Journal of Gerontological Nursing

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Long-Term Care for Older Adults: The Role of the Family

Wonita Janzen, PhD

Abstract

ABSTRACT

Family members are involved in all aspects of a frail or ill older adult's care before, during, and after admission into a long-term care facility. However, their role within the facility is not always clearly defined. This article addresses issues regarding facility policies and staff attitudes toward family involvement, particularly whether the family member is seen as an integral part of the care system or peripheral to the care system. An emphasis is placed on the use of open communication to prevent misunderstandings and disagreements between staff and family and to promote good quality care and acceptable quality of life for the resident.

Abstract

ABSTRACT

Family members are involved in all aspects of a frail or ill older adult's care before, during, and after admission into a long-term care facility. However, their role within the facility is not always clearly defined. This article addresses issues regarding facility policies and staff attitudes toward family involvement, particularly whether the family member is seen as an integral part of the care system or peripheral to the care system. An emphasis is placed on the use of open communication to prevent misunderstandings and disagreements between staff and family and to promote good quality care and acceptable quality of life for the resident.

Family members are the main source of support for older adults (Chappell, 1992), providing physical, emotional, social, psychological, and financial support. Many family members are involved in direct informal caregiving to frail or Ul older adults* (Stone, Cafferata, & Sangl, 1987). However, the family cannot always maintain a frail or Hl older adult in the community and may seek placement into a long-term care (LTC) facility, commonly a nursing home. In the United States, an estimated 1.6 million older adults live in long-term care facilities (National Academy on Aging, 1997). In Canada, approximately 191,000 older adults reside in residential care facilities for the aged (Statistics Canada, 1994).

Research indicates that family members remain involved in care after admission of the older adult into a LTC facility (Dempsey & Pruchno, 1993; Gutman & Killam, 1989). Yet, there are issues concerning their involvement with their older adult following LTC admission. What is the role of the family? How do the nurses and family members interact? This article reviews literature regarding family involvement in the care of older adults post-admission and addresses as some of the issues concerning the role of family members within the LTC facility.

FAMILY INVOLVEMENT POST-ADMISSION

Admitting an ill older adult into a LTC facility is a difficult decision for family members and is frequently seen as a last resort (George & Maddox, 1989; Worchester Si Quayhagen, 1983). When the move is finally made, family members may experience stress and guilt, as well as a period of adjustment, while they redefine and adapt their caregiving roles (Buckwalter & Hall, 1987; Linsk, Miller, Pflaum, & Ortigara- Vîcik, 1988; Matthiesen, 1989; Stephens, Ogrocki, & Kinney, 1991). The move is stressful for older adults as well. They leave a familiar home environment and cope with a sense of loss and change (Greenfield, 1984).

Admission of an ill older adult into a LTC facility does not end family caregiving duties, but rather involves a shift in roles and responsibilities (Zarit & Whitlatch, 1993). After admission, many family members continue to maintain ties with their relatives. Studies have shown that family members are frequent visitors to nursing homes residents, averaging 6 to 16 visits per month (Campbell & Line, 1996; York & Calsyn, 1977; Zarit & Whitlatch, 1993).

Family visitation can have positive psychosocial consequences for the LTC residents. Greene and Monahan (1982) interviewed LTC facility staff regarding resident functioning and family visitation and found that greater frequency of family visits was related to greater psychosocial wellbeing fmeasMS by six survey items regarding resioeht confusion, agitation, depression, regression, verbal hostility, and physical hostility). After surveying the family members of nursing home residents and assessing the residents, Farber, Brod, and Feinbloom (1991) concluded it was not the frequency of family visits that was related to greater psychosocial well-being in residents (as measured by depression, life satisfaction, and hopelessness scales), but rather the quality of the relationship between the residents and family members. George and Maddox (1989) emphasized that for most residents, family members are the primary link to life outside of the facility. Family members provide a sense of continuity with the past, provide information about the present, and assist with decisions about the future.

