hr. J. Nurs. Stud., Vol. 29, No. 1, pp. 49-57, Printed in Great Britain.
1992.
0
0020-7489/92 SS.OO+O.oO 1992 Pergamon Press plc
Family-focused nursing care of hospitalized elderly JO ANN H. COLLIER,
Ph.D.,
R.N.
Associate Professor of Nursing, College of Nursing, University of Akron, Akron, OH 44325-3 701, U.S.A.
VICTORIA
SCHIRM, Ph.D.,
R.N.
Associate Professor of Nursing, College of Nursing, University of Akron, Akron, OH 44325-3701, U.S.A.
purposes of this research were to gain an understanding of how nurses in acute care settings involve families of elderly patients in planning and giving care, and to determine the extent of that involvement in nursing documentation. Data were obtained from patient records and interviews with nurses. Evaluated were characteristics of elderly patients and families, documentation of family involvement in care, and nurses’ descriptions of family care. A comparison of data sources indicated that nurses verbalized far more inclusion of families in care than the written records documented. Results of this research support the importance of clarifying and promoting acute carenurses’ involvement of family members who are central to the care of increasing numbers of elderly persons. Abstract-The
Introduction
Family-focused care has long been espoused by professional nurses in all specialty groups (Miller and Janosik, 1980; Clements and Roberts, 1983; Friedman, 1986). The increasing emphasis on the family in nursing education, practice and research was recently examined by Wright and Leahey (1990), who found that family related content and associated assessment methods were common in undergraduate curricula in both the U.S.A. and Canada. At the graduate level, however, a focus on family was primarily seen in family nursing specialty programs and specialties aimed at nursing of childbearing or childrearing 49
50
J. A. H. COLLIER
AND
V. SCHIRM
families. Wright and Leahey also found that clinical practice settings where students learned, tended to treat families as part of the context of individual clients. Wright and Leahey (1990) found that nursing research focusing on families was increasing. However, studies examining clinical nursing practice using a family focus are still few and they are generally concentrated in the area of families with children (Gilliss el al., 1989). Gonzalez et al. (1989) recently noted a “near vacuum in the clinical literature describing interventions for families coping with serious chronic illnesses and disabilities” (p. 69). Care of the chronically ill has been and is a responsibility of the family (Strauss and Corbin, 1988). Given the aging of the population and the concomitant increase in the prevalence of chronic illness, policy makers are likely to remain reluctant to reduce familial responsibility. The financial, physical and social burdens placed on families who provide care to their elderly members are well documented (Schirm, 1990). In many families, assuming responsibility for an elderly relative begins gradually and continues over an extended period of time. In some cases, however, hospitalization of the elderly person marks the beginning of a family’s entry into the caregiving role, or brings a precipitous need for more intense family involvement in the elderly person’s care. Consequently, an acute illness or an exacerbation of chronic problems requiring hospitalization can have a significant impact on older persons and their families. Nurses as major caregivers in the acute care setting are in a unique position to use hospitalization as a point of access to families of older persons. Effective nursing care during the older person’s hospital stay can enhance family caregiving resources, increase families’ informal caregiving skills and, thus, facilitate transition to the home environment. The recent decreases in hospital stays make it even more imperative to understand how family members can be assisted in their caregiving efforts, since as Lave (1989) indicated, decreased hospital stays have shifted hospital care to home care. Short hospital stays ultimately mean that informal carers, usually family and friends, provide the care formerly provided by the acute care setting. Clearly, if hospital care is to be effective for aged persons who return home, there is a compelling need to identify ways in which nurses in acute care settings can promote the caregiving efforts of families. Empirical studies of familyfocused nursing care to hospitalized elderly persons have not, however, been reported. This study was designed to gain an understanding of how nurses in acute care settings involve families of elderly patients in planning and giving care, and to determine the extent of that involvement in nursing documentation. Methods
Setting and sample Data were obtained from patient records and interviews with nurses at two large acute care hospitals serving a metropolitan area in the Midwestern United States. Both hospitals are teaching institutions offering a fuil range of medical and surgical services to acutely ill adults. They report that 50 to 60 per cent of their average caseload is 65 years of age or older. Patients whose records were included in the study met the following criteria: (a) age 65 years or older, and (b) discharged alive in the first half of 1988. Random sampling was used to generate a list of 100 patient records at each hospital. An effort was made to overrepresent the very old in these limits because of their rapidly increasing numbers and the paucity of reported research on this age group.
