Promoting Person-Centered Care for Older Adults: Development of the Long-Term Care Unit Environment Assessment Tool (LTCU-EAT)

Abstract

Providing older people with quality long-term care (LTC) contributes to the Sustainable Development Goal (SDG) 3—Good Health and Well-being. Person-Centered Care (PCC) is the optimal approach that enhances the quality of life for older adults residing in LTC facilities. This study develops the Long-Term Care Unit Environment Assessment Tool (LTCU-EAT) to assess how LTC environments support PCC goals. The study was conducted in five steps. (1) Reviewing and revising assessment items based on existing literature; (2) Preliminary assessment and protocolling with expert opinions; (3) On-site assessments conducted by two raters among 21 LTC units across 13 facilities; (4) Reliability test of assessment items; (5) Scoring and reliability test of LTC unit samples. The LTCU-EAT, comprising 89 items distributed across 12 subscales within four themes, was developed based on a summary of 14 PCC goals. A total of 83 items (93.26%) demonstrated strong inter-rater reliability. The assessments of all LTC unit samples displayed good criterion-related validity. The LTCU-EAT is a valuable tool for conducting post-occupancy evaluation (POE) of LTC facilities, systematically evaluating the level of environment support for PCC, and providing empirical evidence for future research, policy and practice.

1. Introduction

We are living on a rapidly aging planet. From 2020 to 2050, the global population aged over 60 years will double from 1 billion to 2.1 billion, reaching 22% of the total population. Notably, the number of the oldest-old people (aged 80 years or above) is expected to triple between 2020 and 2050, reaching 426 million [1]. Providing older people with high quality long-term care (LTC) has become a major action of the UN Decade of Healthy Ageing (2021–2030), thereby supporting the realization of the United Nations Agenda 2030, and contributes to the Sustainable Development Goal (SDG) 3—Good Health and Well-being [2,3].

In response to the growing pressure on aging care, efforts have been made globally for decades to explore improved approaches. Person-Centered Care (PCC) has been empirically validated as the optimal approach that enhances the quality of life for older adults residing in LTC facilities [4]. A long-term care facility is described as a skilled nursing facility which provides a range of personal and health care with a focus on medical, nursing care, safety, and support with activities of daily living, especially for the older adults [5]. PCC acknowledges and comprehends the personal value of each individual, which should be respected during caregiving [6]. In the 1980s, a Culture Change movement in long-term care was initiated in the United States. It advocated for a shift from medical care models to PCC models within LTC facilities [7]. This movement emphasizes that LTC facilities should be perceived not merely as healthcare institutions but rather as homes with comprehensive care services [8].

Under the influence of PCC and the Culture Change movement in long-term care, the physical environment design of LTC facilities has undergone a significant transformation. This transformation is primarily characterized by deinstitutionalization and the adoption of small-scale layout approaches. A notable change can be observed in the emphasis on detailed requirements for LTC units. For instance, there has been a shift towards reducing double-loaded corridor configurations (Figure 1) in preference for small group clusters of units (Figure 2), aiming to create an environment that promotes familiarity and a sense of home [9,10]. Each unit is equipped with comprehensive activity, dining, and support spaces that can be managed independently. Each unit provides access to outdoor areas. Nursing stations are designed to be open and less institutionalized [11,12]. Some studies have demonstrated that these innovative PCC-based LTC facilities significantly improve residents’ quality of life compared to traditional ones [13]. Moreover, they contribute to better family satisfaction as well as staff motivation and efficiency at work [14,15].

In recent years, China’s long-term care has been influenced by the progressive nursing concepts introduced by PCC from the western world. However, comparative cultural backgrounds significantly diverge, particularly among the older generation. Chinese older adults, influenced by traditional cultural values and collectivism memories, exhibit distinct preferences in terms of privacy, interpersonal communication, and living arrangements when compared to their western counterparts. Some Chinese scholars have attempted to integrate the PCC concept with the local context and propose design strategies for LTC facilities [16,17].

However, it is important to acknowledge the variation in the quality of LTC facility environmental design worldwide. A considerable number of facilities fall short in supporting PCC goals. For instance, a study conducted on LTC facilities in Sweden revealed satisfactory safety measures for older individuals but lower quality regarding cognitive support and privacy [18]. Similarly, Wahlroos et al. assessed LTC facilities in Finland and identified a need for improvement in the domains of normalness and cognitive support in the physical environment [19]. Furthermore, the deficiencies of LTC facilities in supporting PCC goals have been exposed in developing countries that entered the aging society later, due to a lack of studies, assessment tools, and design guidelines [20]. Identified problems in China’s LTC facilities include neglecting basic principles, such as fall prevention, resulting in reducing residents’ safety [21], or having a hospital-like decoration style that makes people feel depressed [22]. Since there will be a significant future demand, it is urgent to assess the extent to which existing LTC facility environments support PCC goals, thereby facilitating evidence-based design (EBD).

