Family involvement in the nursing home

The Predictors of and Motivations for Increased Family Involvement in Nursing Homes

BACKGROUND AND OBJECTIVES

Quantitative and qualitative data from a statewide survey of family members of nursing home residents were analyzed to determine the predictors of, and motivations for, family involvement.

RESEARCH DESIGN AND METHODS

We examined 3 types of involvement: visiting, providing personal care, and family-staff communication. Our mixed methods approach used (a) multilevel regression models to examine predictors of family involvement, including family member perceptions and resident, family member, and facility characteristics, and (b) a thematic analysis of qualitative data regarding the experiences of family members and their motivations for involvement.

RESULTS

Families were more involved when a short-term stay (<3 months) was expected, and when residents were in poorer physical condition. Spouses and female family members were more involved than others, yet the effect of gender varied by relationship type. At the facility level, families of residents in rural facilities reported less family involvement. Aside from these commonalities, predictors of each type of involvement varied. Themes from the qualitative data identify unique motivations for each type of involvement-to enhance residents' identity, care, or quality of life.

DISCUSSION

Families visit more and provide more hands-on assistance when they are not confident in the care being provided or the well-being and stability of their resident loved one. Receiving adequate information, perceiving staff as friendly, and residents as looking well cared for promote greater family-staff communication.

IMPLICATIONS

Findings can inform strategies to increase meaningful family involvement in nursing homes.

Investigating Barriers to Family Visitation of Nursing Home Residents: A Systematic Review

Families are integral in helping nursing home residents maintain feelings of social inclusion and an overall sense of belonging, thus reducing consequences of social exclusion. Preliminary research, particularly of the culture change movement in long-term care, shows there are barriers to family engagement and visitation of residents. The objective of this study is to: (1) identify and summarize the barriers most reported to family visitation and (2) synthesize the findings to determine which barriers are most often reported in literature, and which may pose the greatest challenges to family involvement. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a final sample of 15 articles across 11 databases report seven barriers to visitation: psychological, health, staff to family member relationship, employment/finances, travel time, access to transportation, and other. Findings suggest barriers to family visitation and point toward a need for further research as relationships between resident and family member is complex and warrants attention across professions. Interprofessional efforts between social work, allied professionals, and transportation planners are necessary to address this pressing concern experienced by residents in nursing homes, with the ultimate goal of lessening such barriers.

Developing the Family Involvement Questionnaire-Long-Term Care: A Measure of Familial Involvement in the Lives of Residents at Long-Term Care Facilities

INTRODUCTION

Existing measures designed to assess family involvement in the lives of older adults residing in long-term care facilities are basic, using visitation frequency as the prominent gauge of involvement in a situation specific fashion. The purpose of this study was to design and validate a measure of family involvement that could be used to gauge more aspects of family involvement than visitation alone and be useful in a variety of settings for both researchers and long-term care facility administrators.

METHODS

Long-term facility staff were asked to assist in creating a 40-item questionnaire that used 4-point Likert scales to measure various aspects of family involvement. The finalized Family Involvement Questionnaire-Long-Term Care (FIQ-LTC) was distributed to the family members of older adults residing in long-term care facilities around the country.

RESULTS

A total of 410 participants responded. Researchers found that the FIQ-LTC was highly reliable (α = .965). Results also indicated that a significant correlation between distance and overall involvement (r = -.121, p = .015) was no longer significant (r = .17, p = .740) when the effect of a question asking the frequency of visitation was controlled for.

DISCUSSION

These results indicate that existing measures that use visitation frequency as the sole measure of involvement are insufficient. The newly developed FIQ-LTC can serve as a more complete measure of family involvement.

