Bridging the gap between families and staff; how one facility focused on communication approaches that have made families allies rather than Adversaries.

It doesn't matter whether your facility is well operated, deficiency-free, state of-the-art, and staffed by the most caring professionals--complaints are inevitable. Suddenly, an "ideal day" falls like a house of cards when the Willful Wife, the Haranguing Husband, the Demanding Daughter, or the Sermonizing Son steps through the door. "Why isn't my husband's hair combed?" "Why Is my wife still in her pajamas at 8:30 a.m.?" "How did my mother get that scratch on her face?" "Why are her clothes disappearing?" Not pleasant--but one way to look at a complaint is that it's an opportunity for improvement.

To build good relationships with families and residents, you must convey to them that their concerns are taken seriously. After all, sometimes even the chronic complainer has a valid grievance that, when resolved, becomes an important lesson in the value of communication.

Clare L. Horn, ACSW, assistant vice-president of Social Services at Morningside House, a 386-bed facility in the Bronx, New York, is a case in point Observing the various communication styles of staff, residents, and families, and witnessing their effects on her nursing home operations, she began to search for a way to make the most of these exchanges. Two years ago she met with William T. Smith, president and CEO of Aging in America (Morningside House's parent company) and current AAHSA chair-elect, to discuss the issue. Smith told her about a nursing home that had implemented a program called Partners in Caregiving (PIC), a program designed to give people the tools to understand and refine their communication styles.

Developed by Karl T. Pellemer, PhD, associate professor of human development at Cornel/University and codirector of the Cornell Applied Gerontology Institute, PIC is an empowerment tool specifically structured for training nursing staff and family members in communicating with each other. Each group undergoes nearly identical training sessions, but the topics are geared to their particular roles in relating to the resident. Through lectures, exercises, and role-playing, participants learn how to air their opinions and/or grievances respectfully, in an open-minded and constructive manner.

"Because Morningside House strives for such exchanges with families," says Horn, "our PIC facilitator, Rhoda Meador, MS, and I agreed to take a 'train the trainer' approach in disseminating this among staff, asking CNAs and others who participated in the workshops to spread the word among their colleagues. In addition to improving communication among residents, staff, and family members, the main program goals were to improve both care and caring by nursing personnel; to increase family satisfaction with and participation in a loved one's care; to improve the entire facility's sense of community; and to promote participation at every staff level--from administration to nursing staff to ancillary service personnel."

Horn and Joan Trendler, RN, director of Clinical Education, revised and expanded the facility's orientation and analyzed ways to sustain ongoing staff education to incorporate PIC principles.

Recruiting PIC Participants

Before beginning the PIC workshops, families who had shown an active interest in the processes of care at Morningside House received a letter detailing PIC and inviting them to participate in two, two-hour training sessions in a particular week. According to Horn, response was enthusiastic and the workshop well attended.

For the staff side of the program, CNAs were recruited from every unit and floor of the facility and attended three two-hour workshops during the week the training was offered. "Of course, this required some scheduling adjustments to cover for those CNAs who were off the floor during their six hours of training," notes Horn.

Highlights of a PIC Workshop

During the PIC training, each group focused on the same communication principles from their own particular perspectives. For example, family members were taught how to complain or criticize in a positive manner, while staff learned how to receive and adjudicate a complaint or criticism constructively. "The course is not just about complaints," explains Horn. "Sessions cover a range of topics that promote cooperation, teamwork, and shared goals." Through PIC, participants learn how to:

Listen effectively. The PIC program introduces advanced listening skills through interactive skill-building sessions that introduce listening and feedback techniques to focus clearly on what is being said. For example, a family member might want to know why a parent has been sitting so long. If the staff member perceives that the question was asked brusquely or with negative body language, he or she might react defensively rather than responding with a reason and, if necessary, correcting the situation. Or maybe the query was asked casually and the CNA, being busy at the moment, brushed it off, leaving the family member with the impression that the caregiver didn't care. In either case, communication has failed.