Empirical and anecdotal information indicates family members continue to be involved in the provision of care to older adults after admission into a LTC facility. Two decades ago, Moss and Kurland (1979) found that family members with relatives in an American nursing home were involved in special activities, such as personal care, laundry, cleaning the room, going for walks, and cheering up their relatives. More recently, Linsk, Miller, Pflaum, and Ortigara-Vicik (1988) examined a program designed to recognize and integrate family involvement with relatives of residents with Alzheimer's disease in a nursing home setting. They found that family members chose to be involved in socializing and relationship-based activities more often than personal care or structured task-oriented activities.

In a Canadian study examining six special care units for persons with dementia, a sample of 39 family members (mostly adult children and spouses) were asked open-ended questions regarding the types of activities they performed for their relatives (Gutman & Killam, 1989). More than one third of the family members were involved in activities related to meals (e.g., feeding relative, taking relative to dining room, encouraging relative to eat) and socializing (e.g., talking, visiting, sitting with relative). Approximately one quarter of the family members were involved in activities related to the resident's clothing (e.g., checking clothes for needed repairs or cleaning, bringing new clothes, sorting laundry), grooming their relative (e.g., shaving, washing hair, manicuring nails), walking with their relative, and bringing flowers to their relative.

The above studies emphasize the fact that family members remain involved in the care of ill older adults following LTC placement and do not abandon their relatives to the formal care system. Researchers maintain it is the responsibility of the staff and administration of the LTC facilities to support families through the difficult process of admission and in dealing with new roles after the admission (Greenfield, 1 984; Pratt, Schmall, Wright, & Hare, 1987). However, the involvement of the family members in the domain of the nurses and other health care staff has produced some concerns regarding long-term care policies, role definitions for the family, and interactions between staff and family.

THE ROLE OF THE FAMILY IN LONG-TERM CARE FACILITIES

Long-Ten» Care Policies Regarding Family Involvement

Although family involvement or programming is a goal of many LTC facilities, the specifics of how family members are to be involved are often unclear (Holmes, et al., 1994). Also, the level of family involvement and satisfaction with the care provided vary greatly from one facility to another (Buckwalter, 1991). How do the administrators and staff of LTC facilities view family members? In some cases, family involvement is seen as peripheral to the resident care provided by staff, while in other cases, "family involvement in care planning" is part of the policy (Holmes, et al., 1994, p. S51). It is generally acknowledged that information from family members can assist staff in providing individualized care, specific to the physical, psychological, and emotional well-being of the resident (Portnoi, 1984). Yet, there is not always agreement in the amount of responsibility and involvement given to or taken by family members.

Defining the role of family members. Defining the role of the family within the formal LTC system continues to be a struggle, as LTC facilities seek to establish their own identity. Carón 's (1997) discussion of the family and the nursing home from an ecosystemic perspective relates to the roles of each group. According to Carón, LTC facilities are part of the health care system and function well in providing health care. However, LTC facilities have also become home for the frail or ill older adults who may spend many years, even decades, living in the facility. Social care and quality of life have been added to the mandate of many facilities (Cantor, 1991; Carón, 1997). The older adult who moves to a LTC facility is already imbedded in a family system with a history of responsibility for the older adult's social care and quality of life. The family system and the LTC system become linked through the older adult and the two systems must find a way to co-exist.

Part of the difficulty with the role of family members in LTC facilities may have to do with the way family involvement is viewed by the administration and staff. The key is whether the family is viewed as integral to the LTC system or peripheral to the system. Montgomery (1982, 1983) has referred don a task that does not fit into its structure (Litwak, Messeri, & Silverstein, 1990). For example, instead of preparing meals for each resident based on the resident's preferences, LTC facilities tend to provide a standard meal which is more cost effective and efficient for the facility. Family members may view this as a reduction in the quality of care given to the older adult and seek to supplement meals by bringing in extra food or treats.

Litwak's (1977, 1985) task-specific theory emphasizes that the family has a role to play within the LTC system and suggests staff and family have separate yet coordinated caregiving tasks to perform. Technical tasks, which require technical knowledge or a detailed division of labor (e.g., giving medications), are best performed by staff, while non-technical tasks, which use everyday knowledge and socialization or cannot be subdivided effectively (e.g., personalized grooming), are best performed by family members. Failure of either group to perform their tasks would have negative results in the resident's care and quality of life.

