Staff-family relationships in residential aged care facilities: the views of residents' family members and care staff.

468503 Journal of Applied GerontologyBauer et al.

JAG33510.1177/0733464812468503

Article

Staff–Family Relationships in Residential Aged Care Facilities: The Views of Residents’ Family Members and Care Staff

Journal of Applied Gerontology 2014, Vol. 33(5) 564–585 © The Author(s) 2012 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0733464812468503 jag.sagepub.com

Michael Bauer1, Deirdre Fetherstonhaugh1, Laura Tarzia1, and Carol Chenco1

Abstract The aim of the study was to examine staff and family members’ perceptions of each other’s roles and responsibilities in the Australian residential aged care setting. Data was collected by interview and focus group from 27 staff and 14 family members at five residential aged care facilities in the state of Victoria, Australia. Findings highlight “communication” as the core category supporting the formation of constructive staff–family relationships, as described by three main themes; “building trust,” “involvement,” and “keeping the family happy.” Staff attitudes, mutual cooperation, meaningful engagement, and shared expectations lay the foundation for relationships. Findings suggest that further efforts to establish and sustain good relationships with families are required by facilities. Characteristics, roles, and expectations of staff and family that can both promote and hinder the formation of constructive staff–family relationships are discussed. Keywords staff-family, relationships, aged care Manuscript received: February 21, 2012; final revision received: October 14, 2012; accepted: October 26, 2012. 1

La Trobe University, Bundoora,Victoria, Australia

Corresponding Author: Michael Bauer, Australian Centre for Evidence Based Aged Care/Australian Institute for Primary Care and Ageing, La Trobe University, Bundoora,Victoria, 3086, Australia. Email: [email protected]

Downloaded from jag.sagepub.com at UNIV OF NORTH DAKOTA on June 10, 2015

565

Bauer et al.

Introduction Within the residential aged care sector, families play a significant role in maintaining resident well-being. They have often been the primary caregivers prior to the resident entering a facility and often continue to be involved in many aspects of the older person’s life after they move into residential care (Bauer, 2006; Gaugler & Kane, 2007). The importance of fostering good relationships between family members and residential aged care facility staff has been well established within the existing literature. Benefits have been observed from the perspective of staff (Moyle, Skinner, Rowe, & Gork, 2003; Utley-Smith, et al., 2009), family members (Bauer & Nay, 2003; Legault & Ducharme, 2009), and residents (Gaugler, 2006; Wilson, Davies, & Nolan, 2009). Despite these benefits however, the role of the family is sometimes seen as ambiguous in terms of the degree and nature of their involvement in the facility, with some staff viewing family members as a disturbance or a hindrance (Bauer, 2006). Conflict can often occur when there are differing expectations of the family’s role (Lindgren & Murphy, 2002; Utley-Smith et al., 2009) or when there is a lack of mutual understanding of the role of the family and that of the staff (Specht et al., 2000). The literature confirms that a major source of conflict is the “Us Versus Them” mentality that can develop between staff and families. Austin et al. (2009) refer to this as a “chasm” (p. 373) and suggest that it can be caused by different and sometimes opposite opinions between staff and families as to what care is in the resident’s best interests. To avoid this, several authors recommend a reciprocal approach to care giving, where families and staff are partners rather than competitors (Dijkstra, 2007; Kemp, Ball, Perkins, Hollingsworth, & Lepore, 2009; Legault & Ducharme, 2009; Majerovitz, Mollott, & Rudder, 2009). Family involvement can help staff provide the best level of care (Kemp, et al., 2009), and a collaborative attitude from staff keeps family members up-to-date as to the health and wellbeing of their relative when they are not there (Legault & Ducharme, 2009). Lau, Shyu, Lin, and Yang (2008) who examined staff–family relationships in Taiwan, provide a good example of how this collaborative process can function in a practical sense. One family member explained: “When they [the staff] cannot calm her [resident] down they call me and I talk to her on the phone and tell her that I will come and see her soon and then she is ok and back to normal” (p. 487). The implications of not fostering constructive staff–family relationships can be significant. Majerovitz et al. (2009) found that when staff–family relationships lacked trust and communication, family caregivers felt that staff were criticizing them directly. This exacerbated existing feelings of guilt at moving their relative in a nursing home, as well as increasing family distress and confusion. Chen, Sabir, Zimmerman, Suitor, and Pillemer (2007) found that perceived conflict


566

Journal of Applied Gerontology 33(5)

between family caregivers and staff directly correlated to levels of caregiver stress and depression. There are also a number of studies that demonstrate the negative effects of staff–family friction on staff. Abrahamson, Jill Suitor, and Pillemer (2010) and Abrahamson, Anderson, Anderson, Suitor, and Pillemer (2010) found that conflict between staff and families led to increased staff burnout and dissatisfaction, which was exacerbated when staff felt that they did not have enough time to complete required tasks. Park (2010), similarly, found that there was friction between families and nursing assistants, and stress levels were high, and suggests that this is due to nursing assistants being “so acutely focused on accomplishing the many physical tasks of care, that they fail to interact with residents and families in appropriate ways” (p. 139). High stress and burnout were found to occur early in the career trajectory (Abrahamson, et al., 2010), which has important implications for the long-term care industry as a whole, as burnout often leads to a staff member leaving a facility. Some participants in Utley-Smith et al.’s (2009) study concurred that negative interactions with family members had made them want to quit their employment. Clearly, the importance of constructive staff–family relationships cannot be underestimated. A systematic review of international research literature (Haesler, Bauer, & Nay, 2006, 2010) highlighted the factors that are most effective in promoting constructive staff–family relationships in the health-care setting and conversely those that hinder them, namely communication, information exchange, education, and administrative support. The factors that are seen to be significant specifically in the Australian residential aged care setting however remain relatively unexplored. In Australia, the residential aged care system is large and complex with services being provided within a two-tiered care structure by a range of providers: the not for profit, the private, and the public sector. “High level care,” also referred to as “high care” or “nursing home” care, is available to those older people who require continuous nursing care. “Low level care” (low care, or assisted living) is available to older people who are generally able to move about independently and who require only limited supervision and assistance with personal care activities such as hygiene, meals, and toileting and only the occasional nursing care. Some homes offer both types of services (a mixed facility), thereby providing a continuum of care so that residents do not need to relocate when their needs increase. The critical role that family and significant others play in the well-being of the older person has been recognized within the Australian residential aged care sector and there is acknowledgment of the need for the family to be given the opportunity to remain part of the care process by both the Commonwealth’s Charter of Resident’s Rights and Responsibilities (Australian Government Department of Health and Ageing, 2006) and by the body responsible for the