Speak clearly. As important as it is to listen carefully, participants are taught to convey their messages clearly and respectfully to diffuse defensiveness and divisiveness. This facet of PIC uses role-playing to convey the message that problem solving is not "I"-focused, but "we"--focused. In the above scenario, for example, instead of just throwing the question at the CNA, participants learned that a family member who prefaces a question with a polite, "Excuse me but ...," will garner a better response, such as, "May I get back to you in a moment because...." In this way, the family member acknowledges the staff member's busyness but realizes, with the staffer's polite response, that his or her concern is seen as valid and that the staff member wants to give it complete attention when he or she is able.

Understand cultural differences. Recognizing and adapting to the various cultures, ethnicities, and languages of residents and staff are essential to effective partnering. Through the workshops' lectures, exercises, and other training modalities, staff learned, for instance, that what might be considered rude or uncaring in one culture or to one ethnicity might simply be a normal style of behavior or speech in another. Horn explains, for example, that Hispanic people generally move closer to a person when conversing, which can be intimidating or seem rude to others who require more personal space.

Another example Horn cites involves touching. "In some cultures touching can be seen as highly improper. For example, Cambodian and Thai mores do not permit touching or patting people, including children, on the head because the head is recognized as being closest to the spirit," remarks Horn. She adds, "Cultural differences are apparent even in decision making. For example, Taiwanese families abide by the decisions made by elders, while Americans generally decide advanced directives and other issues by consensus. Awareness of these differences can prevent accidental affronts."

Improve communication facility-wide. The final segment of each group's workshop was to identify particular areas of concern in the facility that could be remedied by improving communication After each group developed its talking points on these issues, they met in a joint session to brainstorm, design, and implement tasks that would focus on solving them. "The joint meeting," explains Horn, "included administration (CEO, administrator, and department heads), as well as both groups of trainees. With the help of our facilitator, all recommendations were reviewed. From them, a Cooperative Communication Action Plan was developed to pinpoint tasks and measure outcomes."

The action plan recognizes that successful family-staff partnerships begin on the first day of admission. One of the assigned tasks required of everyone--from administration to housekeeping--is to smile and say hello to one another not just to the resident and his or bet family. "Basic courtesy helps immensely when problems do arise," says Horn, "because it reminds people of their common mission--providing optimum care to the resident."

The action plan also recognizes that placing a loved one in long-term care is an emotional experience; not only is the setting unfamiliar to the resident, but also to the family. Feelings of guilt make family members behave more intensely in ensuring their loved one's comfort and care. "We analyze a resident's first week and make it a point to make the family aware of their loved one's daily routine and which staffers are responsible for different aspects of care," explains Horn. "By educating families about our operations, policies, and routines, and by introducing them to the staff involved--giving each person's title, role, and responsibility--we find that families will address their concerns to the appropriate person, which takes the burden off a staff member who just happens to be walking by."

Morningside House has also increased CNA participation in the care-planning process. In doing so, not only do CNAs get a better understanding of their residents' conditions and immediate needs, but also nursing supervisors get a more accurate and insightful understanding of the residents' situations from the hands-on caregivers. This helps the caregiving team to establish individualized approaches to resident care and, in the process, avoid situations that create confrontation.

"Since PIC principles have been introduced, I've seen the number and severity of complaints that cross my desk decrease," observes Horn. Staff members have also become more proactive; the teams will reconvene after three months to analyze whether the assigned tasks have been performed and, if not, what another approach might be. "Moreover, we continue to develop and implement cultural competency in-services," Horn adds.

Staff continue to refine their methods of communication. For example, they are continuing to work at overcoming language barriers and devising communication aids so that they can understand--and be understood--by non-English-speaking residents and personnel. "To meet this need," says Horn, "we have a Language Bank service involving staff who speak a second language (in addition to English). They volunteer to serve as interpreters for residents, family members, and visitors. We are also exploring the feasibility of offering language classes to staff."

Supplementing the Language Bank, Communications Boards (or cueing boards) are available in various languages, including Spanish, Russian, and Italian. "The simple pictorial depictions are very effective in helping staff identify a resident's immediate requests or needs. A visual pain scale is also included to help decipher the resident's intensity and duration of pain," explains Horn.