FAMILY-FOCUSED
NURSING
CARE
51
Sixty nurses, 30 from each hospital, were interviewed. Selection criteria included licensure as a registered nurse and participation in employee orientation at the study hospitals prior to March 1988. A list of nurses employed on units routinely caring for elderly patients was obtained from nursing administration at each hospital. Letters of invitation to participate in the study were sent to one-third more than the desired number of nurses. Those who responded were contacted by a member of the research team for an interview. No attempt was made to link individual patient records to care given by the nurses interviewed. The record review was retrospective and occurred during the fall of 1988. The nurse interviews were conducted between November 1988 and February 1989. Procedures for the protection of human subjects were approved by the Institutional Review Board (IRB) at the researchers’ academic setting and respective IRBs at the cooperating agencies. Study variables and their measurement Characteristics of elderly patients and families. Numerous studies have pointed to characteristics of elderly patients that should alert professionals to the care needed posthospitalization (Inui et al., 1981; Munoz and Mesick, 1979); outcomes that are predictive of nursing home placement (Robertson and Rockwood, 1982; Wachtel et al., 1984); and factors that contribute to untimely hospital readmissions (Gooding and Jette, 1985). Using these studies as a basis for determining variables of interest, a chart review form was developed to collect data on patients’ age, sex, race, length of stay, insurance coverage, illness conditions, source of admission, discharge destination, and in-hospital and home health care referrals. Data collected on family characteristics included marital status, living arrangements, and nurse-identified family caregiver. Each of five investigators conducted chart reviews and assigned codes on 40 records. The coding system mirrored the codes used by the hospitals and the order of presentation within the chart to minimize errors. The records of the two hospitals were quite similar. Documentation of family involvement in care. A measure evaluating nurses’ documentation of the involvement of family members in caregiving of elderly patients was developed for this investigation, on the basis of the Standards of Gerontological Nursing Practice promulgated by the American Nurses’ Association (ANA, 1987). Statements of outcome criteria were adapted from the Gerontological Standards for the chart audit measure, which consisted of 16 criteria (these are listed in Table 1 in abbreviated form). Content validity of the criteria was determined by two nurses with expertise in gerontological nursing. Additionally, a quality assurance nurse from each hospital reviewed the audit form for clarity. Documentation was reviewed in six sections of the patients’ records to determine the extent to which nurses had involved the family in planning and giving care. The six sections were: admission assessment, first 24-hour nursing notes, interim nursing notes, nursing care plan, discharge summary, and medical progress notes. Each criterion was rated as being met, partially met, or not met. The chart audits were conducted by the five investigators. The criteria were pretested in the two hospitals to obtain consensus on the rating process. Three investigators independently rated the same records at each hospital until consensus was achieved. This process required the review of four records at one hospital, and the review of three records at the other hospital. Nurses’ descriptions of family involvement in care. A semi-structured interview protocol was used to determine how nurses perceived they involved families in care of hospitalized elders. The interview consisted of 11 sequential questions based on selected categories of
52
J. A. H. COLLIER
AND
V. SCHIRM
care in the Standards of Gerontological Nursing Practice (ANA, 1987). Questions were openended and broader in focus than the outcome criteria in the chart audit. The content validity of the questions was determined by the same gerontological nurse specialists who reviewed the chart audit criteria. Because of time constraints in the work setting, a 1% to 20-minute interview length was established. The interview schedule was pretested with registered nurse students enrolled in a baccalaureate nursing program. Interviews were conducted either at the worksite or at another convenient location, according to the preference of the nurse. Most interviews were conducted in the hospital during the scheduled shift or at the conclusion of the shift. Each of the five researchers conducted 12 interviews. Findings
Characteristics of elderly patients Two records from the 200 selected were excluded because the data were unusable. The analysis was done on 198 records. Twenty-nine per cent of the sample were 65 to 74 years old, 30% were 75 to 84 years old, and 41% were 85 years old and over. The average age was 80 years, with a median of 81 years. Fifty-six per cent were female and 44% male. Seventy-nine per cent were white; the remaining subjects were either non-white, or race was not specified on the record. All but eight persons were covered by Medicare; only 17 persons had Medicaid. About 73% had additional private insurance. A second private insurance carrier was identified on seven records. The majority of subjects were widowed (53%); 36% were married, 8% were not married and, for 3%, marital status data were not available. Some 33% of the subjects lived alone. Almost 29% lived with a spouse only; 38% fell into the “other” category, which meant that they either lived with relatives or friends (sometimes in conjunction with their spouse), or the living situation was not identified. Most of these elderly persons were admitted from their home (80.3%) and eventually returned there (75.3%). In 22% of the cases, the nurse identified on the record that a spouse was the caregiver to the hospitalized person, while about 18% of the time a child was identified as the caregiver. Siblings, other relatives, or friends were identified as caregivers for 23% of the elderly. On 37% of the records no caregiver was identified by the nurse. In-hospital referrals were made most often to social services (5607o),followed by physicians (55Vo), dietitians (30%), and physical therapists (17%). The mean number of in-hospital referrals for all services was 1.9, with a range of 0 to 7. Even though a large number of the elderly persons were discharged to home, in only about 23% of the cases were referrals made for home health services. Nursing was the most frequent type of home service requested. Illness conditions were classified according to the International Classification of Diseases (9th Revision) and Diagnosis Related Groups (DRG). A wide range of diagnoses was reported with both classification systems. An average of five medical diagnoses per patient were reported. The most common principal medical diagnosis was pneumonia (n = 16). The next most frequent principal diagnoses were congestive heart failure (n = 11) and coronary atherosclerosis (n = 8). Heart failure and shock (n = 14), followed by pneumonia with complications (n = 11) were the most frequent DRG categories. Length of stay varied widely, from 2 to 111 days. Excluding three patients who stayed more than 70 days, the mean hospital stay was 10.1 days, and the median was 8 days.
FAMILY-FOCUSED NURSING CARE
53
Using Pearson’s Correlation Coefficient, a positive relationship was found between the number of medical diagnoses and age (r= 0.14, P= 0.05) and length of stay (r= 0.39, P=O.OOOl). Age was also significantly associated with marital status (x2 = 23.6, df=4, PC 0.001) and type of living arrangement (x2 = 22.53, df =4, P< 0.001). The very old tended to be widowed and, if not living alone, to live with children, other relatives, or in a nursing home. Chi-square analysis indicated that persons entering the hospital from home were likely to return there. Also, persons living alone or with only their spouse at admission tended to return home. Those admitted from institutions were likely to return to a similar setting (x2 = 52.58, df= 1, P< 0.001). Family involvement in care The patient records showed few instances where criteria for family involvement in care were even partially met. Therefore, responses of met and partially met were combined for the analysis. The criteria and the six parts of the patient records used to assess documented family involvement are given in Table 1. The percentages shown are the proportion of criteria evaluated as met or partially met. Table 1. Percentages of met/partially
met audit criteria by section of record (n = 198) Section of record
Abbreviated criteria 1. Family members participate in data collection 2. Health status info shared with family 3. Nursing diagnoses shared with family 4. Affirmation of diagnosis sought 5. Elder, family and health team participate in planning 6. Care plan initiated in 24 hours I. Care plan accompanies patient at discharge 8. Family involved in discharge planning 9. Family encouraged to promote elder’s self-care 10. Family encouraged to give additional care 11. Nursing interventions clearly documented 12. Responses of elders and family documented 13. Elder and family show understanding of aging/health care needs 14. Nurse, patient and family revise priorities 15. Nurse, patient and family revise goals 16. Nurse, patient and family revise interventions *Yes/no response option.