567

Bauer et al.

maintenance of residential aged care standards and accreditation (Aged Care Standards and Accreditation Agency, 2010; McCallion, 2005). There is a dearth of material, however, exploring how this acknowledgment might be realized in a practical, everyday context. In fact, anecdotal evidence suggests that, despite good intentions on all sides, the same obstacles continue to hinder relationships between staff and family within the residential aged care sector. Central to this issue, the perceptions of Australian staff and family members regarding each other’s roles and responsibilities, and how these might impact on the establishment and maintenance of constructive relationships, are underrepresented within the literature. While some empirical studies do exist (Bauer, 2006; Higgins & Cadd, 1999; Kellett, 1996; Marquis, Freeguard, & Hoogland, 2004; Russell & Foreman, 2000), these are somewhat outdated, and mainly focus on one particular aspect of the staff–family relationship rather than examining the issue from both sides. Understanding residential aged care staff and family members’ perceptions of each other’s roles and responsibilities will assist facilities to capture the attributes and/or practices that are important for promoting good relationships between staff and families. This knowledge has the potential to improve staff–family relationships, practices, and care outcomes for residents in this setting.

Aims This qualitative study aimed to describe the perceptions of staff and family members of residents with respect to staff–family relationships in residential aged care facilities. The article reports on the views of residents’ families and residential aged care staff from a range of residential aged care facilities in the state of Victoria, Australia, and aimed to answer the following research questions:

• How do staff and family members perceive each other’s role and responsibilities? • What are the characteristics of a constructive staff–family relationship? • What are some of the issues and points of conflict between staff and family members?

Design A qualitative design was used and data was collected using focus groups, small group interviews, or one-on-one interviews. It was anticipated that participation in a focus group interview might be a more appealing option for staff. Focus groups are cost effective and allow the shared views, or a diversity of views, from people of similar backgrounds and experiences to be easily accessed


568


Table 1. Participating Facility Characteristics. Facility 1 2 3 4 5

Type of facility

Geographical location

Level of care

Bed capacity

Private (for profit) Public Private Private (not for profit) Private (not for profit)

Metropolitan Rural Metropolitan Metropolitan Metropolitan

Mixed High care Mixed Mixed High care

90 30 128 90 42

(Patton, 2002). Focus group participants are also able to provide checks and balances on each other during the course of an interview and interactions enhance data richness (Fontana & Frey, 1994) and quality (Patton, 2002). As all participating staff had interacted with family members of residents, this approach was considered to be an appropriate one. Family members participated in either small group interviews (2-4 participants) or individual interviews.

Participants Purposive sampling was used to recruit participants from five residential aged care facilities in the state of Victoria, Australia. Information flyers explaining the project and inviting staff and residents’ family members to participate in an interview were sent to each facility. Flyers for family members were distributed by the facility managers with the option of participating in either a group interview, or a one-on-one interview with a researcher as preferred. Two high care and three mixed facilities from metropolitan and rural Victoria participated (Table 1). Twenty seven staff (1 male and 26 females) comprising registered nurses (RNs; n = 5), enrolled nurses (ENs or licenced practice nurses [LPNs] in other jurisdictions; n = 7), personal care workers (also known as nursing assistants; n = 8), and allied/lifestyle staff (n = 4) participated in four focus group interviews. Three care staff arrived after the focus group had commenced and their designation was not obtained. Fourteen family members—comprising sons (n = 2), daughters (n = 8), husbands (n = 2), a wife, and a sister-in-law—participated in either a group, or one-on-one interview with a researcher (Table 2).

Data Collection Focus groups/interviews were conducted by the authors who are all experienced interviewers and took place at the respective facility. Each focus group/interview


569

Bauer et al. Table 2. Characteristics of Interviews and Interviewees. Number of staff in focus group

Number of family in group interview

Number of oneon-one interviews

Participants’ relationship to the resident

1 2

7 6

3 4

0 0

3 4 5

10 4 0

2 2 0

0 2 1

1 son; 2 daughters 2 husbands; 1 daughter; 1 wife 1 son; 1 sister-in-law 2 daughters 1 daughter

Facility

occurred once. An interview guide was used to keep interactions focused while also allowing participant’s individual views to emerge (Patton, 2002). Interviews/ focus groups commenced with the broad exploratory question: “What influences the formation of positive staff/family relationships in residential aged care?” Additional questions were aimed at further exploring staff and family members’ views on what factors promote or hinder these relationships. For focus groups, one researcher moderated the discussion and a second researcher observed the interaction and took notes to supplement the interview recording. Interviews were digitally recorded and later transcribed. Data collection was discontinued when no new categories emerged.

