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Article: "Easing Tensions in the Nursing Home"

Original source:

The New York Times
Published: October 19, 2009

Margaret Cunningham remembers a fraught encounter at the nursing home where her father, then 89, lived outside Dallas. A number of things bothered her about her father's care, and she said she felt unable to elicit much cooperation from the staff. So she raised these issues with a social worker.

"She was cold and snippy, just not sympathetic," Ms Cunningham recalled. "She said, 'Well, that's the way it has to be.' "

Ms. Cunningham, a retired union organizer, was anxious about her father and wondering if her criticism might anger staffers and cause retaliation against him. She said she started to weep.
At which point, she recalled, the social worker said: "You need to go home. We can't talk about this now."

That kind of conflict between residents' relatives and nursing home employees isn't merely disagreeable. It can lead to higher levels of depression among family caregivers and to lower job satisfaction and burnout among the staff, according to studies by Karl Pillemer, a gerontologist at Cornell University, and the sociologist J. Jill Suitor of Purdue University.

And University of Pittsburgh researchers have shown that after an older relative with dementia dies, the family members who cared for him eventually find their depression easing. When the relative enters a nursing home, however, depression and anxiety for family caregivers remain as high as when they were doing the bathing and feeding themselves.

Dr. Pillemer said the tension between family and staff helps explain why; he also has demonstrated that these relationships can improve.

"I wouldn't want families to feel powerless or pessimistic," he said in a recent interview. "Family members can actually do quite a bit to work with staff to solve problems. And everything works better if people see themselves as allies instead of adversaries."

Some of his suggestions:

  • Take complaints and requests to the right place. While aides do most of the hands-on care in nursing homes, Dr. Pillemer said: "They're almost never the ones who are making decisions about it. "You've got to go high enough up the chain to make sure the person you talk to has the ability to influence what goes on." He suggested the staff social worker as a starting point.
  • When a problem involves an aide's duties, practice "clear and respectful communication," Dr. Pillemer said. "Avoid blaming the other person. As people get angry, there's a tendency to insult the other party, and it escalates." A demand or reproach - "How come nobody's shaved my father?" - puts overworked staffers on the defensive. Try phrasing it this way: "I noticed my father isn't shaved. This is very important to him. How can we make sure he's shaved every day?" After the conversation, summarize to clarify the agreement you have reached: "I understand that you were short-staffed today. But he will be shaved every morning - is that what you're saying?"
  • Keep visiting, and monitoring. "The amount of visiting people receive is directly related to the quality of care," Dr. Pillemer said. "Families do need to advocate for their relatives, but they need to do it in the right way."
  • Give positive feedback as often as possible. For instance, the staff at one Lancaster County, Pa., nursing home still receives a Christmas fruit basket from a family whose mother died years ago. "That's so thoughtful," said Connie Kreider, a veteran staff member there. "That says we made a difference in people's lives."

As for Ms. Cunningham, she moved her father to another Dallas nursing home, where she developed better relationships with the nurses and aides. "I hug them when I see them; I get them goodies," she said. "I'm constantly coaching them, but we're friendly."

If problems persist, family members can contact the advocate every state has under the federal Older Americans Act. Federal law also requires that nursing homes provide meeting spaces for family councils, so relatives can discuss common predicaments and speak to administrators with a more potent voice.

One thing these relatives might request is the Partners in Caregiving program that Dr. Pillemer and colleagues established a decade ago. Its parallel workshops for family members and staff have worked in a variety of facilities to bolster communication, reduce conflict and ease misunderstanding.

Yet the challenges of today's long-term care system limit how much families can accomplish. Carefully phrased messages won't give stressed staff members a more reasonable workload or raise their salaries. And friendlier interactions won't raise Medicaid reimbursements or alter the reality that today's nursing home patients, sicker than in decades past, require much more attention.

"If you take the most vulnerable people in our population and place them where they're cared for by individuals who don't receive a lot of training and who operate under extraordinarily stressful conditions and receive low pay, you're going to have issues, no matter what," Dr. Pillemer said. "It's an extremely challenged system."

Paula Span is the author of "When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions," recently published by Grand Central Publishing.