The demarcation between technical and non-technical tasks may not always be clear and tasks may require the involvement of both staff and family. For example, giving prescription medications may fall into the technical category, but what about giving vitamins or non-prescription medications? Dempsey and Pruchno (1993) interviewed family members regarding the perceived and actual responsibilities of staff and family members in 200 nursing homes.

In general, there was congruence between who was expected to perform the task and who was actually performing the task, suggesting there is little conflict in the assignment of tasks. While there were clear lines of responsibility for some tasks, others were performed by both staff and family, suggesting there is overlap in responsibilities. For example, emotional support was viewed as a don a task that does not fit into its structure (Litwak, Messeri, & Silverstein, 1990). For example, instead of preparing meals for each resident based on the resident's preferences, LTC facilities tend to provide a standard meal which is more cost effective and efficient for the facility. Family members may view this as a reduction in the quality of care given to the older adult and seek to supplement meals by bringing in extra food or treats.

Litwak's (1977, 1985) task-specific theory emphasizes that the family has a role to play within the LTC system and suggests staff and family have separate yet coordinated caregiving tasks to perform. Technical tasks, which require technical knowledge or a detailed division of labor (e.g., giving medications), are best performed by staff, while non-technical tasks, which use everyday knowledge and socialization or cannot be subdivided effectively (e.g., personalized grooming), are best performed by family members. Failure of either group to perform their tasks would have negative results in the resident's care and quality of life.

The demarcation between technical and non-technical tasks may not always be clear and tasks may require the involvement of both staff and family. For example, giving prescription medications may fall into the technical category, but what about giving vitamins or non-prescription medications? Dempsey and Pruchno (1993) interviewed family members regarding the perceived and actual responsibilities of staff and family members in 200 nursing homes.

In general, there was congruence between who was expected to perform the task and who was actually performing the task, suggesting there is little conflict in the assignment of tasks. While there were clear lines of responsibility for some tasks, others were performed by both staff and family, suggesting there is overlap in responsibilities. For example, emotional support was viewed as a to this as the degree of family orientation. The degree of family orientation of a facility's care policy is measured by (Montgomery, 1983):

* The extent to which services are extended to the residents' families.

* The extent of inclusion of families in activities and events of the institution.

* The degree to which rules and regulations are made with the family's well-being in mind.

Long-term care facilities with a high degree of family orientation provide activities in which the family can function as members of the care team or which provide support to the family as clients, or both. Facilities with a low degree of family orientation tend to keep the family at a distance, relegating tasks to them as "servants'* who assist the staff (e.g., run errands, need direction or permission for involvement in care) or as visitors who come to entertain the older adult, or both.

The policies of the LTC facility can affect the relationships between staff and famiiy and the family's perception of the care provided. Following up on Montgomery's earlier work, Friedemann, Montgomery, Maiberger, and Smith (1997) asked nursing home administrators to rate their policies regarding a list of 20 possible family activities to determine degree of family orientation. The survey included items such as staff calling family for advice with resident problems and hosting family support groups and was rated on a 3-point scale (3 = activity encouraged, 2 = activity available at request only or not encouraged, and 1 = activity not available).

They also interviewed family members about their nursing home experiences. These researchers found that family members cited more problems in care, interactions with staff, and nursing home characteristics (e.g., environment, staffing) when the facility had low family orientation. When the nursing home was ranked high in family orientation, family members were more likely to mention the care was good or excellent and staff cooperated in problem-solving.

Although the policies of the LTC facility have a significant impact on the role of the family, the family can also seek to establish their role in a variety of ways. Carón (1997) describes four roles which emerge along a continuum. First, family members may become disengaged from the LTC system, leaving all care and decisions to the LTC facility staff and administration. Second, family members may play a consultant role, involving themselves in decisions about care but not participating in the care. Third, family members may take on a competitive role with LTC staff, seeking to establish control over the way in which care is delivered and becoming advocates and protectors against poor care of the older adult. Fourth, family members may play a collaborative role with LTC staff, working together in providing daily care to the older adult and supporting the staff's role.