Data Analysis and Rigor A constant comparative method of data analysis was used to explicate issues and generate theoretical propositions that reflected participants’ views on staff– family relationships. Interview transcripts were first read by the researchers to gain an overall impression of participants’ views. They were then reread and examined for meaning. Data from each interview was disaggregated into stand alone meaning units and coded. The coded data were compared to look for similarities and differences in participant’s views and new categories based on the researchers’ interpretations of the data were developed. Comparisons were made across categories and between focus groups/interviews and identified relationships were explored. Critical reflection on the data and the continuous interplay between data collection, analysis, and verification inductively generated new, more complex, and more robust interpretations of the data. The study aimed for an in-depth understanding of the issues as seen by staff and family rather than generalizability to specific staff, family members, or care settings. Rigor was established though purposive sampling to recruit from a range of RACFs and obtain divergent views on the topic from facility staff and families. A process of


570


“member checking,” whereby participants were asked to comment on the views of previous participants, was used and emergent propositions, themes, and categories were verified and authenticated by members of the research team.

Ethical Considerations The study was approved by the University Human Research Ethics Committee (FHEC approval 10/31) and all participating facilities. Informed consent was obtained from all participants prior to interview.

Findings Participating family and staff members acknowledged the importance of establishing and maintaining good relationships with one another and the key role each played in enhancing residents’ quality of life and care delivery. For families, staff members’ relationship with their relative, the resident’s emotional wellbeing, and the provision of quality care that was person-centered, were of paramount importance. Families were aware that the carer role could be a difficult one for staff and they expressed appreciation for what staff did. Although the caliber of paid carers was seen to vary, families were generally satisfied with their relationship with facility staff. While the potential for staff–family tension was recognized by all participants, the staff were relatively more critical of the family and the many challenges that they could present. “Communication” was the overarching category within the findings, with three key themes describing in more detail the perceptions of family and staff regarding the ways in which communication impacts on staff–family relationships: “building trust”; “involvement”; and “keeping the family happy.”

Building Trust Staff participants considered it essential to begin to develop a relationship with the family at the point of first contact by creating a good impression and making family feel welcome and accepted in the facility. Relationships between the two groups were enhanced and trust in staff evolved when family members found staff to be approachable and knowledgeable about the resident. Ongoing interactions and dialogue between staff and family, the mutual sharing of information about the resident, and having confidence in the ability of the staff to provide good care, was further seen to underpin the promotion of constructive staff–family relationships. According to staff participants, the key to developing rapport with the families and gaining their trust was communication:


571

Bauer et al.

I think the most important thing to family members it that you can communicate with them! (Staff focus group, facility 3) That’s the whole key—very good communication. If you communicate well with the relatives, and inform them as to what’s going on, it actually helps so much . . . Even if I’ve been seeing them during the week, we still get in contact with them . . . whether it’s face-to-face, whether it’s on the telephone. (Staff focus group, facility 4) You must have two-way communication otherwise you haven’t got anything. (Husband of resident, facility 2) Unless you have two willing partners meaning staff and family, it’s not going to work. (Daughter of resident, facility 4) Listening to the family’s views, including complaints about the care, was acknowledged by staff and family participants to be vital to the development of trust and good relationships. Families wanted to know that facility staff were interested in what they had to say and that their viewpoints were being heard and, moreover, were valued and would be acted upon: [Staff need to] listen to whatever they want to say. [Let them] express their feelings and thoughts. People just start opening up once you start listening. Once they realize that you’re not in a rush and you’ve got time for them . . . you listen and take it from there. (Staff focus group, facility 4) Just listen to them [the family] . . . And follow through. If they tell you to do something just make sure that you follow through. Assure them that you are listening, whether it be with your body language or whatever. [When] we listen to what they are saying, what their complaints are, that’s the only time we can actually improve and therefore maybe family are satisfied and will be happier. (Staff focus group, facility 1) Families developed confidence and trust in staff who they saw as responsive to their concerns and “ . . . able to resolve them [concerns] straight away, or within a reasonable time. They don’t just palm you off and say ‘I’ll attend to that later’ and then you never hear.” (Family group interview, facility 1) Families appreciated staff who were always available and willing to be of assistance:


572


I ask them [the staff] things on the spot . . . [and they] give you good answers and if they can’t give you the answer, they’ll find the answers out for you. (Husband of resident, facility 2) Participating staff felt that dialogue and cooperation between staff and families were important because families were able to share unique insights into a resident’s past life with staff. This biographical and other information allowed staff to better respond to a resident’s needs and deliver quality care: The family are useful in giving you an insight into what the person themselves would like . . . what the resident was like before they came in here. You can understand where they were, what they did in their life. [This information] just fills the gaps. It’s . . . little things sometimes, that they were interested in . . . or why they react to something more than other things. (Staff focus group, facility 2) We learn from the families about the residents and this gives us something to talk about to the residents. (Staff focus group, facility 2) Families also thought that staff needed to learn about each resident’s unique needs, and were disapproving when this effort did not appear to have been made: They [the staff] have to learn to understand what you [as a resident] like. (Daughter of resident, facility 4) There was no discussion about what my father likes and doesn’t like that would enable [staff] to approach him in the way that they can have an appreciation of his mannerisms, his social requirements (Son of resident, facility 3) Developing trust in staff is made more difficult for family when they do not know which staff member to approach for a particular query, or when staff are not familiar with the needs of the resident. This often occurs when facilities use nonpermanent or casual staff: It’s very important they [the family] see the familiar faces and who’s in charge for the day. (Staff focus group, facility 3)


573

Bauer et al.

