Strategies for Improving Family Satisfaction with Long-Term Care Facilities: Direct Care and Family-Staff Interactions

Families are integral members of the healthcare team in LTC facilities, and the evaluation of their satisfaction has become an increasingly valued measurement. In the authors’ project, a review of the literature was conducted to identify key areas for improving family satisfaction. Two categories were identified as the most important influences on family satisfaction: direct care and family-staff interaction. Families were most satisfied with direct care that was provided with empathy and in a timely and accurate manner. Family-staff interactions were often a source of dissatisfaction that could be addressed by consistent communication. Communication strategies such as contacting family members with general updates instead of only contacting them when an adverse event occurred was one method for improving family satisfaction. (Annals of Long-Term Care: Clinical Care and Aging 2009;17[4]:25-28)
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Selecting a long-term care (LTC) facility for an impaired loved one is one of the most difficult decisions that family members face.¹ In order to facilitate such decisions, consumer reports or report cards are being utilized by state and private organizations to provide information about the quality of healthcare in LTC settings.² Such information can be valuable to families not only in choosing a facility, but also in assessing the ongoing quality of care after the placement has been made.²

The nature of the information contained in the consumer report is critical to its usefulness in helping families make informed decisions. In particular, consumers value information about satisfaction rates and perceptions of quality from people like themselves.² Recognizing the importance of family satisfaction ratings, states are beginning to include this information in their consumer reports.² However, the value of family satisfaction ratings extends beyond facilitating consumer decisions; these evaluations provide important data for the LTC facilities’ quality improvement practices.³

Family satisfaction measurement embraces the fact that families are a part of the long-term caregiving system, having the opportunity to be involved in all phases of care delivery. Perceptions of quality and satisfaction are established, challenged, and reinforced through the multiple interactions between families and staff within the environment of the facility, from pre-admission through discharge. The everyday interface between the LTC facility and families shapes and molds their overall perceptions—perceptions that are often shared with others as informal report cards of quality.

Families, therefore, can be viewed as powerful consumers who have the potential to generate positive or negative reports in their broader social networks, thus impacting the community’s perceptions of quality care.⁴ Family members who are satisfied with the nursing home provide positive feedback in conversations, providing a valued perspective sought by families who ultimately may face placement decisions. These insights shape the facility’s quality image and can generate future referrals. The converse is also true; negative word of mouth may be one of the most challenging marketing dilemmas faced by LTC facilities.

This consumer power gives the LTC facility a strong incentive to focus quality improvement efforts on building or sustaining family satisfaction. Generating a positive image of the LTC facility cannot only strengthen referrals, but may diminish the threat of litigation.⁵ Given the importance of family satisfaction with LTC facilities, we sought to identify factors influencing family satisfaction in LTC facilities and related strategies to enhance satisfaction as cited in recent literature. The overarching goal of this article is to summarize key points for consideration in ongoing quality improvement activities.

Our literature search was limited to articles written in English and published within the last ten years. After reviewing the abstracts of all citations for indications of relevancy to the inquiry, 13 publications were retrieved for inclusion. Thematic analysis of the literature revealed that the primary influences on family satisfaction center around two distinct categories: direct care and family-staff interactions.

Direct Care

The quality of the direct care influences family satisfaction with LTC facilities. A significant quality aspect of direct care was empathy. In one study, researchers discovered that family members ranked the expression of empathy as the most important dimension of care.⁶ Empathy was demonstrated by staff actively listening to residents’ or family members’ concerns, providing care in a sensitive and dignified manner, and treating residents with respect.^7,8

On the other hand, the greatest amount of dissatisfaction was found with the staff’s responsiveness and reliability, defined as the timely and correct completion of tasks and the accuracy of information.⁶ Responsiveness was enhanced when staff took action on requests by family members or residents in a timely manner, as well as answering call bells quickly.⁶ Providing care that is excellent on both the technical and interpersonal levels gives families confidence that their relative is being well cared for.¹ Therefore, showing empathy, improving reliability, and increasing responsiveness are three main ways to improve family satisfaction with direct care.

Hospice care seemed to encompass the key components of empathy, reliability, and responsiveness. The family members of residents receiving hospice care had higher levels of overall satisfaction than family members of residents not receiving hospice care.⁷ Improved satisfaction was noted with greater comfort care, as well as adequate and effective pain control.^8,9 When death occurred, family members indicated greater satisfaction with the level of care when the resident passed away in the LTC facility as opposed to the hospital.⁸ Thus, infusing models of hospice care into the LTC facility may be an important strategy for enhancing family satisfaction with direct care.

The role of family caregiving in the nursing home has been the subject of debate, but it has been shown that family members who were more involved with direct care in the LTC facility were less satisfied overall.¹⁰ Families who assume direct care roles carry a sense of responsibility that is frequently extended into a belief that if they did not provide the direct care, their family member would not receive needed care. As staff members interact with families who choose to continue to participate in their relative’s care, a delicate balance must be struck. Family caregivers must be embraced as co-providers of care within supportive, reassuring staff interactions that reinforce the value of personal interaction, but not the necessity. Staff absolutely must not view the family caregiving as a substitute for the care provided by the staff.¹

Family-Staff Interaction

A family’s interaction with staff was often a source of great dissatisfaction.¹¹ One of the areas of dissatisfaction was with communication and availability of information about their relative.¹ Strategies to improve this potential threat to family satisfaction include having consistent, regular communication with the families, as well as immediately notifying them about any changes in their relative’s health status.^1,5,8

A second area of dissatisfaction for family members when dealing with staff was the level of involvement and influence they were permitted to have in establishing a plan of care and in the decision-making process.^8,11 Families must be given opportunities to become closely involved in care planning, allowing the specific needs of the resident to be identified and understood.⁶ While in most LTC facilities, care plan meetings do occur regularly and family are invited, meetings often are scheduled during normal business hours. Adult children with full-time jobs or family responsibilities may not be able to attend a care plan meeting scheduled during these hours. Alternate scheduling or allowing a family member to participate via a telephone conference could greatly improve communication between family members and the LTC staff. While such efforts may require some flexibility on the facility’s behalf, the potential value in building the families’ sense of caring and commitment could greatly impact their satisfaction, with ripple effects into the community.