Transitions in care: Family carers' experiences of nursing home placement

With demographic trends predicting an increase in the number of older people and a reduction in the number of family carers (Royal Commission on Long Term Care, 1999), it is likely that admission to nursing homes will continue to increase. Although it might be expected that entry to a nursing home, with an anticipated reduction in 24-hour care, would result in a reduction in stress for carers, evidence to date does not support this expectation. Study findings indicate that this experience is associated with guilt, anger, despair, resentment and general psychological distress (Kellett, 1999; Ryan and Scullion, 2000a; Nolan and Dellasega, 2000; Davies, 2001). Therefore, although the physical burden of caring is relieved following nursing home placement, the emotional turmoil often continues, and is exacerbated by the circumstances surrounding the decision to end home care. Although there is evidence to suggest that, following placement, families are often expected to relinquish their dependent older relative to the bureaucracy of the institution, this is not always in the best interest of the resident, the family or the nursing home staff. This paper examines recent literature on the transition from home care to nursing home care and highlights the need for greater collaboration between families and nursing home staff.

Family Involvement Following Institutionalization: Modeling Nursing Home Visits Over Time

Gerontological research has emphasized family members' continued involvement in the lives of loved ones following institutionalization. However, many of these studies are cross-sectional in design and do not ascertain how family members' visits change over time. The present study utilized a growth curve analysis to examine preplacement and postplacement predictors of nursing home visits over a two-year period among a sample of 65 caregivers of dementia patients. Intraindividual patterns of change suggested considerable heterogeneity in family visits. Several variables were also significantly predictive ( p < .05) of change in nursing home visits. Spousal caregivers were more likely to report increased visits. Care recipients with greater cognitive impairment following institutionalization experienced increased visits. Caregivers who perceived respect and support from their social network following institutionalization also reported increased visits over the two-year study period. Caregivers who engaged in socially restorative activities after institutionalization reported decreases in visits. The findings provide a more refined understanding of the long-term involvement process following institutionalization.

The risk to enduring relationships following the move to a care home

Aim.  To explore findings from a study which investigated the meanings that older people attributed to their experiences of living in a care home and consequently the risks that they identify in this. Background.  There is evidence from this and other studies that being able to engage in long-time friendships is important to older people. The move to a care home has the potential to disrupt these relationships and there is a risk of breakdown of the friendships that have been valued throughout life. Method.  A hermeneutic inquiry that explored the meaning that eight older people ascribed to their life in the care home. This paper focuses on the narratives that concerned relationships with long-time friends and the risks to these relationships. Results.  The paper highlights the importance of engaging in meaningful relationships with other people. The participant's stories illuminated the importance of maintaining friendships following the move to a care home and how these had had a positive impact on their lives in that setting. With advancing age and increasing frailty the participants were acutely aware that their friendships were vulnerable to breakdown and they implemented a range of strategies to sustain their relationships with these people. Conclusion.  The findings point to the importance of acknowledging the value of long-time friendships to older people and the need to support them in their efforts to sustain these relationships and reduce risks to them.

Family caregiver involvement for long-term care residents at the end of life

OBJECTIVES

To examine family caregiver involvement for long-term care (LTC) residents during the last month of life. Researchers examined direct (personal care and meals) and indirect (management and monitoring) types of caregiver involvement and the relationship between the type of involvement and predisposing, enabling, and need characteristics. Researchers also examined whether the frequency of involvement changed during the end-of-life (EOL) period.

METHOD

Researchers used an expanded version of Andersen's Behavioral Model to conceptualize predictors of family involvement for 438 residents in 125 residential care/assisted living and nursing home settings. Bivariate and multivariate analyses examined relationships among variables.

RESULTS

More than one-half of family caregivers monitored, managed care and assisted with meals, and 40% assisted with personal care tasks. The enabling characteristic of days visited and the need characteristic of caregiver role strain were related to each of the 4 types of involvement. However, the other correlates were distinct to the type of involvement.

DISCUSSION

Families are involved in EOL care in LTC settings. Higher role strain is related to more involvement in each of the 4 types of involvement, suggesting that whether involvement is by desire, perceived need, or both, there is cause to more critically examine the family caregiver's desired role and need for support.

A quasi-experimental design trial exploring the effect of a partnership intervention on family and staff well-being in long-term dementia care

OBJECTIVES

This study sought to explore the effect of the family involvement in care (FIC) intervention on family and staff well-being over a nine-month period in a long-term care (LTC) facility providing dementia care.