They could be here once a month, you know, not as often. They’re not familiar with the resident . . . they wouldn’t get an overall picture of the family, of the needs. (Staff focus group, facility 3) Sometimes relationships and the development of trust between staff and families were also tested by staff whose first language was not English, as this became a barrier to good communication: They do have people that come here on a less regular basis and they don’t have the English skills and they don’t know the individual (resident) or the family member. (Daughter of resident, facility 4) Staff from other cultures may not have the same standard as what you would like and because their English is not that good . . . you can’t communicate as well. (Daughter of resident, facility 4)

Involvement Family involvement in the facility and in the life of the resident was generally portrayed in a positive light by both staff and family participants. Staff believed family made a valuable contribution to the quality of resident care and enhanced the ambience of a facility. They were appreciative of the family’s involvement and participation, including their involvement in decision making about the resident’s care. Engagement of the family with the facility community was welcomed and encouraged and it was seen as an important factor in establishing and maintaining good relationships with them. To achieve this, staff had to make time for the family: You’ve got to give them all your attention at that time . . . you must ensure that you are giving them your full attention. (Staff focus group, facility 1) Families spoke about their involvement in the facility in terms of their satisfaction with the staff and how the organization was run. Families continually observed what was happening in the facility and how staff went about their work. It was apparent that families were acutely aware of staff members’ interactions with them, with one another, and with the residents. As one family member noted: Running a facility for older people is as much about engaging with the older people and their families as it is about running the facility. (Daughter of resident, facility 4)


574


Staff members who were friendly, respectful, and were seen to genuinely show an interest in both the family and the resident, were well regarded by families. Most staff were seen by the family participants to be dedicated to their work and to do their best, which fostered good relationships with them: Quite a lot of the them seem to be pretty dedicated to the job, enough to actually tend to whatever we’re asking them. (Son of resident, facility 1) I’ve been coming here every day for a couple of years. [The staff] never miss to say “hello, how are you?” “Hello [name of wife,” never! They’re so lovely. They don’t just say “hello” because I say “hello.” They’re very attentive to [the resident]. “How are you today?” And they’ll hold her hand for a minute or two. Their consideration of her has been marvelous. (Husband of resident, facility 2) If you’ve got a few photos up they [the staff] will come in and say “Who’s this one?” It might be one of the grandchildren or something like this. They take an interest. (Husband of resident, facility 2) Some staff however were noted to be less attentive to their role and even insensitive to the family’s and/or resident’s needs: No matter how good staff are . . . they become a bit blasé you know (Daughter of resident, facility 4) One of the things I find really difficult is when you get two staff members who speak the same language. They will often be talking their own language while they’re feeding residents, which I find really appalling. Quite often staff talk amongst themselves. (Daughter of resident, facility 4) I think we all know our staff members and there are girls that will rush and do it. But then there are others, where you’ll have to wait! . . . And it’s not always good for them [residents] to wait. (Daughter of resident, facility 1) Family involvement in the lives and care of residents was noted by staff to vary greatly; some families were perceived to have a strong allegiance with the facility and visit frequently, whereas others did not want to be involved at all. Staff acknowledged that some families could become too involved and demanding which created stress and tension for staff. Families that showed an interest in their relative and the facility by acting as volunteers, or otherwise “helped out” with tasks around the home, were particularly popular with staff. Family


575

Bauer et al.

involvement in a facility was seen to be positive by staff when it was marked by activities such as spending time interacting with residents, assisting with organized activities, accompanying residents on social outings, or aiding staff workloads in other ways. Families that assisted with the “feeding” of residents were especially welcomed by staff: Some of them will come and feed their mother or father, or grandparent . . . and some of them do it regularly. It’s great! Because some of the residents take that long to feed. (Staff focus group, facility 4) Although the involvement of families was generally thought to be of benefit, it could also become a source of frustration and tension for staff. Some families wanted to be involved and help, but lacked understanding about the older person’s state of physical and mental health and what was now appropriate care: Sometimes there are families that want to do too much. They want to help but they’re not helping in the right way. [They] give their family food that’s not appropriate anymore. “Mum used to love marshmallows!” Well, Mum can’t have marshmallows anymore! (Staff focus group, facility 2) We had a man come in and the family kept insisting that he should be playing chess, because he loves playing chess. They didn’t realize that he can’t do that anymore. But every week they’d come in, “He should be playing chess!” We’d set it up and he’d just sit there and look at it. [One day] I suggested that the son should play with him . . . and he never asked me again! The reality was that he couldn’t do it and the son didn’t believe us. (Staff focus group, facility 3) It was generally seen as appropriate for the facility staff to inform families and correct any misapprehensions they may have been under about their involvement: There might be too much family, wearing [the resident] out too much. They’re just trying to show their love and give their love, but sometimes we have to say [enough]. Sometimes families appreciate being told to back off . . . sometimes we have to push regardless of what they say. (Staff focus group, facility 2) Some families could be very challenging for staff, particularly when they were demanding and disputed staff decisions. Occasionally staff had to assert their authority and override the family:


576


They [the family] can be very demanding . . . Different facilities experience it in different ways, but we’ve got some very demanding families. (Staff focus group, facility 4) I think sometimes they have to be told off as well. I’ll push whatever I’m thinking and what would benefit the resident. (Staff focus group, facility 3) Difficulties staff had with families in the facility were often attributed to unrealistic expectations of care delivery and the guilt associated with the placement of their relative. Some families found it very difficult to come to terms with the fact that their relative was now living in an aged care facility and were often seen to project their feelings onto the staff when they visited. I think some people have high expectations that their family [member is] going to get better. They’re really in denial. And they’re angry with you because they’re not [going to get better]. It takes time. They eventually get. . . It’s a lot of guilt. (Staff focus group, facility 3) Families carry a huge amount of guilt . . . Nothing is ever good enough. I think it reflects on their own guilt . . . It’s sometimes easier for the family to believe that we [the staff] might be somehow abusing their family, when it might be that the family are angry at them for putting them here. It can be very tricky. And they don’t want to feel that guilt, so it’s easier to believe that staff might be [responsible]. (Staff focus group, facility 2)