Admission nursing notes
1st 24br nursing notes
Interim nursing notes
Nursing care plan
Discharge plan
Medical progress notes
11.6
1.6
9.6
5.6
7.6
25.8
5.1
8.1
17.1
6.6
15.7
24.2
4.0
4.5
6.6
6.1
5.1
4.0
4.0
5.6
4.5
4.0
3.0 -
2.5 -
13.1 -
9.1 59.6%
17.7
33.3 -
-
-
62.1’
-
2.0
2.5
12.1
3.5
21.7
22.2
2.5
3.0
9.1
4.5
7.6
9.6
2.5
3.5
2.5
4.5
7.6
10.6
54.0
73.1
81.3
48.5
52.5
13.6
26.3
48.0
19.2
24.2
1.0
4.5
18.7
17.7
23.7
2.0
2.0
10.1
6.1
5.6
-
1.5
1.5
6.6
8.6
5.6
-
2.5
3.5
19.2
10.1
8.6
-
-
-
-
54
J. A. H. COLLIER
AND
V. SCHIRM
The medical progress notes contained the most information about family involvement in the care of hospitalized elders. However, the medical progress notes were an appropriate source for data on family involvement on only six of the 16 criteria. Even for these six criteria where documentation would be expected, at most only one-third of the progress notes contained information on the inclusion of family as a participant in care. Yet, these notes provided far more information about how the family was involved compared to the other data sources (nursing admission assessment, first 24-hour nursing notes, interim nurses notes, care plans, and discharge summaries). Family participation in data collection was documented infrequently by nurses. Likewise, sharing information with family members about the elderly persons’ health status or nursing diagnoses was not generally part of the nursing record. In the majority of cases (60%), the nursing plan of care was initiated in the first 24 hours after admission, and a care plan accompanied 62% of the elderly persons upon discharge. Having a care plan initiated within 24 hours of admission was significantly associated with having a care plan accompany the person at discharge (x2 = 14.12, df = 1, P c 0.001). Documentation of nursing care was found primarily on the interim nursing notes. Documentation about the patient’s response to care was sparse, and emphasis was on the patient’s reaction to medications or treatments. Family responses were rarely noted. Nurses’ descriptions of family involvement When nurses were asked how they involved family members in care of hospitalized elderly, they gave diverse examples which included inviting the spouse of a patient to give physically intimate care, telling family members to telephone during the night if they were concerned, and requesting food from home to bolster appetite. Discharge planning and assessment of homegoing needs were also frequently mentioned as ways nurses involved families. The responses conveyed themes of evaluation and communication. Nurses indicated that interactions with families were aimed at evaluating present and future abilities as caregivers as well as assessing family needs. Communication was evident in nurses’ descriptions of keeping family members aware of what was going on, teaching about care provided, preparing for home care, and answering questions. Nurses were asked to identify what differences, if any, in their involvement of the family could be attributed to the medical diagnosis, patient characteristics, or family characteristics. While specific diagnoses were identified, most nurses placed greater emphasis on the elderly person’s functioning and the seriousness of the illness as factors influencing their tendency to involve families. When asked to identify the kinds of families they did not involve in care of an elderly patient, nurses mentioned two types: families who were unwilling or undesirable caregivers, and families who were willing caregivers but were unavailable or incapable. Examples of undesirable families included those with abusive or alcoholic members, families who were chaotic or could not get along, and families who wanted the elderly member placed in a long-term care facility. The nurses’ responses suggested that these family types clearly demonstrated a lack of willingness to be involved. Families described as willing but unable to be caregivers included those living outside the geographic area, and those with excessive work and family responsibilities. In discussing these families, nurses frequently mentioned problems with transportation and an elderly spouse’s ill health. When asked to describe specific situations where the nurses’ inclusion of a family member improved care of the elderly patient, numerous and diverse examples were given.
FAMILY-FOCUSED
NURSING
CARE
55
Family assistance with physical care and monitoring the timeliness of procedures were frequently cited. The family’s presence with the patient was mentioned as having a helpful calming effect. When asked if they sought out family members for answers to health-related assessment questions, over one-third of the nurses responded “yes”. Nurses made it clear, however, that the patient was viewed as the primary source of information. Physical incapacitation or impaired cognitive abilities were frequently cited reasons for turning to family members for information. When health status information was shared with family members, nurses indicated that it was the family who generally initiated the interaction. Information such as condition or health status reports, progress of procedures, and information related to preparation for discharge were frequently shared. In discussing the kinds of information they gave to families, several nurses identified territorial issues with physicians. “If it’s information the physician wants the patient to know”, “Must take care not to preempt the doctor”, or “Will not share diagnostic test results with the patient”, were some typical responses. Nurses were asked if the written record would accurately reflect their involvement with family members of the patient. Of the 60 nurses, 29 said “no”, 10 said “yes”, and the remainder gave equivocal responses. When asked where one could look in the record for documentation of family involvement, areas mentioned as most appropriate were: admission assessments, daily notes, care plans, and discharge summaries. Nurses attributed this lack of documentation of family-focused practice to not having enough time, and the necessity of documenting the patient’s condition in the record. As one nurse said, “getting it done is more important than writing about it”. Nurses also said that the legal or liability concerns of routine practice mandated a focus on individual patients and their medical condition. Discussion The nurses’ responses to the interview questions indicate that more detailed and diverse interactions occurred between nurses and family members of hospitalized elderly than the charts described. Data from interviews suggest that nurses are including families in care of the hospitalized elderly. The extent of this involvement is unclear, however. Written records showed very low percentages of family involvement in almost all categories of care assessed; while the self-report interview data probably give an overly optimistic view. It seems reasonable to assume that the written record understates the extent of family-focused