METHOD

A quasi-experimental design with randomised allocation of two LTC sites but not the participants was employed. Family caregivers (n = 57) of residents with dementia and staff (n = 59) from two LTC facilities in Queensland, Australia, were recruited. Participants were assessed once pre-intervention and three times post-intervention for knowledge, stress and satisfaction outcomes. Between-group and within-group effects were analysed using ANOVAs at <0.05 level of significance. Pre- and post-intervention interviews from a purposive sample of family caregivers were also conducted to enhance understanding of FIC benefits.

RESULTS

Beneficial intervention effects associated with family caregivers' knowledge of dementia were found (p < 0.001). Negative intervention effects were also found for family satisfaction outcomes in relation to staff consideration of their relatives and management effectiveness (p < 0.05). In addition, staff well-being and job satisfaction were found to be negatively affected by their perceived inappropriate behaviour of residents with dementia (p < 0.05).

CONCLUSION

Participation in the FIC intervention improved family caregiver knowledge. The major barrier to the success of the partnership intervention in achieving beneficial long-term psychosocial effects for family and staff caregivers was lack of resources and leadership required to support collaboration between family and staff, mainly due to environment and structural changes. This study contributes to our understanding of the importance of partnerships in promoting family involvement in dementia care.

Seizing possibilities for positive family caregiving in nursing homes

AIMS

This paper explores the ways family members reconstruct meaning through seizing possibilities for positive caregiving in nursing homes.

BACKGROUND

The importance of the ability of family caregivers to adapt and accommodate has been well documented in international family caregiving research. Through engagement in caregiving activities, families learn to modify, adapt and accommodate to changes in their situation and relationships. The support family caregivers experience in learning to accommodate change is crucial in enabling them to reconstruct positive aspects of caregiving in a long-term aged care context.

METHOD

In this study, a hermeneutic phenomenological approach was adopted informed by the philosophical world views of Heidegger and Gadamer. Data collected by in-depth interviews and participant observations, from a purposeful sample of 14 family caregivers, underwent hermeneutic analysis.

RESULTS

Five shared meanings associated with seizing possibilities for positive caregiving were revealed: accommodating new and different ways of caring; feeling a part of the nursing home community; seeing the whole picture; learning to care in stress-reducing ways and learning to seize possibilities for self.

CONCLUSION

This paper illustrates how families, through caregiving experience in nursing homes, learn to become active managers, negotiating, accommodating and redeveloping a sense of future viewed with hope, strength and positive anticipation.

RELEVANCE TO CLINICAL PRACTICE

By highlighting what is attributed significance by families, a critical examination of the difficult issues which obstruct the development of meaningful partnerships among nurses, family and their relatives is facilitated. In particular, an examination of tensions at an ideological level supports the need for future research to focus its efforts on examining the ways of implementing nursing care that facilitates partnerships that incorporate and build upon positive and equal relations among staff, families and residents in the context of the nursing home setting.

The pain of residents with terminal cancer in USA nursing homes: family members' perspectives

Cancer pain continues to be poorly treated despite efforts aimed at improvement. This causes considerable distress to both patients and their families. The purpose of this research is to explore the perspectives of family members of nursing home residents with terminal cancer, about pain and pain management. Participants who believed their pain could be better managed viewed their family member's pain and illness differently than those who believed the pain could not be managed better. The family members who believed better pain management was possible often took on the role of advocate and saw to it that the pain was addressed. Those who believed that their relative did not have adequate pain relief, but felt better management was not possible, expressed no concerns about this aspect of their relatives' care; they could not separate their relatives' pain from their illness. The interpretation and presence of adequate pain management is critical for family members to construct meaning around their relative's pain. When family members do not believe that the pain can be managed any better, this acts as a barrier to the resident's access to adequate pain management.

Informal caregiver involvement and illness detection among cognitively impaired nursing home residents

BACKGROUND

The participation of informal caregivers in the care of nursing home (NH) residents has the potential to positively impact care, especially for cognitively impaired residents whose own ability to advocate for their care is often limited. This study examined relationships between the level of informal caregiver involvement (ICI) in the NH and the degree to which residents' common medical conditions were detected by facility staff.