The fit between the views of the LTC facility administration and staff and the family likely determine how well the family and staff interact after the older adult has been moved into a LTC facility. Facilities low in family orientation may find conflict with family members who seek to establish a competitive or collaborative role, while those high in family orientation may be frustrated with the lack of family involvement when family members seek to establish a disengaged or consultant role.

Interactions Between Staff and Family

Division of labor. When the older adult moves into a LTC facility, many daily caregiving tasks shift from the family to the staff. This transition is not always easy because the staff and family may have different expectations regarding how the tasks should be performed. When the staff take over caregiving tasks, they tend to make the tasks routine to fit into the schedule of the facility or they abandon a task that does not fit into its structure (Litwak, Messeri, & Silverstein, 1990). For example, instead of preparing meals for each resident based on the resident's preferences, LTC facilities tend to provide a standard meal which is more cost effective and efficient for the facility. Family members may view this as a reduction in the quality of care given to the older adult and seek to supplement meals by bringing in extra food or treats.

Litwak's (1977, 1985) task-specific theory emphasizes that the family has a role to play within the LTC system and suggests staff and family have separate yet coordinated caregiving tasks to perform. Technical tasks, which require technical knowledge or a detailed division of labor (e.g., giving medications), are best performed by staff, while non-technical tasks, which use everyday knowledge and socialization or cannot be subdivided effectively (e.g., personalized grooming), are best performed by family members. Failure of either group to perform their tasks would have negative results in the resident's care and quality of life.

The demarcation between technical and non-technical tasks may not always be clear and tasks may require the involvement of both staff and family. For example, giving prescription medications may fall into the technical category, but what about giving vitamins or non-prescription medications? Dempsey and Pruchno (1993) interviewed family members regarding the perceived and actual responsibilities of staff and family members in 200 nursing homes.

In general, there was congruence between who was expected to perform the task and who was actually performing the task, suggesting there is little conflict in the assignment of tasks. While there were clear lines of responsibility for some tasks, others were performed by both staff and family, suggesting there is overlap in responsibilities. For example, emotional support was viewed as a responsibility of both staff and family. This collaboration in performing tasks versus Litwak's (1977, 1985) division of tasks was previously supported by Bowers (1988) and Linsk, Miller, Pflaum, and Ortigara-Vicik (1988) who found overlap in the areas of responsibilities. Dempsey and Pruchno (1993) recommended:

First, those tasks which for the effective management of the institution must be performed by staff should be clearly outlined and explained to family members. Second, nursing home staff training should encourage the staff to view family members as able caregivers who can assist in the provision of tasks. This will increase the quality of care provided and give meaning to the role played by family members (p. 143).

Monitoring care. The division of labor is not the only important aspect regarding staff and family involvement in caregiving. Duncan and Morgan (1994) held focus groups with family members of older adults living in LTC facilities. These focus groups allowed the family members to discuss the topics that were important to them regarding the resident's care and their relationships with staff. The authors noted that the discussion involving the division of tasks was minimal, while dialogue regarding the manner in which care was provided was prominent. Family members emphasized that when the staff are performing tasks, they should do so in a manner which treats the resident with dignity, respect, and personal sensitivity. A constant source of conflict was the family member's dissatisfaction with lack of social and emotional involvement of the staff while performing their technical tasks.

Duncan and Morgan (1994) and Bowers (1988) noted that family members monitored the behavior of the staff to assess the manner in which care was given. Monitoring usually included watching how staff interacted with other residents (and assuming their relative was being treated in the same manner), asking the resident how they are being treated, or assessing the resident's emotional outcome (relating depression, hopelessness, withdrawal, and agitation to poor care). Many family members held themselves responsible for monitoring and evaluating the effectiveness and quality of care tasks, even though the responsibility for performing the tasks was delegated to the staff.

Communication and collaboration. Clearly, communication between the staff and family members is key to the coordination of tasks and responsibilities and to good relationships between staff and family members. Within a collaborative model, staff can teach family members to perform a variety of technical tasks and provide them with clinical information while family members can teach staff about personalizing the residents' care. Bowers (1988) found that family members taught staff how to deliver high quality care in three informal and subtle ways:

* Telling stories which illustrated the resident's uniqueness.