nursing practice. At the same time the interviews, while providing rich detail, do not yield quantitative estimates of the extent of nurses’ involvement of families. The extent of familyfocused nursing practice with hospitalized elderly cannot be established using written records; and yet, there is compelling evidence that families are included in care. The greatest involvement of the family occurred in skills training to meet needs at home. Additionally, there was an emphasis in both the chart audit and the nurse interviews on discharge planning, either for home-going or transfer to another institutional environment. However, most activity related to discharge was noted just prior to the discharge. Given the characteristics of this patient population-the number of medical diagnoses, the presence of numerous chronic conditions with acute illness superimposed, and the high incidence of discharge to the home-greater attention should be given to earlier discharge planning. Social workers provided the most detailed accounts of interactions with families in the medical progress notes section of the patient records. However, this was most often done
56
J. A. H. COLLIER AND V. SCHIRM
in relation to transfer to a long-term care facility. Three-quarters of the elderly in this study were discharged to home. Yet, neither institutions’ records included any format or evidence of systematic evaluation of resources in the home environment. Further, neither hospital included an assessment of functional capabilities as a routine part of nursing care, though the assessment of, and interventions related to, functional capability are well established and are described in the nursing literature on care of the elderly (Lekan-Rutledge, 1988; Miller, 1990). Of note is that functional assessments of elderly patients have been incorporated in routine care at the study hospitals since completion of this investigation. Beliefs about the role of the family in providing emotional and instrumental support were apparent in the nurse interviews. Yet, there was no mention of a family caregiver on 37% of the records in the nursing sections of the chart. There was also no agreed-upon language or system of assessing families. Nurses used terminology to talk about assessment categories and care planning that focused on the individual patient and physical condition. These findings suggest that the elderly patient is considered the unit of care in the acute care setting. Although this situation is not inappropriate, there is an urgent need to broaden the conception of the family role in the acute care setting and to build a better bridge to the family who manages illness care in the home. As Strauss and Corbin (1988) pointed out, the family is central to chronic illness management. Responses of nurses show dividend opinions as to whether the forms in use invited, or even permitted, notation of family involvement. This finding is especially troublesome in light of the widespread use of written records as indicators of practice in utilization review and quality assurance. We questioned staff development instructors about orientation to institutional charting protocols and were assured that family-focused practice was to be documented in the record. Clearly, there is a crucial need to promote documentation of the actual implementation of family-focused care which is an integral part of the standards of professional gerontological nursing practice. Contemporary discussions of the ethical dimensions of nursing practice focus on the paradox of individually-focused care embedded in a relational context of caring (Davis, 1990). This seems to parallel some of our findings about family-focused nursing. The lack of consensus among nurses about a language to describe families and their relationships to the patient and health problems, the questions about appropriateness of viewing family as client, and the references to liability issues related to documentation suggest that continued efforts to refine our understanding of family-focused nursing are appropriate. Families are increasingly being called upon to manage more and more care for chronically ill elderly relatives and they will be well served by further work to clarify family-focused nursing. Acknowledgements-This study was funded by an Ohio Board of Regents’ Research Challenge Grant Number OBRS-3400. The authors acknowledge the contributions of Drs V. Ruth Gray, A. Jeanne Hoffer, and Sandra A. Jones to the project. References American Nurses’ Association (1987). Standards and Scope of Gerontological Nursing Practice. American Nurses’ Association, Kansas City, MO. Clements, I. W. and Roberts, F. B. (1983). Family Health: A TheoreticalApproach to Nursing Care. John Wiley, New York. Davis, A. J. (1990). Ethical issues in nursing research. Western J. Nurs. Res. 12, 128-130. Friedman, M. M. (1986). Family Nursing: Theory and Assessment. Appleton-Century-Crofts, Norwalk, CT. Gilliss, C. L., Highley, B. L., Roberts, B. M. and Martinson, I. M. (1989). Toward a Science of Family Nursing. Addison-Wesley, Menlo Park, CA.
FAMILY-FOCUSED NURSING CARE
5-l
Gonzalez, S., Steinglass, P. and Reiss, D. (1989). Putting the illness in its place: discussion groups for families with chronic medical illnesses. Family Process 28, 69-87. Gooding, J. and Jette, A. M. (1985). Hospital readmissions among the elderly. J. Am. Geriatrics Sot. 33, 595-601. Inui, T. S., Stevenson, K. M., Plorde, D. and Murphy, I. (1981). Identifying hospital patients who need early discharge planning for special dispositions: a comparison of alternative techniques. Med. Care 19, 922-929. Lave, J. R. (1989). The effect of the Medicare prospective payment system. A. Rev. Public Health 10,141-161. Lekan-Rutledge, D. (1988). Functional Assessment. In Gerontological Nursing: Concepts and Practice (Matteson, M. A. and McConnell, E. S., Eds), pp. 57-91. W. B. Saunders, Philadelphia. Miller, C. A. (1990). Nursing Cure of OlderAdults: Theory and Practice. Scott, Foresman/Little, Brown Higher Education, Glenview, IL. Miller, J. R. and Janosik, E. H. (1980). Family-Focused Cure. McGraw-Hill, New York. Munoz, R. A. and Mesick, B. (1979). Hospitalization of the elderly patient for acute illness. J. Am. Geriatrics Sot. 27, 415-417. Robertson, D. and Rockwood, K. (1982). Outcome of hospital admission of the very elderly. J. Am. Geriatrics sot. 30, 101-104. Schirm, V. (1990). Shared caregiving responsibilities for chronically ill elders. Holistic Nurs. Practice 5, 54-61. Strauss, A. and Corbin, J. (1988). Shaping a New Health Care System: The Explosion of Chronic Illness as a Catalyst for Change. Jossey-Bass, San Francisco. Wachtel, T. J., Derby, C. and Fulton, J. P. (1984). Predicting the outcome of hospitalization for elderly persons: home versus nursing home. Southern Med. I. 77, 1283-1285. Wright, L. M. and Leahey, M. (1990). Trends in nursing of families. J. Adv. Nurs. 15, 148-154. (Received 8 February 1991; accepted for publication 19 September 1991)
1992.