There are currently numerous assessment tools available for LTC facilities. This paper identifies 13 widely utilized tools through a literature review (

Table 1. Widely Used Existing Assessment Tools for LTC Facilities.

No.	Name of Instruments	Country/Year	Target Environments	Assessment Domains	Number of Items
1	Environment–Behavior Model (E–B Model) [31]	USA/1994	Alzheimer special care units	8 environmental design principles: exit control, wandering path, individual away places, common space structure, outdoor freedom, residential character, autonomy support	61
2	Professional Environmental Assessment Procedure (PEAP) [32,33]	USA/1996	Special care units for people with dementia	9 environmental design principles: maximize safety and security, maximize awareness and orientation, support functional ability, facilitation of social contact, provision of privacy, opportunities for personal control, stimulation and coherence (regulation), stimulation and coherence (quality), continuity of the self	148
3	Therapeutic Environment Screening Survey for Nursing Homes (TESS-NH) [34,35]	USA/1996	Institutional facilities for persons with dementia	13 environmental design principles and elements: safety/security/health (exit control, maintenance, cleanliness, safety), orientation (orientation/cueing), privacy/ control/autonomy (privacy, unit autonomy, outdoor access, lighting, noise, visual/tactile, stimulation), social milieu (space/seating) Overall assessment: overall subjective assessment (pleasant, positive, functional)	84
4	Special Care Unit Environmental Quality Scale (SCUEQS) [26]	USA/2002	Physical environment for persons with dementia	7 environmental design principles: maintenance, cleanliness, safety, lighting, physical appearance/homelikeness, orientation/cueing, noise	18
5	The Japanese version of the Professional Environmental Assessment Procedure (PEAP Japanese Version) [36]	Japan/2002	Residential care facilities for persons with dementia	8 environmental design principles: maximize awareness and orientation, provision of privacy, Regulationand quality of stimulation, support for functional abilities, maximize safety and security, opportunities for personal control, continuity of the self, facilitation of social contact	112
6	Environmental Audit Tool (EAT) [37]	Australia/2003	Residential care facilities for persons with dementia	10 environmental design principles: safety and security, small size, visual access features, stimulus reduction features, highlighting useful stimuli, provision of wandering and access to outside area, familiarity, privacy and community, community links, domestic activity	72
7	Dementia Design Audit Tool (DDAT) [38,39]	UK/2009	Facilities for people with dementia	11 environmental design elements: hall/entrance/way-finding, lounge/day room, meaningful occupation and activity, bedrooms, toilet area, bathroom/shower room (en-suite), dining room, treatment areas, lighting	181
8	The Environmental Audit Tool-High Care (EAT-HC) [40]	Australia/2015	Residential care facilities for persons with dementia, including those who are immobile or in palliative care	10 environmental design principles: safety and security, small size, visual access features, stimulus reduction features, highlighting useful stimuli, provision of wandering and access to outside area, familiarity, privacy and community, community links, domestic activity	77
9	The Physical and Architectural Features Checklist (PAF) [41]	USA/1986	Residential facilities for older people	8 environmental design principles: community accessibility, physical amenities, social-recreational aids, prosthetic aids, orientation aids, safety features, staff facilities, space availability	153
10	Sheffield Care Environment Assessment Matrix (SCEAM) [42]	UK/2004	Residential care facilities for older people	7 environmental design elements: location, outdoor spaces, form/circulation, day spaces, bathrooms/WCs, private rooms, staff spaces 11 environmental design principles: privacy, personalization, choice and control, community, safety and health, physical support, comfort of the environment, cognitive support, awareness, normalness authenticity, and provision for staff	337
11	Therapeutic Environment Screening Survey for Nursing Homes and Residential Care (TESS-NH/RC) [26]	USA/2005	Long-term care settings	15 domains (including environmental design elements and principles): facility maintenance, cleanliness, handrails, call buttons, light intensity, light glare, light evenness, hallway length, homelikeness, room autonomy, telephones, tactile stimulation, visual stimulation, privacy, outdoor areas	31
12	Environmental Quality Assessment for Living checklists (EQUAL) [43]	USA/2006	Physical environment for older people with or without dementia	3 environmental design elements: residents’ own room and toilet area, LTC unit, the common space 11 environmental design principles: autonomy, dignity, privacy, meaningful activity, enjoyment, relationships, comfort, security, functional competence, spiritual well-being, individuality	387
13	The Swedish version of the Sheffield Care Environment Assessment Matrix (S-SCEAM) [44]	Sweden/2015	Residential care facilities for older people	7 environmental design elements: external/entrance, outdoor spaces, form/circulation, day spaces, dining rooms, bathrooms/WCs, private rooms 8 environmental design principles: integrity, choice, openness and integration, safety, physical support, comfort, cognitive support, normalness	210