* Demonstrating activities or directing conversations to coincide with a staff member's appearance in the room.

* Sharing with the staff the affective outcome of inadequate care, particularly the resident's distress or depression.

Family members perceived that the staff's unwillingness or inability to incorporate the family member's knowledge about the resident into the care and to pass the information on to other staff members who also provided care for the resident were barriers to effective collaboration (Bowers, 1988; Duncan & Morgan, 1994).

The flow of information goes two ways - from the family to the staff and from the staff to the family. Gutman and Killam (1989) interviewed a sample of 40 staff members involved in six special care units regarding the nature and amount of information staff should provide to family members. Approximately half of the staff were care or activity aides; just more than a quarter were RNs, registered practical nurses, or graduate nurses; and one fifth were other staff (e.g., occupational therapist, social worker, dietician). Eleven of the staff in their study stated it was not part of their job to respond to family members' requests for information, while 15 staff members believed families should be given as much information as possible.

Other staff recommended family members be given as much information as possible, with discretion. Discretion included not providing information which would be very upsetting to the family member, not focusing on the resident's negative behaviors, or not providing all the information if the family relationships were tenuous and the family member was deemed to not have the resident's best interests in mind. It appears there are judgments by both the family and staff regarding the monitoring of care and the flow of information, with both groups taking responsibility.

As with the care provided, the issue is not only whether or not communication happens, but also the manner in which it happens. Gutman and Killam (1989) reponed that both staff and family members believed communication was very important in creating a supportive and helpful environment. They emphasized qualities such as honesty, openness, friendliness, encouragement, pleasantness, trust, and reassurance.

When communication or collaboration breaks down or is poorly formed, negative interactions can occur between staff and family members. Vinton and Mazza (1994) surveyed administrators from 70 LTC facilities regarding aggressive behaviors directed toward staff by family members during a 6-month period. Verbally aggressive acts included insults, berating or belittling, chastising, calling names, making fun of, yelling, cursing, or threatening. Physically aggressive acts included punching, slapping, striking with an object, studies, with few comparisons between the views of the staff and the family.

Further research would benefit from inclusion of a greater variety of types of LTC facilities, larger sample sizes, and comparisons between the involvement and attitudes of both the family and staff/administration. Concepts and relationships for exploration in future research may include:

* How the facility's definition of the role of the family influences actual family involvement (e.g., using Montgomery's [1982, 1983] degree of family orientation).

* How the family's view of their role within the LTC facility influences staff-family relationships (e.g., using Caron's [1997] four roles of family involvement).

* How caregiving tasks are divided or coordinated between family and staff (e.g., using Litwak's [1977; 1985] task-specific theory).

* How the perceived quality of communication between staff and family is associated with family involvement in care and with conflict between family and staff.

CLINICAL IMPLICATIONS

Long-term care facilities which view the family as integral to the care system, encourage family involvement, and promote open communication between staff and family members are most beneficial for all parties involved (Buckwalter Oc Hall, 1987; Dempsey & Pruchno, 1993). Family involvement can have positive consequences to the psychosocial and physical health of family members and residents, as well as easing some of the care load of staff (Duncan & Morgan, 1994; Pratt, Schmall, Wright, & Hare, 1987).

There are many ways to promote family involvement and positive staff-family interactions. First, outline the facility policies regarding the roles and responsibilities of both staff and families. These policies should be reviewed and revised as needed on a regular basis by the studies, with few comparisons between the views of the staff and the family.

Further research would benefit from inclusion of a greater variety of types of LTC facilities, larger sample sizes, and comparisons between the involvement and attitudes of both the family and staff/administration. Concepts and relationships for exploration in future research may include:

* How the facility's definition of the role of the family influences actual family involvement (e.g., using Montgomery's [1982, 1983] degree of family orientation).

* How the family's view of their role within the LTC facility influences staff-family relationships (e.g., using Caron's [1997] four roles of family involvement).

* How caregiving tasks are divided or coordinated between family and staff (e.g., using Litwak's [1977; 1985] task-specific theory).

* How the perceived quality of communication between staff and family is associated with family involvement in care and with conflict between family and staff.