0
0020-7489/92 SS.OO+O.oO 1992 Pergamon Press plc
Family-focused nursing care of hospitalized elderly JO ANN H. COLLIER,
Ph.D.,
R.N.
Associate Professor of Nursing, College of Nursing, University of Akron, Akron, OH 44325-3 701, U.S.A.
VICTORIA
SCHIRM, Ph.D.,
R.N.
Associate Professor of Nursing, College of Nursing, University of Akron, Akron, OH 44325-3701, U.S.A.
purposes of this research were to gain an understanding of how nurses in acute care settings involve families of elderly patients in planning and giving care, and to determine the extent of that involvement in nursing documentation. Data were obtained from patient records and interviews with nurses. Evaluated were characteristics of elderly patients and families, documentation of family involvement in care, and nurses’ descriptions of family care. A comparison of data sources indicated that nurses verbalized far more inclusion of families in care than the written records documented. Results of this research support the importance of clarifying and promoting acute carenurses’ involvement of family members who are central to the care of increasing numbers of elderly persons. Abstract-The
Introduction
Family-focused care has long been espoused by professional nurses in all specialty groups (Miller and Janosik, 1980; Clements and Roberts, 1983; Friedman, 1986). The increasing emphasis on the family in nursing education, practice and research was recently examined by Wright and Leahey (1990), who found that family related content and associated assessment methods were common in undergraduate curricula in both the U.S.A. and Canada. At the graduate level, however, a focus on family was primarily seen in family nursing specialty programs and specialties aimed at nursing of childbearing or childrearing 49
50
J. A. H. COLLIER
AND
V. SCHIRM
families. Wright and Leahey also found that clinical practice settings where students learned, tended to treat families as part of the context of individual clients. Wright and Leahey (1990) found that nursing research focusing on families was increasing. However, studies examining clinical nursing practice using a family focus are still few and they are generally concentrated in the area of families with children (Gilliss el al., 1989). Gonzalez et al. (1989) recently noted a “near vacuum in the clinical literature describing interventions for families coping with serious chronic illnesses and disabilities” (p. 69). Care of the chronically ill has been and is a responsibility of the family (Strauss and Corbin, 1988). Given the aging of the population and the concomitant increase in the prevalence of chronic illness, policy makers are likely to remain reluctant to reduce familial responsibility. The financial, physical and social burdens placed on families who provide care to their elderly members are well documented (Schirm, 1990). In many families, assuming responsibility for an elderly relative begins gradually and continues over an extended period of time. In some cases, however, hospitalization of the elderly person marks the beginning of a family’s entry into the caregiving role, or brings a precipitous need for more intense family involvement in the elderly person’s care. Consequently, an acute illness or an exacerbation of chronic problems requiring hospitalization can have a significant impact on older persons and their families. Nurses as major caregivers in the acute care setting are in a unique position to use hospitalization as a point of access to families of older persons. Effective nursing care during the older person’s hospital stay can enhance family caregiving resources, increase families’ informal caregiving skills and, thus, facilitate transition to the home environment. The recent decreases in hospital stays make it even more imperative to understand how family members can be assisted in their caregiving efforts, since as Lave (1989) indicated, decreased hospital stays have shifted hospital care to home care. Short hospital stays ultimately mean that informal carers, usually family and friends, provide the care formerly provided by the acute care setting. Clearly, if hospital care is to be effective for aged persons who return home, there is a compelling need to identify ways in which nurses in acute care settings can promote the caregiving efforts of families. Empirical studies of familyfocused nursing care to hospitalized elderly persons have not, however, been reported. This study was designed to gain an understanding of how nurses in acute care settings involve families of elderly patients in planning and giving care, and to determine the extent of that involvement in nursing documentation. Methods
Setting and sample Data were obtained from patient records and interviews with nurses at two large acute care hospitals serving a metropolitan area in the Midwestern United States. Both hospitals are teaching institutions offering a fuil range of medical and surgical services to acutely ill adults. They report that 50 to 60 per cent of their average caseload is 65 years of age or older. Patients whose records were included in the study met the following criteria: (a) age 65 years or older, and (b) discharged alive in the first half of 1988. Random sampling was used to generate a list of 100 patient records at each hospital. An effort was made to overrepresent the very old in these limits because of their rapidly increasing numbers and the paucity of reported research on this age group.
