Nursing Interventions for Families of Nursing-Homc Residents

Structured discuss ion of concerns can ease the transition

nurs ing-home care for both residents and their families.

B Y M A R A F E R R I S

A dmission to a nursing home is generally recog- nized as a traumatic event in an individual's life. Whether basing their actions on research, experi-

ence, or intuition, both staff and family do whatever they can to minimize the new resident's grief and to shorten the transition period. More recently recognized, but al- ready well documented, is the crisis experienced by the family before, during, and after a relative's admission to the nursing home. Because institutionalization imposes changes on individual roles within families, we must an- ticipate stress on every member of the immediate family.

Is your nursing staff able to recognize the signs of a family or individual struggling to cope? Are they able to provide the needed help?

Whose responsibility is it to assist these families? Ide- ally, it is the community's responsibility. In theory, it is the responsibility of the facility's social worker. In prac- tice, responsibility falls largely on the staff nurses and nursing assistants. This is true for several reasons. First, family members who have concerns about a resident's condition or care want to speak directly with those pro- viding the care. Another reason is the limited availability and multiple responsibilities of the social worker. Also, many families are able to visit only in the evenings or on weekends when few social workers are at work. The only practical resource therefore is the nursing staff. Finally, and perhaps most important, many troubled families do not recognize their own need for help.

To help prepare your nursing staff, offer in-services to

MARA FERRIS, RN,C, is the executive coordinator of American Ge- riatric Resource of Lexington, Massachusetts. 34/1/35530

should fall between formal and informal. The subject does not lend itself to the for- mal presentation of "this is" or "this is how to." On the other hand, informality is an invitation for a "gripe" ses- sion about, for example, "Edna's daughter always . . . . " Conversation is to be encouraged but with guidelines clearly stated from the outset and enforced throughout the session.

Begin the staff session by describing typical behavior patterns of troubled families. Having observed families in nursing homes, Dickstein 1 has identified and aptly named three behavior patterns. These three will probably in- clude all of the difficult behaviors your staff is likely to have encountered.

First is the "White Knight." This person is very critical of the care given to his or her relative and generally brings complaints directly to supervisory staff. When the "problems" have been corrected, the Knight is likely to find or point out another rather than acknowledge cor- rection of the first.

The second group are the "Staffers." These people be- have as though they are part of the nursing staff by pro- viding direct care. Some care provided by families is very appropriate and should be encouraged. Such care main- tains social integrity of the family, emphasizes the im- portance of continued involvement of family members, and reinforces the personal value of the resident. Unfor- tunately, the Staffers tend to provide or attempt to pro- vide care that is inappropriate.

The line between appropriate and inappropriate is vari- able. If for example a resident is relatively mobile and

Geriatric Nursing January/February 1992 37

needs minimal assistance transferring from bed to chair, it may be appropriate that the visiting family member as- sist him or her. If the resident is more dependent or if the family member has limited mobility, such help is inap- propriate and possibly dangerous. Toileting presents sim- ilar concerns but has the added concern of protecting the dignity and privacy of the resident. "Edna" may prefer to have a member of the nursing staff assist her in such a private activity rather than have her daughter see her in a socially embarrassing or dependent situation. Assis- tance with meals seems simple enough, but if the resident has difficulty swallowing or is receiving rehabilitation to regain self-feeding skills, it may be inappropriate for family members to help.

C O M M E N T S T H A T S H O W E M P A T H Y

• "1 know admitting your mother to a nursing home was a very hard decision for you. How are you feeling now?"

• "You and your sister didn't agree on admitting your father to a nursing home. Does she feel any better about it now?

• "You did a wonderful job taking care of your wife at home for so long into her illness. You must have been very tired. Are you able to get the rest you need now?"

• "1 think you made the right decision bringing your mother here, but I know she's still angry with you. Are your visits with her getting any easier?"

Finally, the third behavior type is described by Dick- stein as the "Retreaters." This group is the least disrup- tive but equally in need of our attention. The Retreaters increasingly limit contact with the resident, although they may "check in" regularly. The reasons for their "re- treat" are varied. Perhaps they are feeling guilt about the admission, or perhaps the resident is angry with them or is "playing on their guilt," making avoidance of direct contact preferable. Perhaps the family is feeling revulsion at their relative's deterioration or the handicaps of other residents. Perhaps they feel unneeded or redundant now that the staff is meeting the daily needs of the resident.

Your staff has already dealt with all of these behaviors and their insight should be shared and acknowledged as valuable. During the in-service, ask staff to describe how they have dealt with each behavior and to discuss the suc- cess these methods have achieved.

Simple interventions can be used for both families who are having relatively minor difficulties and those who are severely stressed. These interventions include the follow- ing: 1. Make comments to family that show empathy. (See

"Comments that Show Empathy.") These may foster a more frank discussion of the needs, feelings, and

concerns of the family as a whole and of individual family members.

2. Ask questions that solicit information about the res- ident's habits, preferences, or "'quirks." (See "'Ques- tions that Solicit b~formation.") These acknowledge the continued importance of the family to the resident and therefore to the nursing staff providing care to that resident.

3. Introduce families to other fanlilies and residents. This will help develop a sense of community within the home, will foster the formation of mutual support sys- tems, and will reduce the feelings of isolation.

4. Inform family of planned social events and in-house activities, particularly, but not exchtsively, those in which their resident family member will participate and in which they may want to participate. This will help reduce the image of warehousing the elderly and will encourage the family's continued participation in the resident's daily life.

5. Always, ahvays follow-up on family members" com- plaints or concerns. This shows respect for their in- sight, a concern for their feelings, and an appreciation of their continuing involvement.

Q U E S T I O N S T H A T S O L I C I T I N F O R M A T I O N

• "Your mother eats well at breakfast and lunch but never eats more than half of her dinner. Did she always do this?"

• "John wakes up about the same time every night. Did he do this at home?"

• "We have a hard time getting your sister to let us brush her hair, but we know you did it well at home and even when you visit. How do you do it?"

• "Mary enjoys the activities that have music. We'd like to tune her radio to a station she'll enjoy at other times of the day. What type of music does she like best?"

The well-being of your residents' families is important to the well-being of the residents. If families are confused, frustrated, emotionally stressed, or alienated, they cannot effectively support the residents. When families are knowledgeable, satisfied, and comfortable with and in- volved in the resident's care, the residents, staff, and the facility as a whole benefit. Acquainting nursing staff with the simple skills needed to recognize families' needs and to provide basic care is neither expensive nor difficult. The benefits to the residents, families, staff, and facility can be enormous.

REFERENCE

1. Dickstein H. Family guilt: a study of causes and approaches. In: Fourth American Symposium on Long-Term Care Administration Proceedings. Washington, DC: American College of Nursing Home Administrators, 1978.

38 Geriatric Nursing January/February 1992