CLINICAL IMPLICATIONS

Long-term care facilities which view the family as integral to the care system, encourage family involvement, and promote open communication between staff and family members are most beneficial for all parties involved (Buckwalter Oc Hall, 1987; Dempsey & Pruchno, 1993). Family involvement can have positive consequences to the psychosocial and physical health of family members and residents, as well as easing some of the care load of staff (Duncan & Morgan, 1994; Pratt, Schmall, Wright, & Hare, 1987).

There are many ways to promote family involvement and positive staff-family interactions. First, outline the facility policies regarding the roles and responsibilities of both staff and families. These policies should be reviewed and revised as needed on a regular basis by the kicking, biting, choking, pinching, spitting, forcefully squeezing, restricting from moving, shoving, or pulling forcibly. Results showed that two thirds of the facilities experienced verbally aggressive acts while 11% reported physically aggressive acts. Nearly 1,200 verbally aggressive acts and 13 physically aggressive acts were reported. The number of aggressive acts per facility ranged from 1 to 410, with the largest nursing home reporting the greatest number of verbally aggressive acts. The mean number of verbally aggressive acts was 17.8.

The administrators who completed the survey suggested that care issues, theft of the resident's belongings, and billing disputes prompted the majority of aggressive acts. According to the survey responses, social work staff were most frequently contacted to resolve the conflicts. The most common resolution strategies included discussing the incident with either the staff member or family member alone, documenting the incident in the resident's record, or discussing the incident with the staff member and family member together.

Vinton and Mazza (1994) recommended that communication and understanding are important in resolving and preventing negative interactions. They suggested the administrators and staff try to understand the purpose of aggressive behavior (e.g., are aggressive responses typical for a particular family or do family members perceive aggressive behaviors are the only way to effect change for residents?); set up a consultant or counselor to deal with issues; have policies which clearly outline the rights, roles, and responsibilities of all panics involved in the resident's care; and train staff in conflict resolution strategies.

SUMMARY

In summary, family members may be involved in all aspects of a frail or ill older adult's care before, during, and after admission into a LTC facility (Chappell, 1992; Dempsey & Pruchno, 1993; Zarit & Whitlatch, 1993). However, their role within the facility is not always clearly defined. Issues arise regarding facility policies and staff attitudes toward family involvement, particularly whether the family member is seen as an integral part of the care system or peripheral to the care system. Researchers recommend that family involvement can have positive consequences for the residents, family, and facility (Duncan & Morgan, 1994; Farber, Brod, & Feinbloom, 1991). The relationships between staff and family are key to providing coordinated and complete quality care to the resident. Communication is important in preventing misunderstandings and disagreements between staff and family and in promoting good quality care and quality of life for the resident.

The focus of this article was on the interaction between the LTC facility and family members in regard to the role of the family members. It is recognized that other factors may also influence the family role and level of involvement, such as (Minichiello, 1989):

* Availability of family members.

* Distance that family members live from the facility.

* Gender of family members.

* Pre-admission quality of the relationship between the family member and older adult.

* Functional ability of the older adult.

In addition, the preferences or opinions of the resident may influence family involvement in care within the LTC facility. However, discussion of these other factors was beyond the scope of this article.

The research to date provides valuable insight into the role of the family within the LTC system. However, most of the studies used small sample sizes and were conducted within one facility, with few comparisons across types of facilities. In the majority of articles reviewed, the views of the family were the main focus of the studies, with few comparisons between the views of the staff and the family.

Further research would benefit from inclusion of a greater variety of types of LTC facilities, larger sample sizes, and comparisons between the involvement and attitudes of both the family and staff/administration. Concepts and relationships for exploration in future research may include:

* How the facility's definition of the role of the family influences actual family involvement (e.g., using Montgomery's [1982, 1983] degree of family orientation).

* How the family's view of their role within the LTC facility influences staff-family relationships (e.g., using Caron's [1997] four roles of family involvement).

* How caregiving tasks are divided or coordinated between family and staff (e.g., using Litwak's [1977; 1985] task-specific theory).

* How the perceived quality of communication between staff and family is associated with family involvement in care and with conflict between family and staff.