FAMILY-FOCUSED
NURSING
CARE
51
Sixty nurses, 30 from each hospital, were interviewed. Selection criteria included licensure as a registered nurse and participation in employee orientation at the study hospitals prior to March 1988. A list of nurses employed on units routinely caring for elderly patients was obtained from nursing administration at each hospital. Letters of invitation to participate in the study were sent to one-third more than the desired number of nurses. Those who responded were contacted by a member of the research team for an interview. No attempt was made to link individual patient records to care given by the nurses interviewed. The record review was retrospective and occurred during the fall of 1988. The nurse interviews were conducted between November 1988 and February 1989. Procedures for the protection of human subjects were approved by the Institutional Review Board (IRB) at the researchers’ academic setting and respective IRBs at the cooperating agencies. Study variables and their measurement Characteristics of elderly patients and families. Numerous studies have pointed to characteristics of elderly patients that should alert professionals to the care needed posthospitalization (Inui et al., 1981; Munoz and Mesick, 1979); outcomes that are predictive of nursing home placement (Robertson and Rockwood, 1982; Wachtel et al., 1984); and factors that contribute to untimely hospital readmissions (Gooding and Jette, 1985). Using these studies as a basis for determining variables of interest, a chart review form was developed to collect data on patients’ age, sex, race, length of stay, insurance coverage, illness conditions, source of admission, discharge destination, and in-hospital and home health care referrals. Data collected on family characteristics included marital status, living arrangements, and nurse-identified family caregiver. Each of five investigators conducted chart reviews and assigned codes on 40 records. The coding system mirrored the codes used by the hospitals and the order of presentation within the chart to minimize errors. The records of the two hospitals were quite similar. Documentation of family involvement in care. A measure evaluating nurses’ documentation of the involvement of family members in caregiving of elderly patients was developed for this investigation, on the basis of the Standards of Gerontological Nursing Practice promulgated by the American Nurses’ Association (ANA, 1987). Statements of outcome criteria were adapted from the Gerontological Standards for the chart audit measure, which consisted of 16 criteria (these are listed in Table 1 in abbreviated form). Content validity of the criteria was determined by two nurses with expertise in gerontological nursing. Additionally, a quality assurance nurse from each hospital reviewed the audit form for clarity. Documentation was reviewed in six sections of the patients’ records to determine the extent to which nurses had involved the family in planning and giving care. The six sections were: admission assessment, first 24-hour nursing notes, interim nursing notes, nursing care plan, discharge summary, and medical progress notes. Each criterion was rated as being met, partially met, or not met. The chart audits were conducted by the five investigators. The criteria were pretested in the two hospitals to obtain consensus on the rating process. Three investigators independently rated the same records at each hospital until consensus was achieved. This process required the review of four records at one hospital, and the review of three records at the other hospital. Nurses’ descriptions of family involvement in care. A semi-structured interview protocol was used to determine how nurses perceived they involved families in care of hospitalized elders. The interview consisted of 11 sequential questions based on selected categories of
52
J. A. H. COLLIER
AND
V. SCHIRM
care in the Standards of Gerontological Nursing Practice (ANA, 1987). Questions were openended and broader in focus than the outcome criteria in the chart audit. The content validity of the questions was determined by the same gerontological nurse specialists who reviewed the chart audit criteria. Because of time constraints in the work setting, a 1% to 20-minute interview length was established. The interview schedule was pretested with registered nurse students enrolled in a baccalaureate nursing program. Interviews were conducted either at the worksite or at another convenient location, according to the preference of the nurse. Most interviews were conducted in the hospital during the scheduled shift or at the conclusion of the shift. Each of the five researchers conducted 12 interviews. Findings
Characteristics of elderly patients Two records from the 200 selected were excluded because the data were unusable. The analysis was done on 198 records. Twenty-nine per cent of the sample were 65 to 74 years old, 30% were 75 to 84 years old, and 41% were 85 years old and over. The average age was 80 years, with a median of 81 years. Fifty-six per cent were female and 44% male. Seventy-nine per cent were white; the remaining subjects were either non-white, or race was not specified on the record. All but eight persons were covered by Medicare; only 17 persons had Medicaid. About 73% had additional private insurance. A second private insurance carrier was identified on seven records. The majority of subjects were widowed (53%); 36% were married, 8% were not married and, for 3%, marital status data were not available. Some 33% of the subjects lived alone. Almost 29% lived with a spouse only; 38% fell into the “other” category, which meant that they either lived with relatives or friends (sometimes in conjunction with their spouse), or the living situation was not identified. Most of these elderly persons were admitted from their home (80.3%) and eventually returned there (75.3%). In 22% of the cases, the nurse identified on the record that a spouse was the caregiver to the hospitalized person, while about 18% of the time a child was identified as the caregiver. Siblings, other relatives, or friends were identified as caregivers for 23% of the elderly. On 37% of the records no caregiver was identified by the nurse. In-hospital referrals were made most often to social services (5607o),followed by physicians (55Vo), dietitians (30%), and physical therapists (17%). The mean number of in-hospital referrals for all services was 1.9, with a range of 0 to 7. Even though a large number of the elderly persons were discharged to home, in only about 23% of the cases were referrals made for home health services. Nursing was the most frequent type of home service requested. Illness conditions were classified according to the International Classification of Diseases (9th Revision) and Diagnosis Related Groups (DRG). A wide range of diagnoses was reported with both classification systems. An average of five medical diagnoses per patient were reported. The most common principal medical diagnosis was pneumonia (n = 16). The next most frequent principal diagnoses were congestive heart failure (n = 11) and coronary atherosclerosis (n = 8). Heart failure and shock (n = 14), followed by pneumonia with complications (n = 11) were the most frequent DRG categories. Length of stay varied widely, from 2 to 111 days. Excluding three patients who stayed more than 70 days, the mean hospital stay was 10.1 days, and the median was 8 days.
FAMILY-FOCUSED NURSING CARE
53
Using Pearson’s Correlation Coefficient, a positive relationship was found between the number of medical diagnoses and age (r= 0.14, P= 0.05) and length of stay (r= 0.39, P=O.OOOl). Age was also significantly associated with marital status (x2 = 23.6, df=4, PC 0.001) and type of living arrangement (x2 = 22.53, df =4, P< 0.001). The very old tended to be widowed and, if not living alone, to live with children, other relatives, or in a nursing home. Chi-square analysis indicated that persons entering the hospital from home were likely to return there. Also, persons living alone or with only their spouse at admission tended to return home. Those admitted from institutions were likely to return to a similar setting (x2 = 52.58, df= 1, P< 0.001). Family involvement in care The patient records showed few instances where criteria for family involvement in care were even partially met. Therefore, responses of met and partially met were combined for the analysis. The criteria and the six parts of the patient records used to assess documented family involvement are given in Table 1. The percentages shown are the proportion of criteria evaluated as met or partially met. Table 1. Percentages of met/partially
met audit criteria by section of record (n = 198) Section of record
Abbreviated criteria 1. Family members participate in data collection 2. Health status info shared with family 3. Nursing diagnoses shared with family 4. Affirmation of diagnosis sought 5. Elder, family and health team participate in planning 6. Care plan initiated in 24 hours I. Care plan accompanies patient at discharge 8. Family involved in discharge planning 9. Family encouraged to promote elder’s self-care 10. Family encouraged to give additional care 11. Nursing interventions clearly documented 12. Responses of elders and family documented 13. Elder and family show understanding of aging/health care needs 14. Nurse, patient and family revise priorities 15. Nurse, patient and family revise goals 16. Nurse, patient and family revise interventions *Yes/no response option.