). Many of these instruments underwent systematic development processes. For instance, MEAP, SCEAM, TESS-NH, and EAT were developed through comprehensive literature reviews followed by expert judgment [23]. However, most of these tools were developed before PCC concepts gained widespread application in environmental design practices. Therefore, none of these instruments targeted PCC as the assessment focus, limiting their applicability in meeting contemporary demands for LTC services. Due to the lack of valid and reliable instruments for assessing the matching relation between the environment design of LTC units and PCC goals, post-occupancy evaluations (POE) are seldom conducted adequately, especially in China. In contrast to Western practices of identifying issues through POE, Chinese studies lack effective evaluation methods and practices for addressing the user needs [24]. Consequently, there is a lack of feedback to building planners, architects and care staff on how environmental elements works with PCC in practice. Additionally, it had been reported that most instruments suffered from shortcomings, such as relying on professional expertise [25,26], and the assessment items were organized by design principles rather than physical environment elements. In China, the evaluation criteria of relevant existing standards mainly focus on meeting the basic needs of residents, such as accessible design and environmental sanitation, instead of paying much attention to the older adults and staffs’ quality of life [27,28]. These factors contributed to confusing assessment procedures and limited usability. Considering the significant impact of cultural values on care preferences and facility design [29,30], it is essential to develop assessment tools that are adaptable to Chinese cultural contexts.

Therefore, this paper develops the Long-Term Care Unit Environment Assessment Tool (LTCU-EAT) to address the above research gaps, aiming to provide a practical guide for assessing the physical environment quality of LTC units from a person-centered perspective. The assessment results are expected to identify current issues, provide empirical evidence for future environment design and revision of relevant policies and standards, enhance the quality of built environment in LTC units, and improve quality of person-centered care for the older adults.

2. Methods

This study developed the LTCU-EAT following five steps. (1) Reviewing and revising assessment items: summarizing the key concepts of PCC, screening items from existing instruments, and revising by focus group method; (2) Preliminary assessment and protocolling: prior assessment of eight LTC units and revising the items again, consulting eight experts, confirming content validity, and determining the final 89 items; (3) On-site assessment of LTC unit samples: two raters assessing 21 LTC units individually; (4) Reliability test of assessment items: inter-rater reliability test of each item; (5) Scoring, scoring bias and inter-rater reliability test within LTC unit samples: confirming the criterion-related validity.

The tool was tested among LTC facilities for older adults in China. The detailed study procedure is described as follows (Figure 3).

2.1. Step (1) Reviewing and Revising Assessment Items

This study summarized the key concepts of PCC through a systematic literature review. Compared to traditional care models, the concept of PCC primarily influences the environmental design of LTC units [8]. Therefore, this instrument focused on assessing LTC units. Other aspects, such as location selection, central kitchen, and staff living space that were not closely associated with PCC concepts, were excluded from the scope of assessment.

On this basis, according to existing assessment tools, scales, empirical studies, reviews, guidelines and other literature related to PCC-based environment design of LTC units, key points were extracted and revised as assessment items. The research team conducted a preliminary screening of the key points and determined the assessment items using the focus group method, which involved following three routes.

International references: the LTCU-EAT incorporated certain items from existing tools. For example, assessment item 23 (see Supplementary Materials S1), regarding personalization of bedroom layout, was derived from PEAP (Japanese version), the E–B Model, and EAT [31,36,37].

Local references: existing studies have emphasized that the development of assessment tools necessitates a strong foundation in policies and culture [44]. Therefore, it is not possible to completely detach from the main cultural background. Nevertheless, the methodologies, processes, and conceptual frameworks employed in tool development possess a universal nature that allows for adaptation and translation across diverse cultural backgrounds. Since the LTCU-EAT was developed and tested in China, some items referred to Chinese policy documents, design standards and codes, especially the Guidelines of Classification and Accreditation for Long-term Care Organization, which was co-authored by a researcher involved in this study [45].

Integration and composition: a majority of items were derived through a comprehensive analysis of different categories of references, including existing instruments, scales, design standards, codes, research papers, and guidelines. During the development of the LTCU-EAT, there were instances where certain content requiring assessment may have multiple sources that can be referenced, or no direct reference items available. In either of the situations, an integration and composition method were utilized.

2.2. Step (2) Preliminary Assessment and Protocolling

To validate the applicability of the assessment indicators and ensure their adaptation to the construction and occupancy state of LTC units in the Chinese context, the study conducted a preliminary assessment to determine the suitability of items derived from literature research in eight LTC facilities. Subsequently, modifications were made to nine items that posed challenges in evaluation or did not align with actual usage scenarios.

This study then consulted the opinions of eight experts to assess the content validity. These experts had backgrounds, including the architecture, gerontology, geriatrics, nursing, and urban planning fields, related to the preliminarily identified items. All the experts had strong experience in either research or practice. These experts made comments on each individual item concerning (a) the relevance to PCC; (b) the relevance to local settings (i.e., China in this research); (c) the importance of unit environment design; (d) clarity and operability. The procedure partially referred to the COSMIN model steps [46,47]. According to the results of expert evaluation, items were further screened and optimized to improve the validity of assessment indicators.