The process overall has moved the facility's communications to a new level of effectiveness. Now, when a complaint is registered, staff express thanks to the family member for bringing the matter to their attention and apologize for any problems that might have been caused. Then, after gathering information about the incident, they immediately correct the problem to the extent possible, and take time to reassure family members that their concerns have been addressed. Later, a staff member follows up with the family to see whether they are satisfied with the remedy.

Has PIC training had an effect on customer satisfaction? "We benchmark our surveys with those of 18 other member facilities in the Alliance for Continuing Care Network," says Horn. "Looking at the positives and negatives, we've found that families are focusing on respect, dignity, caring, and compassion and, because we are communicating more effectively, satisfaction is growing."

Along with the PIC program, Morningside House supplements its partnership efforts through a program called FRAT (Friends, Relatives, and Administrators Together). "Three times a year, our administrator, Richard Zeitoun, schedules a meeting on a Sunday afternoon, so more families can attend. He presents a program, accompanied by myself and selected department heads, to let families know what is happening at the facility and what is going on regarding federal and state regulations and legislation," explains Horn. After the presentation, families are given the floor to ask questions or raise other issues of importance.

Because today's family caregivers are more knowledgeable about long-term care through media reports, new research resources, and networking, they have become a valuable resource to facility caregiving. The Morningside House approach recognizes this new reality. A family's involvement might have begun as a complaint, but through clear communication based on mutual respect with staff, they become partners, and the quality of care becomes that much better. NH

For further information, contact Clare L. Horn, ACSW, assistant vice-president of Social Services: phone [phone], fax [phone], e-mail [e-mail], or visit www.aginginamerica.org. For information on Partners in Caregiving, contact Rhoda Meador, MS, at the Cornell Gerontology Research Institute at [phone] or fax [phone]. To comment on this article, please e-mail [e-mail].

MORE "FAMILY FRIENDLY" GLEANINGS FROM THE PIONEER NETWORK

Cartmell Home for the Aged, Palestine, Texas 

Each quarter, a member of the nursing staff places a courtesy call to each resident's principal family contact to inquire about the family's overall satisfaction with the facility and offer reassurances, if necessary. The comments collected from these calls enable file facility to rectify situations that could become major problems. As a by-product, families' volunteerism has grown. For example, Cartmell has trained family members as nutritional aides through a special program called Mealtime With Friends.

For more information on Cartmell's family involvement programs, contact Peggy Cowland at [phone].

Loomis House, Holyoke, Massachusetts 

Loomis House, a full-service CCRC, communicates with family members through monthly neighborhood council meetings. Each campus neighborhood appoints a coordinator to serve as a family liaison. The councils also give families a forum to share their observations and, if warranted, change neighborhood practices--such as items on the daily schedules--to avoid conflicts. Realizing that not all family members can attend council meetings, the facility maintains information boards with the meeting minutes posted on them to keep families up to date.

For further information on Loomis House, contact Lori Todd at [phone].

Sarah Neuman Center, Westchester, New York

Part of the Jewish Home and Hospital Lifecare System, the Sarah Neuman Center enhances its relationship with families throughout every aspect of facility operations, as evidenced by its Finance Department. This department actively works with families to help them complete applications for Medicaid and other insurance, as well as resolve bill-paying problems, and offers valuable insights into other resident related financial issues.

By working closely with family members on personal issues, including nutritional concerns or laundry requirements, department staff gain insight into each resident's family dynamics and can anticipate particular needs or programs that might help remedy problems, Furthermore, the facility finds that maintaining a warm, friendly attitude and dialogue promotes partnerships with families to the extent that they become more comfortable and confident with the care provided. Families become more willing to participate in new programs, such as Sarah Neuman Center's Moms and Tots, in which very young children meet and play with the residents, with their moms sitting nearby. All in all, Sarah Neuman encourages friendships between staff and families, and the residents are the ultimate beneficiaries.

For further information on Sarah Neuman, phone [phone].

The Pioneer Network is a nonprofit organization dedicated to changing the culture of aging for elders and those who work with them. For more information, visit www.pioneernetwork.org.