METHODS

One hundred pairs of cognitively impaired residents and their primary informal caregivers were enrolled from three facilities in the Baltimore, Maryland area. Data collection involved interviews with informal caregivers and facility staff, as well as a medical evaluation and chart review of residents. A measure of illness detection was created by comparing a medical examination of the resident with chart review information. ICI was measured via staff rating and informal caregiver self-report.

RESULTS

Correlations between illness detection and ICI were significant, with r = -.46 (p <.001) and r = -.39 (p <.001), for staff rating and self-reports, respectively. In regression models taking into account resident characteristics (age, race, gender, comorbidities, payment status, duration of stay, and cognitive impairment) and facility differences, higher ICI and being female predicted higher rates of illness detection.

CONCLUSIONS

Though the cross-sectional nature of the study prevents the analysis of causal relationships, the involvement level of informal caregivers in the NH care of cognitively impaired residents was statistically related to higher rates of illness detection. Ramifications for the role of informal caregivers in long-term care are discussed.

Impact of the Eden Alternative on Family Satisfaction

OBJECTIVES

The purpose of the study was to determine the impact of the Eden Alternative on family satisfaction.

DESIGN

The study was a one-group pre-post design. Families were surveyed prior to the beginning of implementation of the Eden Alternative and again 2 years later.

SETTING

The study was conducted at a 150-bed nursing home in the Midwest.

PARTICIPANTS

Thirty-seven family members completed the survey at both time points.

INTERVENTION

More than 80 in-services on the 10 principles of the Eden Alternative were provided to the staff on all shifts over the first year. Implementation of the Eden Alternative began during the second year.

MEASUREMENTS

The Family Questionnaire, which measures perception of skill and caring nature of caregivers, quality of activities, the environment, contentment of elders, and relationships with administration, was mailed to a family member of each elder living in the nursing home in March of 2002 and again in March of 2004.

RESULTS

There was a significant improvement in family satisfaction, as measured by the Family Questionnaire (P < .0001) after implementation of the Eden Alternative.

CONCLUSION

The Eden Alternative provided many opportunities for family involvement. The improved satisfaction scores reflected greater communication and interaction among families, staff, and residents.

Family involvement in residential long-term care: a synthesis and critical review

The objective of this review is to critically synthesize the existing literature on family involvement in residential long-term care. Studies that examined family involvement in various long-term care venues were identified through extensive searches of the literature. Future research and practice must consider the complexity of family structure, adopt longitudinal designs, provide direct empirical links between family involvement and resident outcomes, and offer rigorous evaluation of interventions in order to refine the literature.

Unit Manager's Role with Family Members of Clients in Complex Continuing Care Settings: An Untold Story

Most literature on staff-family relationships has come from studies of long-term care settings, has focused mainly on the families' perspectives on factors affecting their relationships with staff, and has included scant findings from the staff's perspective. No studies that examined staff-family relationships in complex continuing care (CCC) environments from the perspective of staff were found in the literature. A qualitative study that draws on a grounded theory approach was conducted to explore staff-family relationships in CCC, and the findings presented in this article illuminate the unit manager's role. Data were collected through in-depth interviews with nine unit managers and a follow-up focus group with five unit managers who work in three CCC facilities. Three categories reflecting the unit manager's role with family members of clients in CCC settings were derived: establishing supportive entry; building and preserving relationships; and closing the loop. Implications of the findings for practice and future research are presented.

Identifying Changeable Barriers to Family Involvement in the Nursing Home for Cognitively Impaired Residents

PURPOSE

Barriers to family involvement in the nursing home with the potential for change through intervention are examined, including transportation, caregiver health, relationships with staff, and resident characteristics.

DESIGN AND METHODS

Data were collected for 93 family caregiver-resident pairs by means of telephone interviews and chart review. Regression modeling was used to identify relationships between involvement (caregiver visit frequency) and the changeable barriers after the known variables of distance, kinship, payment source, length of stay, and cognitive function were taken into account.