Keeping the Family Happy A key factor determining family members’ satisfaction with a facility was the degree to which the staff kept them up-to-date about the resident’s well-being: One of the most important things to me is that they [the staff] keep me informed about her (wife’s) condition. (Husband of resident, facility 2) I said, “Anytime call me,” and they did call me and I came and I calmed her down right away. I was very grateful. I said, “That was really nice of you to call.” (Daughter of resident, facility 4) However, while the merits of family involvement were acknowledged by staff, it was also observed that keeping families happy could be very time consuming. Some families, it was noted by one staff member, “actually need more care than the residents”:


577

Bauer et al.

Some of the families need a lot of time. They want you to spend that time with them, whether it’s over the phone, or when they come to visit. Some families need everyday contact. (Staff focus group, facility 3) I’ve got to be in constant contact with them. I’m constantly either on the phone to them or writing in the books. I see a lot of them, it’s not just on the phone, they come in and visit their loved ones regularly. I see them in the evenings and . . . (Staff focus group, facility 4) Contact with families often alerted staff to the extent of their grief as well as other issues such as dysfunctional familial relationships, and many times revealed that the family members themselves were in need of support. Some families were seen as high maintenance and in need of a lot of attention and reassurance to keep them happy: Some of us [staff] stay back till 6-7 o’clock at night because if those loose ends aren’t tied up they’ll blow up into something serious . . . You just have to. Even if there’s a pot boiling over, I just stop, and focus . . . that really is important. (Staff focus group, facility 1) You can tell by the look on their face . . . You can feel the urgency sometimes . . . if you set them aside . . . they’ll be angrier by the time you get there. And it will take longer for them to be pacified. (Staff focus group, facility 3) We have. . . siblings that have issues with each other, and that projects onto the parent, and then projects further onto the staff. And it can cause quite a lot of distress all round. (Staff focus group, facility 4) Staff at all the participating facilities generally felt that they dealt well with the needs—both practical and emotional—of family members, even the “high maintenance” ones. For some family members however, the efforts of individual wellmeaning staff were not enough to keep them happy. Several family members perceived that the barriers to constructive staff–family relationships existed at a higher level, including lack of resources, inadequate funding, insufficient staff training, or poor attitudes from senior management: More money, that would solve [the problems]! More money, more staff, more everything! (Daughter of resident, facility 4)


578


It all comes back to the board and management, the philosophy that they’re teaching both to staff and to families about what are the expectations and responsibilities of both sides, and creating processes and an atmosphere that encourages that between staff and families. (Daughter of resident, facility 4) I feel intimidated by the Director Of Nursing at forums and people don’t express their concerns because it’s not a conducive environment. (Daughter of resident, facility 5) Some family members who attempted to challenge issue of concern “higher up” in the organization believed that staff saw them as troublemakers. I think that probably . . . when senior management and staff get together there would be a lot of grinding of teeth and “oh those families are so difficult.” (Daughter of resident, facility 4)

Discussion The findings of this study support the well-established view that constructive staff–family relationships are more likely to develop when both staff and family recognize and value one another’s knowledge and expertise and work together to improve resident care (Friedemann, Montgomery, Mailberger, & Smith, 1997). In particular, communication was an underlying theme throughout the findings, which is consistent with existing literature on this topic (Austin et al., 2009; Majerovitz et al., 2009; Utley-Smith et al., 2009). For staff and families, relationships that were collaborative, harmonious, and underscored by good communication and where there was an exchange of information about resident’s nuances, likes and dislikes, and other biographical data, were highly regarded. Good relationships in this study were seen by staff to be based on a reciprocal sharing of information about the resident’s care and staff practices and behaviors which demonstrated to families that staff were knowledgeable about the resident and had an understanding of their care needs. The development of a cooperative and trusting staff–family relationship was dependent on having knowledgeable and consistent staff who were able to adhere to commitments they had made with family, and confer with and use family’s local knowledge (Harvath et al., 1994) to deliver care. All participants acknowledged the families’ involvement in the facility and the importance of providing opportunities for communication (Abrahamson et al., 2009) and information exchange between staff and families. Findings further underscore


579

Bauer et al.

