations between those constructs and loneliness. Next steps may include research initiatives designed to identify better assessment and intervention techniques for fulfilling resident preferences and choices (see Schnelle, Bertrand et al., [32]; Schnelle, Rahman et al., [33]). Examining potential differences between nursing home facilities may help clinicians and facility staff work to implement measures to expand resident choices, autonomy, and satisfaction regarding their living environment.

Loneliness is a clinical issue relevant to vulnerable nursing home residents struggling to adjust to their ever-changing social climate, and it is important to understand how the construct is related to aspects of their care experience. The problem of loneliness in long-term care facilities is under-researched and undertreated. To alleviate loneliness, it will be important to continue to explore factors in the nursing home psychosocial experience that may be associated with loneliness. This study suggests that fulfilled preferences are a potential target for such exploration. Increased emphasis on person-centered care movement ideals may encourage nursing facilities to invest more resources to provide more enjoyable activities, a more flexible routine and schedule, and a greater awareness of opportunities to engage in positive social interactions. The person-centered care movement recognizes the significance of offering a care environment suitable not just for residents' medical needs, but also their quality of life needs. It is necessary to understand nursing home residents' broader care experience in the context of fulfilled preferences and psychosocial needs.

Older adults who transition into long-term care often find themselves in a situation where their selection of activities, decisions regarding their schedule, and opportunities for social interactions are vastly different from when they lived at home. For example, going outside or attending entertainment events may not be as simple as when they lived outside the facility. Choices regarding a desired morning routine or how to arrange the room may no longer remain viable options. Regular contact with family and friends may decrease below a desirable level. Nursing facilities may not be able to consistently satisfy the preferences of nursing home residents due to the lack of resources, time, or general awareness of the need. However, for nursing home residents, a lifestyle that does not support their basic psychosocial needs and preferences may have a negative impact on quality of life outcomes. Offering nursing home residents a flourishing rather than deteriorating psychosocial environment must involve opportunities to live a more satisfying life, and satisfying basic psychosocial preferences is a crucial step in moving toward that ideal.


This study was developed and implemented with support from the Aging and Mental Health Lab at the University of Louisville.

DMU Timestamp: November 27, 2019 01:26

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