RESULTS

Lower visit frequency was found for caregivers reporting problems with transportation, poor relationships with staff, and a smaller network of supportive family and friends. Higher caregiver anxiety was related to higher visit frequency.

IMPLICATIONS

Several barriers to family involvement are shown to be as or more influential than ones identified in previous research, thus providing empirical support for interventions currently used as well as suggesting new areas for intervention.

Maintaining family connectedness in long-term care. An advanced practice approach to family-centered nursing homes

The decision to place a relative in a long-term care institution is one of the most difficult processes families can go through. Family members often experience conflicting feelings of stress, shock, anxiety, fear, resistance, and guilt. In addition, many individuals, regardless of the amount of previous nursing home experiences, possess misconceptions about nursing home care (Grove, 1997; Mastrian & Dellasega, 1996; Tickle & Hull, 1995). Even after the family realizes the necessity of nursing home placement, achieving a level of comfort with such a decision and maintaining family relationships is a difficult challenge. Unfortunately, family-centered nursing care in long-term care settings is hindered by multiple barriers, including resistance to institutional change, family members' fear and hesitation, institutional rules and protocols, lack of institutional encouragement of family involvement, insufficient programs and activities addressing the social and emotional needs of the family, and ineffective communication between the staff and families. To remedy these barriers, it is suggested the family advanced practice nurse (APN) view the families as clients and initiate family-centered policies to encourage family involvement in the caregiving experience. Ultimately, this will promote individualized care of elderly adults and encourage family processes within the walls of the nursing home.

'Relatives are a resource, but...': registered nurses' views and experiences of relatives of residents in nursing homes

Registered Nurses (RNs) working in nursing homes in Sweden have obligations towards the residents' relatives, besides the care of residents. Relatives' involvement and satisfaction with the care partly depend on their contacts and communication with the staff. This study aimed to explore and describe RNs' views and experiences of relatives of residents who live in nursing homes. Open interviews were conducted with 19 RNs at three nursing homes. The verbatim-transcribed interviews were subjected to qualitative content analysis. Relatives were seen as a resource (with some restrictions) and nice, although demanding. The RNs saw relatives as part of their work--a part that could be time-consuming and had low priority. Interviewees noticed a difference between young and old relatives, and between female and male relatives. A large proportion of accounts could be related to issues about communication and interpersonal relationships with relatives. Building a trusting relationship with relatives may result in them being involved in residents' care and thus giving the nurses time rather than consuming time.

Family care for older adults with disabilities: toward more targeted and interpretable research

Family care of the elderly is key to the long-term care system, and its importance has led to an abundance of research over the past two decades. Several methodological and substantive issues, if addressed, could create even more targeted and interpretable research. The present review critically examines methodological topics (i.e., definitions of family caregiving, measurement of caregiving inputs) and conceptual issues (i.e., family involvement in long-term residential settings, and the care receiver's perspective on care) that have received insufficient attention in the caregiving literature. Throughout this review recommendations are offered to improve these areas and advance the state of the art.

Moving into a care home: the role of adult children in the placement process

Admission of an older person to a care home is widely recognised as a very stressful period for the family and one which, despite community care policy, is likely to be an increasingly common experience. Although there is a growing research base in this area, there have been few studies on the role of adult children in supporting their parents during this difficult transition. This paper reports on the third stage of a grounded theory study conducted in Sweden which explored the part played by adult children in the placement process. Data were collected from 13 adult children using in-depth semi-structured interviews and the results are compared with themes previously derived from interviews with 26 spouse carers. The analysis reveals important overlaps and differences and suggests the need for further research exploring the dynamics of the placement process.

Placing a spouse in a care home: the importance of keeping

Despite a universal policy of community care, the number of frail older people entering care homes is likely to increase in the future. There have been relatively few studies exploring the experience of spouses who have placed a partner in care. Due to a lack of preparation, the placement process is often ad hoc, with little attention being given to spouses' emotional reactions or their efforts to maintain their relationship with their partner. The relationship between care home staff and families is often superficial and strained. There is a need for more proactive efforts to facilitate a partnership between care home staff and families.