CLINICAL IMPLICATIONS

Long-term care facilities which view the family as integral to the care system, encourage family involvement, and promote open communication between staff and family members are most beneficial for all parties involved (Buckwalter Oc Hall, 1987; Dempsey & Pruchno, 1993). Family involvement can have positive consequences to the psychosocial and physical health of family members and residents, as well as easing some of the care load of staff (Duncan & Morgan, 1994; Pratt, Schmall, Wright, & Hare, 1987).

There are many ways to promote family involvement and positive staff-family interactions. First, outline the facility policies regarding the roles and responsibilities of both staff and families. These policies should be reviewed and revised as needed on a regular basis by the administration and staff representatives. Those caregiving tasks which clearly fall into the staff domain and those which are not part of the staff duties should be explained to family members. However, there are many tasks, such as outings, clothing care, or birthday celebrations, for which responsibility may need to be negotiated. An example of family involvement in care intervention protocol has been outlined by Maas, et al. (1994). These authors recommended family involvement be addressed early in the LTC process, introduced at the intake meeting and discussed in greater detail during subsequent meetings.

It should be stressed that the agreement or contract is open for renegotiation as life situations of the family or resident change or if the facility changes its policies. This is important because the transition from community to facility of an older adult can be very stressful for family members and their desired involvement may change once the situation stabilizes.

Second, include a component on family involvement in staff training or orientation programs. Explain the philosophy behind the policies and procedures regarding family involvement to the staff. Specific examples of how the staff can facilitate family involvement can be suggested or demonstrated (e.g., training family members in lift procedures). Staff can be taught approaches to deal with family reactions to LTC admission of the older adult, as well as conflict resolution strategies. If a more structured assessment of a family member's caregiving situation is desired, a stress or burden assessment tool (e.g., The Caregiver Burden Inventory [Novak & Guest, 1989]) can be used to help staff determine the family member's readiness for involvement. The process of negotiation for involvement in tasks can also assist the staff in understanding the family member's desire and willingness for providing continued care. Family involvement in care protocol or contract, if used, should be familiar to the staff and available for reference as they provide care to the residents and interact with family members.

Third, promote open communication between family and staff. Arrange regular meetings between family and staff. These meetings wouîd be most productive if the nurses and other staff who have the most direct contact with the resident attended the meetings, in addition to managers or other administration staff. The discussion should not be merely a report on the status of the resident, but should allow the family to bring up concerns, re-negotiate care responsibilities, collaborate in problem-solving, and express satisfaction with care.

To facilitate communication between the family and staff, designate a specific nurse or other staff member with whom the family may consult between meetings. With a designated contact person, family members can establish rapport and feel free to ask questions as they arise. The contact person, as well as other staff members, should be encouraged to answer family questions openly and honestly. If they do not know an answer, they should refer the family to the person with the answer. Relationships break down quickly and family members may become suspicious and distrustful if they feel that the staff are holding back information or being untruthful.

Fourth, improve communication among staff members and between nursing shifts so information provided by family members or to family members is consistent. Family members may find it frustrating to relay the same information to each staff member on each shift responsible for caring for their relative. This communication can be improved by maintaining a log book on the residents and asking staff to read the log book prior to their shift, or by holding regular staff meetings to discuss specific resident care.

Fifth, offer services specifically for family members. Such services can include support groups and educational workshops. Support groups can be facilitated by a staff member or a willing family member. Educational workshops can focus on issues commonly experienced when an older adult is moved into a LTC facility or the specific needs of groups of families (e.g., when the older adult has a cognitive impairment). Family members can be surveyed to find out what topics would be of interest to them.

Sixth, offer social activities for the staff, family, and residents to promote positive relationships among the groups. Such activities can include picnics, dances, banquets, or fair days, and should occasionally be held on weekends or in the evenings so employed family members are able to attend. Social activities allow the family, residents, and staff to interact in an informal way and may encourage a "family feeling" among the entire group.

Finally, promote the philosophy that family members truly are an important resource for the LTC facility (Buckwalter & Hall, 1987). The above suggestions for clinical practice emphasize that the family is an integral part of the LTC system and that communication is vital to positive staff-family relationships.

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