the need for staff to establish clear lines of communication with family at the outset, make them aware of whom they can consult and ensure that staff members are actually available and moreover prepared to confer with families about their needs when required. The latter it was noted, could be particularly problematic for families in facilities when nonregular or agency staff were providing care. The importance of having a welcoming environment and staff who are approachable and able to interact with visiting families in a friendly manner has been previously reported (Bauer & Nay, 2011) and the present findings reinforce the significance of families’ daily encounters with staff to the establishment of constructive relationships. An inviting and welcoming environment characterized by frequent opportunities to interact with the staff creates a sense of community for family and contributes to their feeling of safety and security in a facility (Westin, Öhrn, & Danielson, 2009). When family members have developed a sense of trust and security about their role in the facility (Wilson et al., 2009), they are much more likely to engage with the home and involve themselves in positive ways. Staff acknowledged that the degree of involvement of families within a facility varied considerably; however it was also a widely held view that staff could develop better relationships with families who showed an active interest in their relative and the facility and who wanted to share information with them, than with those families who disengaged and visited less often. While family involvement in the facility was generally viewed as desirable by staff, it was also evident that conflict could ensue when the views of staff and family about care and the role of the family diverged or where both staff and family expectations were not made clear. Although it has been reported that most care staff desire cooperation with the family and want the relationship to work (Weman & Fagerberg, 2006), tensions between staff and families are also frequently cited in the literature (Bauer, 2007). Utley-Smith et al (2009) found that family expectations often clashed with staff expectations and while staff–family relationships were described as helpful, important and trusting, they were more commonly portrayed as difficult, problematic, time consuming, conflictual, and challenging. Majerovitz et al. (2009) have indicated that conflict commonly arises when there is confusion about the role of family members and poor communication about the level of involvement that is expected from them. This was reflected in the comments from staff participants who indicated that it was important to let families know when they had “overstepped the mark.” According to Hertzberg (2003), staff usually have no problem “keeping the families happy” provided they share the same view. It is when families have a different view, that the staff have trouble listening to them and go their own way. Our findings suggest that some staff all too often view families in terms of their own role and how the family’s presence impacts on the work they are required to


580


do. When families are viewed through such a narrow lens, they can readily be perceived as a hindrance. Families who assisted with activities in the facility such as resident “feeding,” an activity that is seen by staff to be very time consuming, were spoken about favorably. Families that demanded staff attention on the other hand, such as those who made frequent requests, disputed staff decisions, or required lots of staff time and additional support, were more likely to be perceived as distractions from the “should do work” (Bowers, Lauring, & Jacobson, 2001) of resident care. Family members who were unhappy with aspects of the organizational structure were viewed as difficult and tiresome, and were met with defensiveness from staff. While our findings highlight the areas that participants believed would contribute toward the formation of positive staff–family relationships, it is important to acknowledge the realities of the residential care environment, and how they might impact on the abilities of staff in particular, to foster these relationships. A recent systematic review highlights staff workload as a common barrier to the formation of positive staff–family relationships (Haesler et al., 2010), and understaffing and lack of time for staff to engage with family have also been cited in the literature as contributing toward tensions between staff and families (Bowers, et al., 2001; Buelow & Cruijssen, 2002). Bowers, Lauring, and Jacobson (2001), for example, indicated that nursing home carers’ struggle to fit all the necessary tasks into their day, and therefore sacrifice “the flexibility to respond to events and people” (p. 489). Majerovitz et al. (2009) also notes that time pressures cause staff to cut communication short and use strategies that signal to families that they are not receptive to their concerns. Our findings similarly found that families who were perceived as too demanding, or who detracted from the “should do work,” were viewed negatively. Furthermore, the context of the Australian residential aged care environment is one that is increasingly multicultural. In 2007, 33% of the residential aged care workforce were born outside of Australia (Martin & King, 2008), and it is likely that this percentage will have increased since then. While many migrant aged care workers come from countries where English is the first language, many do not, and this is likely to have an impact on successful communication between staff and families. A report by Martin and King (2008) for example, indicated that of those aged care facilities who reported difficulties with carers whose first language was not English, in about three quarters of these cases, “the difficulties were in a range of communications—with management and other staff, with residents, and with residents’ families” (p. 57). Given the importance the participants in this study placed on communication as a cornerstone of constructive staff– family relationships, the findings highlight a potential area of concern for the future of Australian residential aged care services.


581

Bauer et al.

Conclusion This study contributes to the existing body of literature by providing a more detailed picture of staff–family relationships within the Australian residential aged care context. Previous studies conducted within Australia have not explored the views of both staff and family members together, nor have they explored staff–family relationships in a wide variety of residential aged care settings (metropolitan, rural, public, and private). Findings further confirm the centrality of constructive relationships between staff and family in the care of older people living in residential aged care facilities. It also confirms that, despite the growing body of research conducted on this topic, the role of the family within the residential aged care setting in Australia remains somewhat complex and ambiguous, and many of the same issues continue to be a problem. Communication featured prominently throughout our data as a key factor in the success of staff–family relationships. While communication has been repeatedly raised as a central element of positive staff–family relationships in the literature, it would appear something prevents this knowledge from being successfully translated into practice. While there were many indications within the study findings that families and staff can and do work together in positive, constructive ways, there were limits to how far this cooperation extended. Providing that family members’ involvement was defined as “helpful,” it was welcomed and appreciated by staff, however, family members who sought to overstep an unspoken line and became too demanding or critical were perceived as difficult by staff. The findings furthermore highlight the “Catch 22” evident in the formation of constructive staff–family relationships. On the one hand, family members’ involvement in the facility environment was shown to depend greatly on the degree to which they felt welcomed and appreciated by staff. On the other hand, staff members tended to be more welcoming and friendly toward family members who showed an interest and were actively involved in the facility and contributed toward residents’ care. While the question may be asked as to who is responsible, ultimately, for the initiation of a mutual attitude of respect and cooperation that can set the tone for the future of the relationship; we believe it is incumbent on staff working in residential aged facilities to start the conversation about family expectations and how families both perceive and wish to pursue their role, before their family member moves into the facility. Such a conversation can form the basis of a constructive relationship, as at least some mutual and realistic understanding of roles and expectations can be discussed, so that any issues might be proactively explored. While structural issues within residential care facilities such as understaffing and time constraints are acknowledged as potential stumbling blocks toward staff


582


taking the initiative to engage with family members, research indicates that, ironically, building trusting between staff and family actually helps the relationship and alleviate the problem. As Hertzberg (2003) has suggested, “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” (p. 431).