Meetings between family and staff can also allow for the discussion of actual and potential problems, which helps identify specific areas of dissatisfaction.¹⁰ When there is a complaint from the family, it is important to treat it as a high priority and to have a process in place for handling such complaints.⁵ Staff must be trained to shift negative perceptions of complaints into opportunities for quality improvement. Early identification of areas of dissatisfaction and responsive action to complaints demonstrate the facility’s commitment to quality, which contributes to an overall sense of satisfaction.

Models of care have incorporated processes to improve communication between staff and family members, thus permitting early identification and rapid response to concerns. One example of such a program is The Partners in Caregiving Program.¹² Through this program, families and staff were trained in techniques for effective communication and were taught conflict resolution skills. Not only did this program result in extremely high levels of family satisfaction, there were also many positive changes in the ways that the families and staff interacted.¹² The Eden Alternative is another program which, through changing the culture of the organization, has also been shown to increase family satisfaction related to the increased communication and interaction between families and staff.¹³ Whether organizational approaches or interpersonal strategies are employed, enhancing communication and problem resolution are key components of family satisfaction. It is important to consider patterns of family interaction in the facility so that strategies may be implemented by staff members who regularly interact with families.

Implications for Practice

In the domain of direct care, it is important that facilities go beyond competency in task performance to determine the staff’s baseline understanding of empathy, responsiveness and reliability. A cost-effective strategy for assessment of staff attributes would be to include this topic at a regularly scheduled in-service education session. Ask staff members to identify ways in which they demonstrate these characteristics to both the residents and families, and then have them identify ways to increase and improve empathy, responsiveness, and reliability. In conjunction with this discussion, the concept of the role of family caregivers may be broached.

While allowing staff to share their feelings and experiences is important, the primary focus of in-service education should be on developing concrete strategies for staff to use during interactions with family members. Emphasis on the individualization of resident and family care must be maintained. For example, if a family chooses to come in daily to feed its resident, strategies could include providing comfortable space, offering any skills teaching as needed, confirming the value of the interpersonal time spent with the resident, and acknowledging the family’s contribution to care while reassuring them that the staff would cover the task as needed.

In contrast, families who rely on the facility’s staff for feeding support may benefit from a brief comment on how well the resident ate or how problems were resolved in order to reassure the family that the resident’s needs are being met. The themes of devising strategies for family-staff interactions include: opening lines of communication; acknowledging but not expecting contributions to care; and providing support through difficult transitions in the caregiver role.

Concerning family-staff interactions, effective and consistent communication with families is essential to improving satisfaction. Facility assessment may begin with an examination of how family is involved in the care planning process. Families should be formally involved in the care planning process on a consistent basis, allowing them an opportunity to not only provide input, but to express concerns. Options such as alternative scheduling or telephone conferencing would demonstrate to the family members that they are a valued part of the care planning team.

Communication needs to be consistent and not just limited to care planning meetings. In order to develop this steady communication, family members, especially those unable to visit regularly, should be routinely called with a general update. One mistake most facilities make is only notifying family when an adverse event has occurred, such as a fall. When there is a health status change, family members should not only be notified in a timely manner, but updated at regular intervals. Administrators should develop a formal plan for handling both general updates and adverse events to ensure that staff members are equipped with strategies to promote the facility’s caring attitude, commitment to quality, and responsiveness to needs. Keeping families informed of when to expect the next update and meeting the set expectations is critical in this process. Effective communication with family members on both a routine and as-needed basis is a significant consideration for building family satisfaction with the facility and warrants careful consideration.

Because end-of-life care is highly relevant to LTC, and plays a significant role in family satisfaction, it is important to evaluate the facility’s current policy and standard of care concerning end of life. End-of-life care may be approached organizationally, or generalist strategies may be infused throughout the system. A feasibility assessment may demonstrate that the implementation of a service line within the LTC facility may be warranted, or community resources in palliative and hospice care may provide contracted services.

Even with such organizational approaches, staff would benefit from enhanced understanding of end-of-life issues and interventions. An infusion of generalist strategies may begin with training the facility’s leadership group; however, in order to be effective, front-line staff must be better educated in addressing the care of the dying patient. Nursing, social work, and pastoral care staffs are often good resources to launch generalist training. By attuning staff to the needs of residents and families at the end of life, important strides in building family satisfaction may be made.

Conclusion

Family satisfaction is a key component of quality improvement efforts in LTC settings. Families are involved from the very beginning in helping to choose a facility, as well as being active in the continual evaluation of the facility and the care that their relative receives. Enhancing family satisfaction is beneficial to the LTC facility. In order to improve family satisfaction, two main areas within the LTC facility require examination and evaluation: direct care and family-staff interactions. By evaluating and improving these areas, a LTC facility can maximize family satisfaction.

The authors report no relevant financial relationships.

Ms. McVeigh is Education Coordinator, HealthSouth Nittany Valley, Pleasant Gap, PA; and Dr. Jablonski is Assistant Professor and Dr. Penrod is Associate Professor at The Pennsylvania State University School of Nursing, University Park.