2.3. Step (3) On-Site Assessment of LTC Unit Samples

A total of 13 LTC facilities were selected for the on-site assessment procedure (

Table 2. Features of LTC Unit Samples in this Study.

Facility No.	Facility Type	Construction Forms	Location	Opening Year	Building Area m2 (Only Considering Above-Ground Area)	Building Storeys	Number of Beds	Number of LTC Unit Samples
1	Independent Long-term Care Facility	Renovation	Beijing	2015	14,200	Ground3 Partial4	270	2
2		Newly Built	Beijing,	2018	5865	Ground5	201	1
3		Renovation	Beijing	2012	1650	Ground2	68	2
4		Newly Built	Beijing	2017	9246	Ground5 Underground2	190	1
5		Renovation	Beijing	2016	1278	Ground3 Underground1	28	1
6		Renovation	Foshan	2000	2366	Ground5	98	1
7		Newly Built	Foshan	1998	5034	Ground4	174	1
8		Renovation	Foshan	2014	5400	Ground4	130	1
9	Community Embedded Long-term Care Facility	Renovation	Beijing	2017	2300	Ground4	50	1
10		Renovation	Nanjing	2017	2247	Ground4 Underground1	83	3
11		Renovation	Nanjing	2016	1650	Ground3	48	3
12	Long-term Care Facility within a Retirement Community	Newly Built	Shenzhen	2015	31,469	Ground10 Underground1	791	2
13		Newly Built	Nanjing	2019	16,316	Ground6 Underground1	316	2
Total number of LTC unit samples								21

). Supplementary Materials S2 presents plans and photos of the 13 facilities. The selection strategy for the facilities took into consideration facility types (independent, community embedded, or within a retirement community), construction type (newly built or renovated), geographical location (North/South/East/West; metropolis or small city), opening time (before 2000, between 2000 and 2010, or after 2010), building area (large, medium, or small scale), and number of floors (lower floors or higher floors). Each selected facility had one to three LTC units for assessment purposes. In total, there were 21 LTC units included in the assessment.

The assessment was conducted by two research managers acting as independent raters. Each LTC unit was observed on the same day through systematic on-site visits, without any coordination between the raters. Each item was scored “0 or 1”, with certain items including a “0.5” score to differentiate the degree. Items not applicable were marked “NA”. Data were collected using either paper sheets or electronic spreadsheets. Furthermore, the raters captured detailed photos of environmental features within each LTC unit for future reference.

2.4. Step (4) Reliability Test of Assessment Items

The reliability of each item was measured. Inter-rater reliability was determined by comparing the assessment results of the two raters as part of the reliability analysis. In order to evaluate the reliability of the individual items, the inter-rater reliability of the repeated assessment data of the same item by the two raters was evaluated. Cohen’s Kappa statistic (κ) was calculated for the effects of the chance agreement to assess the reliability of both dichotomous and Likert-like variables, and it is widely used in assessment tool development [48,49]. Cohen’s Kappa value can be evaluated using Landis and Koch’s classification: Excellent to good (κ ≥ 0.60); Moderate (0.60 > κ ≥ 0.40); Fair to poor (κ < 0.40) [49,50,51,52].

Given that Cohen’s Kappa calculations rely on the presence of variability in ratings, the value may be low or with p > 0.05 when one or both raters exhibit limited rating variability [53,54]. In this study, certain items exhibited inadequate variability in the responses of the raters. Consequently, the percentage agreement was also calculated for these items to exclude those that were misjudged due to insufficient variability. The results of the percent agreement were classified to indicate reliability as follows: percent agreement ≥75% (for dichotomous response items: 0/1) and percent agreement ≥60% (for ordinal or continuous response items: 0/0.5/1, 0/1/NA, 0/0.5/1/NA) were considered reliable [54,55]. All the analysis processes were performed through the SPSS 27 Software.

2.5. Step (5) Scoring, Scoring Bias and Inter-Rater Reliability Test within LTC Unit Samples

Existing literature on the assessment of LTC facility environments typically focuses solely on reliability testing of the item scale. However, we have identified that the difference in environment quality of LTC unit samples may also exhibit variations in agreement between two raters’ assessment results, leading to bias in the total score assigned to an LTC unit sample by the two raters. Therefore, we also performed three calculations which could contribute to confirming criterion-related validity:

Scoring: summing up each rater’s responses for every item and dividing it by the number of valid items (89 minus the number of “N/A” items). The score for each LTC unit sample is the average rating from both raters.

Scoring bias: calculating the difference value between scores given by the two raters.

Reliability of ratings within LTC unit samples: calculating Percent Agreement and Cohen’s Kappa value for these samples.

