“While
you are in this facility, how important is it to you to …?”
“Very important. Somewhat important. Not very important. Not important at all. Important but can’t do or have no choice.”
I’d like to turn that question around …
“As an activity professional, how
important is it to you to use up to date interview techniques that directly generate
meaningful information about your residents?”
- Very important (If I’m going to be held accountable for the numbers generated by the MDS, I want them to reflect reality.)
- Somewhat important (I’m kind of tired of residents telling me things that are the opposite of what their activity choices will be.)
- Not very important (Don’t know, don’t care.)
- Not important at all (I truly don’t mind wasting a lot of time to satisfy the folks at the Center for Medicare/Medicaid Services.)
- Important but can’t do or have no choice (The system is crippled, but nobody cares what I, a lowly AP, have to say about it.)
Back in the 1950s, a fledgling
psychologist named Daniel Kahneman was given the job of evaluating the new
soldiers in the Israeli army. They had
been using interviews, but the results were pretty meaningless. They didn’t help predict how the soldiers
would perform. Sound familiar? So, he designed a new type of interview. Michael Lewis describes the situation in his
book, The Undoing Project.
“He
[Kahneman] told them to pose very specific questions, designed to determine not
how a person thought of himself but how the person had actually behaved” (80).
Suddenly, they were generating more
meaningful data, data that had predictive value.
In the 60s and onward, Amos Tversky joined Kahneman to study how people make decisions. Again, Lewis describes their findings:
“When
people make decisions, they are also making judgements about similarity,
between some object in the real world and what they ideally want” (114).
Residents in long-term care are asked
to make decisions about which activities to participate in. At that point, they are making judgements
about the activities offered compared to what they ideally might want. But judgements about similarity, Lewis
continues, are related to the features we choose to compare, like how
noticeable they are, the context we see them in, and how our brains classify
them. For instance, a resident who likes
music might chose to skip a group music event because “it’s for old people who
have lost their minds.” He knows that other
seniors, ones with memory/health issues are likely to be there. However, if his room is close enough to the
event, he might hear the music and excitement, change his mind, and show up. Or not. Decision-making is highly subjective and can
change at any moment.
Tversky and Kahneman also realized
that people make decisions based on the potential loss or gain they associate
with the decision. But to use potential
loss vs. potential gain you have to start at some “reference point” of how you
value where you are right now. The
problem is that the reference point can also vary. It is basically a “state of mind” (275). I don’t know about you, but my state of mind
changes all the time. I have good days
and bad days, good moments and bad moments.
I remember skipping a good friend’s wedding back in the days when I was
single. It was only at the last minute
that the prospect of sitting through a lively Polish wedding reception with no
date suddenly sounded like a more of a downer than I wished to risk.
In the 1980s, I was in graduate school
studying sociolinguistics. We were
trying to find out which language people would tend to use, and for what
reasons, in societies that were multilingual.
Some languages enjoy higher prestige.
Some languages provide more credibility on the street. “Do not base your
data on self-reported language preferences,” my professors told me. Instead, we read about ingenious work-arounds
that linguists use to ferret out when, where and why people choose to use one
language instead of another. I have
interviewed people who claimed to always use a certain higher status
language. Only when pressed did they admit
to using a lower status language for some situations. Self-reported language use is more about
self-image, than fact. I suspect that
the self-reported importance of religious participation also often falls into
this category. It’s a normative, a “what
should be”, rather than what is.
Even major league baseball and
basketball have learned to upgrade the metrics they study. These teams compete during games, but they
also compete to sign the best players. Lewis
documented how the 2002 Oakland Athletics baseball team competed successfully
against teams with much more money to hire new talent. They found that the normal statistics that
scouts had been using failed to predict future performance. The Oakland A’s knew what to look for and could
get those players more cheaply because the big teams were overlooking them. I wonder what metrics we could come up with
that would more accurately predict future activity participation. And what if
what is important to US, and what WE prefer, is more relevant to their
participation than any data we could get from the residents themselves?
Do our residents maximize their
utility? Short answer – no. “Maximizing utility” means that people will
reliably attempt to get the most value for their expenditure, the most bang for
their buck. In the case of activity
programming, it could mean the most happiness for the expenditure of time and
energy. Kahneman saw that economists lagged
behind the psychologists because the economists
“…assumed
that you could simply measure what people wanted from what they chose. But what if what you want changes with the
context in which the options are offered to you?” (278)
Just
because someone used to enjoy doing something independently doesn’t guarantee
they will want to do it with our “facilitation,” or in the nursing home
environment at all. Ever.
Lewis
summarizes Kahneman’s conclusion about maximizing utility.
“…people’s anticipation of happiness
differed from the happiness they experienced, and … both differed from the
happiness they remembered.
…
If happiness was so malleable, it made a mockery of economic models that were
premised on the idea that people maximized their utility. What, exactly, was to be maximized?” (351).
In 2001, Kahneman, the psychologist,
won the Nobel Prize in …economics!
Scientists, psychologists, linguists,
statisticians, sports analysts, and economists, have found that people in
general are systematically irrational in their thinking processes and choices. We don’t really know why we do what we
do. Making irrational choices is not an
aberration. It is normal.
Fast forward to 2018, and CMS still has
us ask our residents to self-report on their activity preferences in the
absence of any observable behaviors.
That is the MDS 3.0. Then we are
expected to relate that to the activity decisions the residents will actually
make. That is the activity care
plan. Then we are held accountable for
any pattern of discrepancies between the MDS 3.0 and the residents’ actual
behavior. That generates a CAA and
potentially a flag.
I know it’s possible to make lemonade
out of a lemon and use the MDS interview to also generate a certain amount of
activity history. But that doesn’t make
up for the amount of time and energy that CMS wants us to waste on the quest
for that precious #1 – 5 that we have to try to coax from the residents. There are better ways to get an activity
history. There are better ways to develop
care plans. And there are better ways to
help activity professionals and residents develop good activity programs. My activity director gave me a chuckle and a
quote for this paper when she wrote to me that, “I am blessed to have you on
our ALF actively engaging those folks into things THEY never knew THEY wanted!”
What am I saying? Activity professionals are made to use
methodology that is as much as 60 years out of date. We are held to bad science that academics who
study human behavior have spent whole careers discrediting. There is a big difference in why our residents
do things as opposed to why they think they do them. Study after study has shown that nobody is a
rational decision-maker. So, who at CMS still
thinks that you generate meaningful numbers by asking our residents “how
important” something is? And how long
are we going to go along with it?
©Donna Stuart, ADC January 21, 2018, 2019
Lewis, Michael. The Undoing Project.
New York: W. W. Norton & Company, Inc., 2017.
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/Archive-Draft-of-the-MDS-30-Nursing-Home-Comprehensive-NC-Version-1140.pdf
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