Limitations The study has captured the views of a relatively small but diverse number of participants from a range of aged care facilities on the issue of staff–family relationships. It cannot be concluded that the views expressed would be shared by staff and families across all aged care facilities, however there is a consistency to the views that were expressed and the study’s findings are consistent with other research on this topic (Haesler et al., 2010). We have endeavored to provide sufficient data to enable the reader to determine the study’s broader applicability and relevance.

Implications for Further Research and Practice While this research explored the factors that promote and hinder the formation and promotion of constructive staff–family relationships in residential aged care, it did not explore any practical strategies that may be utilized. To determine the impact and effectiveness of identified strategies that are implemented to improve the relationship between staff and families in aged care, valid and reliable tools to measure the constructiveness of the relationship need to be developed.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

References Abrahamson, K., Anderson, J. G., Anderson, M. M., Suitor, J., & Pillemer, K. (2010). The cumulative influence of conflict on nursing home staff. Research in Gerontological Nursing, 3(1), 39-48. Abrahamson, K., Jill Suitor, J., & Pillemer, K. (2009). Conflict between nursing home staff and residents’ families: Does it increase burnout? Journal of Aging and Health, 21, 895-912. doi: 10.1177/0898264309340695.


583

Bauer et al.

Aged Care Standards and Accreditation Agency. (2010). Accreditation. Retrieved November 15, 2010, from http://www.accreditation.org.au/ Austin, W., Goble, E., Strang, V., Mitchell, A., Thompson, E., Lantz, H., & Vass, K. (2009). Supporting relationships between family and staff in continuing care settings. Journal of Family Nursing, 15, 360-383. Australian Government Department of Health and Ageing. (2006). Rights and responsibilities of residents of aged care homes. Retrieved August, 2007, from http:// www.health.gov.au/internet/wcms/Publishing.nsf/Content/ageing-publicat-qcoa08info.htm Bauer, M. (2006). Collaboration and control: Nurses’ constructions of the role of family in nursing home care. Journal of Advanced Nursing, 54, 45-52. Bauer, M. (2007). Staff-family relationships in nursing home care: A typology of challenging behaviours. International Journal of Older People Nursing, 2, 213-218. Bauer, M., & Nay, R. (2003). Family and staff partnerships in long term care: A review of the literature. Journal of Gerontological Nursing, 29(10), 46-53. Bauer, M., & Nay, R. (2011). Improving staff-family relationships in assisted living facilities: The views of the family. Journal of Advanced Nursing, 67, 1232-1241. Bowers, B. J., Lauring, C., & Jacobson, N. (2001). How nurses manage time and work in long-term care. Journal of Advanced Nursing, 33, 484-491. Buelow, J. R., & Cruijssen, M. (2002). Long-term care nurses speak out. Long Term Care Management, 51(3), 50-53. Chen, C., Sabir, M., Zimmerman, S., Suitor, J., & Pillemer, K. (2007). The importance of family relationships with nursing facility staff for family caregiver burden and depression. Journals of Gerontology Series B: Psychological Sciences & Social Sciences, 62B(5), P253-260 Dijkstra, A. (2007, April). Family participation in care plan meetings. Journal of Gerontological Nursing, 33(4), 22-29. Fontana, A., & Frey, J. (1994). The art of science. In N. Denzin & Y. Lincoln (Eds.), The handbook of qualitative research (pp. 361-376). Thousand Oaks, CA: SAGE. Friedemann, M., Montgomery, R. J., Mailberger, B., & Smith, A. (1997). Family involvement in the nursing home: Family-oriented practices and staff-family relationships. Research in Nursing and Health, 20, 527-537. Gaugler, J. (2006). Family involvement and resident psychosocial status in long-term care. Clinical Gerontologist, 29(4), 79-98. Gaugler, J., & Kane, R. (2007). Families and assisted living. Gerontologist, 47(supplement 1), 83-99. Haesler, E., Bauer, M., & Nay, R. (2006). Factors associated with constructive stafffamily relationships in the care of older adults in the institutional setting. International Journal of Evidence-Based Healthcare, 4, 288-336.


584


Haesler, E., Bauer, M., & Nay, R. (2010). Recent evidence on the development and maintenance of constructive staff-family relationships in the care of older people— A report on a systematic review update. International Journal of Evidence-Based Healthcare, 8(2), 45-74. Harvath, T. A., Archbold, P. G., Stewart, B. J., Gadow, S., Kirschling, J., Miller, L., & Schook, J. (1994). Establishing partnerships with family caregivers: Local and cosmopolitan knowledge. Journal of Gerontological Nursing, 20(2), 29-35. Hertzberg, A. (2003). “Relatives are a resource, but . . . ”: Registered nurses’ views and experiences of relatives of residents in nursing homes. Journal of Clinical Nursing, 12, 431-441. Higgins, I., & Cadd, A. (1999). The needs of relatives of the hospitalised elderly and nurses’ perceptions of those needs. Geriaction, 17(2), 18-22. Kellett, U. (1996). Caring in nursing homes: The family perspective. Geriaction, 14(4), 18-23. Kemp, C. L., Ball, M. M., Perkins, M. M., Hollingsworth, C., & Lepore, M. J. (2009). “I get along with most of them”: Direct care workers’ relationships with residents’ families in assisted living. Gerontologist, 49, 224-235. Lau, W., Shyu, Y., Lin, L., & Yang, P. (2008). Institutionalized elders with dementia: Collaboration between family caregivers and nursing home staff in Taiwan. Journal of Clinical Nursing, 17, 482-490. Legault, A., & Ducharme, F. (2009). Advocating for a parent with dementia in a longterm care facility: The process experienced by daughters. Journal of Family Nursing, 15, 198-219. Lindgren, C. I., & Murphy, A. M. (2002). Nurses’ and family member’s perceptions of nursing home residents’ needs. Journal of Gerontological Nursing, 28(8), 45-55. Majerovitz, S., Mollott, R., & Rudder, C. (2009). We’re on the same side: Improving communication between nursing home and family. Health Communication, 24(1), 12-20. Marquis, R., Freeguard, H., & Hoogland, L. (2004). Influences on positive family involvement in aged care: An ethnographic view. Contemporary Nurse, 16(3), 178-186. Martin, B., & King, D. (2008). Who cares for older Australians? A picture of the residential and community based aged care workforce, 2007. Canberra, Australia: Australian Government. McCallion, P. (2005). Supporting families of persons with dementia. In Gaugler. J (Ed.), Promoting family inovolvement in long-term care settings (pp. 123-140). Baltimore, MD: Health Professions. Moyle, W., Skinner, J., Rowe, G., & Gork, C. (2003). Satisfaction and dissatisfaction in Australian long-term care. Journal of Clinical Nursing, 12, 168-176.