3. Results

3.1. The 89-Item LTCU-EAT Supporting the 14 PCC Goals

14 goals of PCC were summarized through literature review. These goals were classified into three major needs: physiological needs of older adults, psychological needs of older adults, and needs of staff. The basic concept of each PCC goal is explained in

Table 3. 14 PCC goals and related items in the LTCU-EAT.

PCC Goals		Description	Related Items in the LTCU-EAT
Physiological needs of older adults	(1) Safety and Health	The physical environment can prevent risks, reduce the incidence of falls, accidents and cross-infections, and provide a sense of safety for residents.	5, 15, 19, 25, 35, 41, 45, 50, 58, 59, 60, 61, 62, 63, 71, 75, 76
	(2) Physical Frailty Support	The physical environment can fit with the physical conditions of residents, support those with mobility challenges (such as those using wheelchairs or walking aids) to use the space independently or with assistance, and allow residents to maintain their capabilities.	4, 13, 14, 17, 18, 24, 25, 26, 33, 35, 40, 41, 42, 44, 45, 47, 50, 51, 52, 56, 57, 58, 60, 61, 73
	(3) Functional Support	The LTC unit has complete functional spaces and rational layouts to meet the basic needs of residents. The physical environment can provide convenience to users.	5, 7, 9, 16, 17, 18, 19, 20, 26, 27, 29, 30, 31, 32, 33, 38, 42, 43, 45, 46, 47, 48, 63, 64, 76, 77
	(4) Accessibility	The functional spaces within the LTC unit are easily identifiable and accessible for residents, ensuring residents can navigate without getting lost. Residents with different physical conditions can reach their destinations independently or with assistance.	3, 4, 6, 22, 27, 28, 31, 36, 38, 43, 53, 54, 71, 72, 73
	(5) Comfort	The acoustic, lighting, and thermal environment can fit with the physical conditions of residents. The environment is clean and fresh, providing a pleasant and comfortable experience.	25, 41, 59, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 89
Psychological needs of older adults	(6) Privacy	The physical environment can ensure the privacy of residents, provide personal spaces, and maintain respect for them.	10, 12, 13, 49
	(7) Choice and Control	The physical environment is diverse and flexible, allowing residents to make choices and decorate living spaces based on their personal preferences.	9, 23, 29, 30
	(8) Home Likeness	The physical environment has a warm and familiar atmosphere instead of hospital or hotel characteristics. The scale, furniture, layout, and decorations have homelike qualities.	1, 2, 10, 11, 18, 22, 23, 54, 74, 82, 87, 88, 89
	(9) Social-Recreational Support	The LTC unit is equipped with various activity spaces, promoting residents to engage in a wide range of social activities.	3, 28, 29, 55
Psychological needs of older adults	(10) Outdoor Freedom	The LTC unit has visual and direct access to outdoor spaces, providing outdoor freedom for residents. The layout of the outdoor areas can meet the needs of residents.	3, 4
	(11) Cognitive Support	The physical environment is dementia friendly and can support residents with dementia in being safe and independent.	2, 6, 22, 23, 53, 54, 60, 73
Needs of staff	(12) Service Support	The physical environment can support staff in providing care and services for residents.	1, 2, 7, 8, 21, 26, 34, 42, 48
	(13) Work Support	The LTC unit has spaces for staff to work in and manage.	34, 36, 37, 63, 64, 65, 66, 67, 68, 69
	(14) Staff Facilities	The LTC unit has spaces for staff to rest and relax.	39, 70

.

Based on the 14 PCC goals, the 89-item version of the LTCU-EAT was developed. Each item may contribute to 1–4 targets. The items were primarily organized by 12 subscales under 4 themes: Overall Layout (8 items), Functional Space (62 items), Facilities and Equipment (6 items), and Sensory Environment (13 items) (

Table 4. Four themes and 12 subscales of the LTCU-EAT.

Themes	No. of Items	Subscales	No. of Items
Overall Layout	8	Number of beds	2
		Function organization	6
Functional Space	62	Resident room	18
		Living Room and Nursing Station	11
		Public Restroom	5
		Public Bathroom	7
		Corridor, staircase and elevator	13
		Support area	8
Facilities and Equipment	6	Signage system	4
		Fire protection facilities	2
Sensory Environment	13	Lighting, ventilation temperature and sound	10
		Homelike quality	3
Total	89

). The judging criteria were explained through comprehensive descriptions provided for each individual item. The complete tool is available in Supplementary Materials S1.

3.2. Inter-Rater Reliability of Items

Table 5. Item inter-rater reliability.