Admission nursing notes
1st 24br nursing notes
Interim nursing notes
Nursing care plan
Discharge plan
Medical progress notes
11.6
1.6
9.6
5.6
7.6
25.8
5.1
8.1
17.1
6.6
15.7
24.2
4.0
4.5
6.6
6.1
5.1
4.0
4.0
5.6
4.5
4.0
3.0 -
2.5 -
13.1 -
9.1 59.6%
17.7
33.3 -
-
-
62.1’
-
2.0
2.5
12.1
3.5
21.7
22.2
2.5
3.0
9.1
4.5
7.6
9.6
2.5
3.5
2.5
4.5
7.6
10.6
54.0
73.1
81.3
48.5
52.5
13.6
26.3
48.0
19.2
24.2
1.0
4.5
18.7
17.7
23.7
2.0
2.0
10.1
6.1
5.6
-
1.5
1.5
6.6
8.6
5.6
-
2.5
3.5
19.2
10.1
8.6
-
-
-
-
54
J. A. H. COLLIER
AND
V. SCHIRM
The medical progress notes contained the most information about family involvement in the care of hospitalized elders. However, the medical progress notes were an appropriate source for data on family involvement on only six of the 16 criteria. Even for these six criteria where documentation would be expected, at most only one-third of the progress notes contained information on the inclusion of family as a participant in care. Yet, these notes provided far more information about how the family was involved compared to the other data sources (nursing admission assessment, first 24-hour nursing notes, interim nurses notes, care plans, and discharge summaries). Family participation in data collection was documented infrequently by nurses. Likewise, sharing information with family members about the elderly persons’ health status or nursing diagnoses was not generally part of the nursing record. In the majority of cases (60%), the nursing plan of care was initiated in the first 24 hours after admission, and a care plan accompanied 62% of the elderly persons upon discharge. Having a care plan initiated within 24 hours of admission was significantly associated with having a care plan accompany the person at discharge (x2 = 14.12, df = 1, P c 0.001). Documentation of nursing care was found primarily on the interim nursing notes. Documentation about the patient’s response to care was sparse, and emphasis was on the patient’s reaction to medications or treatments. Family responses were rarely noted. Nurses’ descriptions of family involvement When nurses were asked how they involved family members in care of hospitalized elderly, they gave diverse examples which included inviting the spouse of a patient to give physically intimate care, telling family members to telephone during the night if they were concerned, and requesting food from home to bolster appetite. Discharge planning and assessment of homegoing needs were also frequently mentioned as ways nurses involved families. The responses conveyed themes of evaluation and communication. Nurses indicated that interactions with families were aimed at evaluating present and future abilities as caregivers as well as assessing family needs. Communication was evident in nurses’ descriptions of keeping family members aware of what was going on, teaching about care provided, preparing for home care, and answering questions. Nurses were asked to identify what differences, if any, in their involvement of the family could be attributed to the medical diagnosis, patient characteristics, or family characteristics. While specific diagnoses were identified, most nurses placed greater emphasis on the elderly person’s functioning and the seriousness of the illness as factors influencing their tendency to involve families. When asked to identify the kinds of families they did not involve in care of an elderly patient, nurses mentioned two types: families who were unwilling or undesirable caregivers, and families who were willing caregivers but were unavailable or incapable. Examples of undesirable families included those with abusive or alcoholic members, families who were chaotic or could not get along, and families who wanted the elderly member placed in a long-term care facility. The nurses’ responses suggested that these family types clearly demonstrated a lack of willingness to be involved. Families described as willing but unable to be caregivers included those living outside the geographic area, and those with excessive work and family responsibilities. In discussing these families, nurses frequently mentioned problems with transportation and an elderly spouse’s ill health. When asked to describe specific situations where the nurses’ inclusion of a family member improved care of the elderly patient, numerous and diverse examples were given.
FAMILY-FOCUSED
NURSING
CARE
55
Family assistance with physical care and monitoring the timeliness of procedures were frequently cited. The family’s presence with the patient was mentioned as having a helpful calming effect. When asked if they sought out family members for answers to health-related assessment questions, over one-third of the nurses responded “yes”. Nurses made it clear, however, that the patient was viewed as the primary source of information. Physical incapacitation or impaired cognitive abilities were frequently cited reasons for turning to family members for information. When health status information was shared with family members, nurses indicated that it was the family who generally initiated the interaction. Information such as condition or health status reports, progress of procedures, and information related to preparation for discharge were frequently shared. In discussing the kinds of information they gave to families, several nurses identified territorial issues with physicians. “If it’s information the physician wants the patient to know”, “Must take care not to preempt the doctor”, or “Will not share diagnostic test results with the patient”, were some typical responses. Nurses were asked if the written record would accurately reflect their involvement with family members of the patient. Of the 60 nurses, 29 said “no”, 10 said “yes”, and the remainder gave equivocal responses. When asked where one could look in the record for documentation of family involvement, areas mentioned as most appropriate were: admission assessments, daily notes, care plans, and discharge summaries. Nurses attributed this lack of documentation of family-focused practice to not having enough time, and the necessity of documenting the patient’s condition in the record. As one nurse said, “getting it done is more important than writing about it”. Nurses also said that the legal or liability concerns of routine practice mandated a focus on individual patients and their medical condition. Discussion The nurses’ responses to the interview questions indicate that more detailed and diverse interactions occurred between nurses and family members of hospitalized elderly than the charts described. Data from interviews suggest that nurses are including families in care of the hospitalized elderly. The extent of this involvement is unclear, however. Written records showed very low percentages of family involvement in almost all categories of care assessed; while the self-report interview data probably give an overly optimistic view. It seems reasonable to assume that the written record understates the extent of family-focused nursing