585

Bauer et al.

Park, M. (2010). Nursing staff stress from caregiving and attitudes toward family members of nursing home residents with dementia in Korea. Asian Nursing Research, 4(3), 130-141. Patton, M. Q. (2002). Qualitative research and evaluation methods (3rd ed.). Thousand Oaks, CA: Sage. Russell, H., & Foreman, P. (2000). Facilitating family involvement in a residential aged care setting. Melbourne, Australia: Lincoln Gerontology Centre and Villa Maria Society. Specht, J. P., Kelley, L. S., Manion, P., Maas, M. L., Reed, D., & Rantz, M. J. (2000). Who’s the boss? Family/staff partnership in care of persons with dementia. Nursing Administration Quarterly, 24(3), 64-77. Utley-Smith, Q., Colon-Emeric, C., Lekan-Rutledge, D., Ammarell, N., Bailey, D., Corazzini, K., & Ruth, A. (2009). Staff perceptions of staff-family interactions in nursing homes. Journal of Aging Studies, 23, 168-177. Weman, K., & Fagerberg, I. (2006). Registered nurses working together with family members of older people. Journal of Clinical Nursing, 15, 281-289. Westin, L., Öhrn, I., & Danielson, E. (2009). Visiting a nursing home: Relatives’ experiences of encounters with nurses. Nursing Inquiry, 16, 318-325. Wilson, C. B., Davies, S., & Nolan, M. (2009). Developing personal relationships in care homes: Realising the contributions of staff, residents and family members. Ageing & Society, 29, 1041-1063.

Author Biographies Michael Bauer is a senior research fellow. His current work is focused on the development of an on-line resource package and education program to improve and support collaborative staff-family relationships in long term care facilities. His other projects are focused on sexuality in aged care; dementia and involvement in decision making and the development of measures and tools for assessing staff-family relationships. Deirdre Fetherstonhaugh is a senior research fellow and acting director of the Australian Centre for Evidence Based Aged Care. Her research focuses on: the translation and implementation of research evidence into practice; the ethical implications of clinical practice and research; the conceptualisation and operationalization of person-centred care; the promotion of participation in decision-making for older people with dementia; measuring and improving staff/family relationships; and sexuality and older people. Laura Tarzia is a sociologist and a research officer with an interest in dementia, sexuality and decision making. Carol Chenco is a research officer and works part time for the Victoria and Tasmania Dementia Training Study Centre.


Advance care planning in care homes: the experience of staff, residents, and family members.

Caring for acutely unwell older residents in residential aged-care facilities: Perspectives of staff and general practitioners.

Medication charts in residential aged-care facilities.

Attitudes towards family-staff relationships in Australian residential aged care settings: development and psychometric evaluation of the 'Family and Staff Relationship Attitude Tool' (FASRAT).

Evaluation of a mobile X-ray service for elderly residents of residential aged care facilities.

Quality of advance care planning policy and practice in residential aged care facilities in Australia.

Immigrants with dementia in Swedish residential care: an exploratory study of the experiences of their family members and Nursing staff.

What Happens in Their Bedrooms Stays in Their Bedrooms: Staff and Residents' Reactions Toward Male-Female Sexual Intercourse in Residential Aged Care Facilities.

A multi-organisation aged care emergency service for acute care management of older residents in aged care facilities.

Supporting residents' expression of sexuality: the initial construction of a sexuality assessment tool for residential aged care facilities.

Advance care planning in aged care facilities.

Interprofessional learning in residential aged care: providing optimal care for residents.

'We need to know what's going on': views of family members toward the sexual expression of people with dementia in residential aged care.

Employee influenza vaccination in residential care facilities.

Pandemic influenza plans in residential care facilities.

Communication between residential aged care facilities and the emergency department: a review of the literature.

Bone mineral density in residents of care facilities for the aged and effect of pharmacotherapy.

An assessment of the educational value of service-learning community placements in residential aged care facilities.

Residents' perceptions and experiences of social interaction and participation in leisure activities in residential aged care.

Texture-modified food and fluids in dementia and residential aged care facilities.

Prevalence of vitamin D supplement use in Australian residential aged care facilities in November 2014.

Treatment of Osteoporosis in Australian Residential Aged Care Facilities: Update on Consensus Recommendations for Fracture Prevention.

Prescribing for older people discharged from the acute sector to residential aged-care facilities.

Implementation of 'Goals of Patient Care' medical treatment orders in residential aged care facilities: protocol for a randomised controlled trial.