Themes OR Subscales	Total No. of Items	Cohen’s Kappa (κ) of Items with Adequate Variability a					Percent Agreement (PA) of Items with Inadequate Variability a			Total No. of Reliable Items f
		No. of Items	Average and Range of κ	Excellent to Good b	Moder-ate c	Fair to Poor d	No. of Items	Average and Range of PA	No. of Items with High PA e
Overall Layout	8	7	0.934 0.934–0.934	4	3	0	1	85.71 85.71–85.71	1	8
Number of beds	2	2	0.889 0.877–0.901	2	0	0	0	N/A	N/A	2
Function organization	6	5	0.632 0.478-0.919	2	3	0	1	85.71 85.71–85.71	1	6
Functional Space	62	48	0.793 0.357–1.000	40	7	1	14	78.57 38.10–95.24	11	58
Resident room	18	14	0.814 0.571–1.000	13	1	0	4	69.05 38.10–95.24	3	17
Living Room and Nursing Station	11	11	0.905 0.512–1.000	10	1	0	0	N/A	N/A	11
Public Restroom	5	5	0.726 0.620–0.855	5	0	0	0	N/A	N/A	5
Public Bathroom	7	7	0.842 0.586–0.932	6	1	0	0	N/A	N/A	7
Corridor, staircase and elevator	13	6	0.690 0.357–1.000	3	2	1	7	83.68 42.86–95.24	6	11
Support area	8	5	0.610 0.432–0.797	3	2	0	3	79.36 57.14–95.24	2	7
Facilities and Equipments	6	1	0.704 0.704	1	0	0	5	77.14 47.62–95.24	4	5
Signage system	4	1	0.704 0.704	1	0	0	3	68.25 47.62–80.95	2	3
Fire protection facilities	2	0	N/A	N/A	N/A	N/A	2	90.48 85.71–95.24	2	2
Sensory Environment	13	7	0.581 0.308–.908	4	3	0	5	69.53 47.62–90.48	4	11
Lighting, ventilation temperature and sound	10	5	0.578 0.308–0.908	2	2	1	5	69.53 47.62–90.48	4	8
homelike quality	3	3	0.587 0.472–0.675	2	1	0	0	N/A	N/A	3
Total	89	63	0.788 0.357–1.000	49	13	1	25	76.76 38.10–95.24	20	82

Notes: ^a Since Kappa calculations rely on some variability in ratings, the values can be low and suggest poor agreement when one or both raters have little variability. In this study, the items with p > 0.05 when processing Kappa calculation might have inadequate variability of the rater’s responses. Kappa value of these items were excluded. Percentage agreement was the judgment rule for these items’ reliability; ^b Excellent to good = Number of items considered excellent to good reliability by Kappa/ICC (κ ≥ 0.60); ^c Moderate = Number of items considered moderate reliability by Kappa/ICC (0.60 > κ ≥ 0.40); ^d Fair to poor = Number of items considered fair to poor reliability by Kappa/ICC (κ < 0.40); ^e High PA = Number of items with high percentage agreement (for dichotomous response items ≥75% and for ordinal or continuous response items ≥60%); ^f A reliable item was defined as one that exhibited an excellent to moderate Cohen’s Kappa value (with adequate variability) or a high level of percentage agreement (with inadequate variability).

displays the results of the inter-rater reliability test of each item of the LTCU-EAT. A total of 82 items (92.13%, among the 89 items) exhibited excellent to moderate Cohen’s Kappa values (with adequate variability) or high level of percentage agreement values (with inadequate variability), which indicated sufficient inter-rater reliability. The remaining seven items (7.87%) showed low reliability.

3.3. Scoring, Scoring Bias and Inter-Rater Reliability within LTC Unit Samples

In addition to the reliability test of the assessment items, the analysis of the scoring of each LTC unit also contributes to the criterion-related validity confirmation of the tool (

Table 6. Scoring, scoring bias and inter-rater reliability of LTC unit samples.

LTC Facility No. OR LTC Unit No.	Scoring		Average Score a	Scoring Bias b	Percent Agreement (PA)	Cohen’s Kappa (κ)
	Rater A	Rater B
1
1a	78.98	80.68	79.83	1.70	86.50	0.775
1b	78.98	81.82	80.40	2.84	86.50	0.733
2
2	69.88	63.86	66.87	6.02	71.90	0.644
3
3a	60.24	59.64	59.94	0.60	68.50	0.591
3b	60.00	59.38	59.69	0.62	77.50	0.745
4
4	95.51	90.45	92.98	5.06	88.80	0.527
5
5	86.36	82.95	84.66	3.41	78.70	0.539
6
6	42.36	56.85	49.61	14.49	70.80	0.703
7
7	60.39	59.74	60.07	0.65	85.40	0.859
8
8	86.93	82.02	84.48	4.91	86.50	0.705
9
9	83.15	88.07	85.61	4.92	80.90	0.559
10
10a	81.93	72.89	77.41	9.04	77.50	0.716
10b	80.00	75.88	77.94	4.12	82.00	0.766
10c	77.84	76.44	77.14	1.40	79.80	0.644
11
11a	73.78	76.83	75.31	3.05	84.30	0.826
11b	80.72	78.31	79.52	2.41	93.30	0.924
11c	78.65	83.71	81.18	5.06	84.30	0.719
12
12a	68.07	60.98	64.53	7.09	83.10	0.806
12b	61.11	63.75	62.43	2.64	86.50	0.836
13
13a	84.83	79.21	82.02	5.62	85.40	0.716
13b	88.20	82.58	85.39	5.62	85.40	0.660
Average	74.10	75.14	74.62	4.35	82.10	0.714

Notes: ^a Scoring: summing up each rater’s responses for every item and dividing it by the number of valid items (89 minus the number of N/A items). The score for each LTC unit sample is the average rating from both raters; ^b Scoring bias: calculating the difference value between scores given by the two raters.