practice. At the same time the interviews, while providing rich detail, do not yield quantitative estimates of the extent of nurses’ involvement of families. The extent of familyfocused nursing practice with hospitalized elderly cannot be established using written records; and yet, there is compelling evidence that families are included in care. The greatest involvement of the family occurred in skills training to meet needs at home. Additionally, there was an emphasis in both the chart audit and the nurse interviews on discharge planning, either for home-going or transfer to another institutional environment. However, most activity related to discharge was noted just prior to the discharge. Given the characteristics of this patient population-the number of medical diagnoses, the presence of numerous chronic conditions with acute illness superimposed, and the high incidence of discharge to the home-greater attention should be given to earlier discharge planning. Social workers provided the most detailed accounts of interactions with families in the medical progress notes section of the patient records. However, this was most often done
56
J. A. H. COLLIER AND V. SCHIRM
in relation to transfer to a long-term care facility. Three-quarters of the elderly in this study were discharged to home. Yet, neither institutions’ records included any format or evidence of systematic evaluation of resources in the home environment. Further, neither hospital included an assessment of functional capabilities as a routine part of nursing care, though the assessment of, and interventions related to, functional capability are well established and are described in the nursing literature on care of the elderly (Lekan-Rutledge, 1988; Miller, 1990). Of note is that functional assessments of elderly patients have been incorporated in routine care at the study hospitals since completion of this investigation. Beliefs about the role of the family in providing emotional and instrumental support were apparent in the nurse interviews. Yet, there was no mention of a family caregiver on 37% of the records in the nursing sections of the chart. There was also no agreed-upon language or system of assessing families. Nurses used terminology to talk about assessment categories and care planning that focused on the individual patient and physical condition. These findings suggest that the elderly patient is considered the unit of care in the acute care setting. Although this situation is not inappropriate, there is an urgent need to broaden the conception of the family role in the acute care setting and to build a better bridge to the family who manages illness care in the home. As Strauss and Corbin (1988) pointed out, the family is central to chronic illness management. Responses of nurses show dividend opinions as to whether the forms in use invited, or even permitted, notation of family involvement. This finding is especially troublesome in light of the widespread use of written records as indicators of practice in utilization review and quality assurance. We questioned staff development instructors about orientation to institutional charting protocols and were assured that family-focused practice was to be documented in the record. Clearly, there is a crucial need to promote documentation of the actual implementation of family-focused care which is an integral part of the standards of professional gerontological nursing practice. Contemporary discussions of the ethical dimensions of nursing practice focus on the paradox of individually-focused care embedded in a relational context of caring (Davis, 1990). This seems to parallel some of our findings about family-focused nursing. The lack of consensus among nurses about a language to describe families and their relationships to the patient and health problems, the questions about appropriateness of viewing family as client, and the references to liability issues related to documentation suggest that continued efforts to refine our understanding of family-focused nursing are appropriate. Families are increasingly being called upon to manage more and more care for chronically ill elderly relatives and they will be well served by further work to clarify family-focused nursing. Acknowledgements-This study was funded by an Ohio Board of Regents’ Research Challenge Grant Number OBRS-3400. The authors acknowledge the contributions of Drs V. Ruth Gray, A. Jeanne Hoffer, and Sandra A. Jones to the project. References American Nurses’ Association (1987). Standards and Scope of Gerontological Nursing Practice. American Nurses’ Association, Kansas City, MO. Clements, I. W. and Roberts, F. B. (1983). Family Health: A TheoreticalApproach to Nursing Care. John Wiley, New York. Davis, A. J. (1990). Ethical issues in nursing research. Western J. Nurs. Res. 12, 128-130. Friedman, M. M. (1986). Family Nursing: Theory and Assessment. Appleton-Century-Crofts, Norwalk, CT. Gilliss, C. L., Highley, B. L., Roberts, B. M. and Martinson, I. M. (1989). Toward a Science of Family Nursing. Addison-Wesley, Menlo Park, CA.
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Gonzalez, S., Steinglass, P. and Reiss, D. (1989). Putting the illness in its place: discussion groups for families with chronic medical illnesses. Family Process 28, 69-87. Gooding, J. and Jette, A. M. (1985). Hospital readmissions among the elderly. J. Am. Geriatrics Sot. 33, 595-601. Inui, T. S., Stevenson, K. M., Plorde, D. and Murphy, I. (1981). Identifying hospital patients who need early discharge planning for special dispositions: a comparison of alternative techniques. Med. Care 19, 922-929. Lave, J. R. (1989). The effect of the Medicare prospective payment system. A. Rev. Public Health 10,141-161. Lekan-Rutledge, D. (1988). Functional Assessment. In Gerontological Nursing: Concepts and Practice (Matteson, M. A. and McConnell, E. S., Eds), pp. 57-91. W. B. Saunders, Philadelphia. Miller, C. A. (1990). Nursing Cure of OlderAdults: Theory and Practice. Scott, Foresman/Little, Brown Higher Education, Glenview, IL. Miller, J. R. and Janosik, E. H. (1980). Family-Focused Cure. McGraw-Hill, New York. Munoz, R. A. and Mesick, B. (1979). Hospitalization of the elderly patient for acute illness. J. Am. Geriatrics Sot. 27, 415-417. Robertson, D. and Rockwood, K. (1982). Outcome of hospital admission of the very elderly. J. Am. Geriatrics sot. 30, 101-104. Schirm, V. (1990). Shared caregiving responsibilities for chronically ill elders. Holistic Nurs. Practice 5, 54-61. Strauss, A. and Corbin, J. (1988). Shaping a New Health Care System: The Explosion of Chronic Illness as a Catalyst for Change. Jossey-Bass, San Francisco. Wachtel, T. J., Derby, C. and Fulton, J. P. (1984). Predicting the outcome of hospitalization for elderly persons: home versus nursing home. Southern Med. I. 77, 1283-1285. Wright, L. M. and Leahey, M. (1990). Trends in nursing of families. J. Adv. Nurs. 15, 148-154. (Received 8 February 1991; accepted for publication 19 September 1991)