).

Scoring: In this study, we tried to choose different LTC units in PCC support quality based on information from the pre-assessment step. The results of scoring indicated that the LTCU-EAT can identify the difference in PCC support quality. The lowest score of the 21 LTC unit samples was 49.61, while the highest was 92.98. The average score was 74.62.

Scoring bias: The scores given by two raters for each LTC unit sample exhibited slight variation, with an average bias of 4.35 (out of 100). Only one sample demonstrated a significant high scoring bias, reaching 14.49.

Inter-rater reliability within LTC unit samples: all the LTC unit samples showed both high percent agreement and excellent to moderate Cohen’s Kappa value, indicating that the raters using the LTCU-EAT generally have consistent assessment results for the same LTC unit. The average percentage agreement was 82.10%, and the average Cohen’s Kappa was 0.714.

4. Discussion

4.1. Reliability and Validity

The inter-rater reliability of 82 items (92.13%) among the total of 89 items indicated a satisfactory level. This suggests that LTCU-EAT demonstrates high reliability, which can be attributed to multiple rounds of revisions based on expert consultations, focus group discussions, and pre-assessments. The tool aimed to minimize unclear assessment criteria and enhance objectivity in subjective judgments, resulting in greater consistency among different raters’ scoring results.

The content validity was confirmed during the expert consultation process. The analysis of scoring for each LTC unit sample demonstrated that the tool effectively discriminates between units with varying levels of design quality, thereby confirming its criterion-related validity.

Although the LTCU-EAT demonstrated overall reliability, there were still seven items (7.87%) that exhibited low levels of reliability. The factors influencing the reliability of these items can be primarily classified into three situations.

Firstly, due to inevitable subjective judgments, there was a significant amount of discretion in scoring. For example, item 19 stated: “The storage spaces within the room are sufficient, with no stacked things impeding movement or daily activities.” The two raters had a discrepancy in determining how much storage space should be considered sufficient for an older adult’s resident room. This difference may stem from varying understandings of environmental design quality among raters. Similar issues could also be observed in item 54, assessing as “dead-end corridor”, item 82, about “homelike lighting atmosphere”, and item 84, regarding “well-ventilated environment”.

Secondly, in one item, there were too many scoring points, which made it easy to ignore certain details during the assessment process. For example, item 73 stated: “All types of signs must meet the following requirements: a. They should be securely installed and free from any defects that may pose a safety risk to residents. b. They should be accurately positioned and highly visible for residents, avoiding obstruction from lights, cameras, plants, or other facilities. c. They should be designed with consideration for residents’ visual characteristics by using larger texts and high-contrast colors for easy recognition.” This item contained the comprehensive requirements of the signage system. However, its excessive content rendered it complex and made it easy to make mistakes by raters. Similar challenges could also be observed in item 65 on “design details in the laundry room”.

Thirdly, some items required certain professional knowledge to allow judgement. For example, item 7 stated: “The layout of each LTC unit is flexible and adaptable, for example, units can be separated or combined to fit varying needs because of the complete functional configurations.” This requires raters to have knowledge of nursing and environmental design. In the future popularization of this tool, consideration still needs to be given on how individuals without a professional background can use it effectively. The LTCU-EAT had made efforts to avoid this issue, so the problem was not very common.

4.2. Advantages in Operability

Compared to existing tools, the LTCU-EAT had advantages in terms of operability.

Firstly, the LTCU-EAT classified items based on environmental design elements that correspond to the walking route of an LTC unit. This approach effectively streamlined raters’ assessment procedures without frequent backtracking to locate evaluation scenarios. In contrast, most existing instruments organize assessment items according to environmental design principles, such as accessibility and safety [31,33]. This mismatch between the organizational logic of assessment tools and the built environment may lead to confusing assessment processes and limited tool operability.

Secondly, the items of the LTCU-EAT were detailed and generally straightforward to evaluate, requiring minimal professional expertise from raters and ensuring ease of future popularization and utilization. Notably, it has been reported that certain items in existing assessment tools for LTC facilities, such as PEAP and the E–B Model, were found to lack detail and were considered to be too professional. Many of their items required expert judgment based on knowledge and experience, which made the assessment difficult to operate [25,26]. However, during the field test of the LTCU-EAT, these issues were significantly reduced.

Thirdly, the LTCU-EAT demonstrated a relatively unbiased approach, ensuring fair assessments for both larger high-end projects and smaller community projects. Throughout the tool development process, this study considered different types of LTC unit samples to ensure compatibility with all facilities. This included large-scale new facilities, renovated facilities, as well as extremely small-scale ones. This consideration was prompted by literature suggesting that certain instruments, like PAF and EQUAL, may exhibit a bias towards larger facilities, which has led to limited applicability to smaller ones [41,43].

Additionally, the LTCU-EAT was expected to be applicable to regions with similar cultural backgrounds, and explored a comprehensive methodology for developing an operational assessment tool. Previous research has highlighted the importance of grounding assessment tool development in local policies and cultures [44]. Therefore, it is essential to acknowledge that complete detachment from a local cultural background is not feasible. Nevertheless, although the LTCU-EAT was developed and tested in China, its methodologies, processes, and conceptual frameworks possess a universal nature that facilitates adaptation and translation across diverse cultural contexts.

4.3. Effectiveness of Assessing the Environmental Support for PCC

The development of the LTCU-EAT aimed to effectively address evolving needs and support for residents and staff in LTC facilities, reflecting current PCC concepts. Multiple items contributed to physiological and psychological needs of older adults. For instance, item 23 emphasized that “The rooms have spaces and facilities for personal photographs, books, and furniture, offering residents the flexibility to arrange their rooms as they wish.” This assessment item facilitated recognition of a diverse and flexible physical environment within LTC units, enabling residents to exercise choice and control over their living spaces based on personal preferences (PCC Target (7)—Choice and Control). Additionally, the convenience of staff service also significantly impacts residents’ quality of life. The LTCU-EAT included assessments that highlight this aspect too. For example, item 8 stated that “The layout of each LTC unit is easy for staff to serve residents, providing convenient working paths.” This assessment item helped determine whether the physical environment adequately supports staff in providing care and services without encountering difficulties (PCC Target (12)—Service Support). Based on the 14 goals of PCC, the LTCU-EAT showed potential for the person-centered improvement of LTC unit environment.

4.4. Implications for Policy and Practice

The LTCU-EAT can play a crucial role in policy development and various stages of practice. During the planning and design process, the LTCU-EAT can serve as a valuable guide for designing PCC-based LTC units and facilitating interdisciplinary communication among experts from architecture, engineering, and nursing. During the occupancy period, care staffs can utilize this user-friendly tool to learn how to implement PCC principles in different environments. During the post-occupancy evaluation (POE) procedure, the LTCU-EAT holds significant value due to its validity, reliability, and ease of use in exploring variations in environmental quality. Consequently, it can offer valuable insights to enhance future policies, design codes, and standards.

4.5. Limitations and Future Research

This study is subject to certain limitations. Firstly, despite efforts made to ensure accuracy, clarity, and objectivity in formulating the items, it was challenging to completely avoid incorporating some subjective judgment-based items into the tool. Moreover, due to the extensive number and detailed nature of the LTCU-EAT items, assessing a single LTC unit requires a considerable amount of time (raters typically report needing approximately 2 h), which may lead to fatigue and potential errors during the assessment process. Furthermore, this study had a limited sample size under examination, making further validation through additional samples highly valuable.

There are potential directions for further research on the LTCU-EAT. The first future research direction involves optimizing the items to enhance their precision, objectivity, and conciseness. Additionally, apart from revising the items for increased detail and specificity, an alternative approach with potential is integrating a condensed version of the assessment tool (e.g., LTCU-EAT mini version) with a small selection of highly reliable and important indicators, aiming to improve efficiency and universality. The second direction focuses on promoting widespread implementation of the LTCU-EAT as a tool for evaluating the quality of built environments in LTC facilities, identifying current issues, and proposing optimization strategies. The third direction entails utilizing LTCU-EAT for interdisciplinary studies that investigate how residential environmental factors impact the physical and mental health of older adults.

5. Conclusions

PCC concepts are now widely adopted in long-term care LTC facilities worldwide. However, there is a lack of reliable and valid instruments to assess how LTC environments support PCC goals. This study presents the development and evaluation of the LTCU-EAT, specifically designed to assess the provision of PCC in LTC units, aiming to address existing research gaps. The tool comprised 89 items across 12 subscales under four themes, supporting the 14 PCC goals. A field test involving 21 LTC units was conducted to establish the reliability and validity of the tool. Notably, 83 items (93.26%) demonstrated high inter-rater reliability, while the tool also exhibited satisfactory content and criterion-related validity. The LTCU-EAT classified items based on environmental design elements that correspond to the walking route of a LTC unit, effectively streamlining raters’ assessment procedure. The assessment items were detailed, comprehensible and did not necessitate raters to possess much professional expertise. The LTCU-EAT was expected to effectively identify issues related to PCC support, providing empirical evidence for future construction projects and revisions of design standards. It had potential to enhance the quality of built environments in LTC facilities, improving the quality of life for older adults, supporting the realization of the United Nations Agenda 2030, and contributing to the Sustainable Development Goals (SDGs) on people’s good health and well-being.