Staff relationships with families span the whole gamut, from mutually supportive to deeply destructive. A new study examines the factors for building strong rapport with relatives. Linda Belardi reports.

Effective collaboration between staff and families is underutilised in aged care and greater clarity is needed when defining the role of families in care.

Dr. Michael Bauer, co-author of an extensive literature review of staff-family interaction, says whilst staff have an understanding of the importance of including families in care, they often lack the skills or knowledge to put it into practice.

Best available evidence suggests some discrepancy between in theory support and the practice of collaboration at the coalface.

“Although staff expressed support of family involvement, it appeared they frequently prevented relatives being involved to their preferred level, and were sometimes fearful of allowing the relative to have responsibility for care,” says the review conducted by the Australian Centre for Evidence Based Aged Care.

Families were also frustrated by what they perceived as a lack of staff openness to receiving personalised information about residents.

Studies found that efforts on behalf of relatives to share information about residents’ personality, preferences and personal biography were not appreciated, despite their perceived value to quality care.

“When staff did receive information about the resident it was not always relayed to other carers or considered in care implementation.”

However, Bauer says the mutual sharing of information is critical to providing person-centred care and proper care planning.

“To deliver person-centred care it is vital that staff know as much about the resident as possible. In the absence of this information, it is not possible to provide this form of direct care.”

When staff were perceived as open to learning about the resident, family satisfaction with care improved.

The negotiation of control was a significant battleground and care staff were criticised in some studies for using their expertise to intimidate and embarrass families.

“In most facilities in which the research in this review was conducted, aspects of control were more evident than the collaborative process,” the review says.

In some cases, families would establish strategic relationships with staff to achieve a position of ongoing influence.

Staff perceptions of family:

While families were positively seen as bringing a sense of fun to facilities, the concept of demanding relatives and unrealistic expectations was universal throughout the research.

At worst, staff described families as interfering and said their presence added to their workload, workplace stress and to problem behaviours in residents.

In response, individual staff have developed a variety of coping mechanisms – some destructive such as avoiding or limiting communication with families.

The implication for management is to implement proactive rather than reactive strategies before conflict develops, says Bauer.

While staff attitudes could be overly negative, Bauer says the overall number of families reported as difficult is small.

The significant issue here is workplace flexibility. Staff that view their work as a set of rigid patterns and deadlines are more likely to view family members as a distraction.

“Some staff are less able to navigate the tensions of workplace routine,” he says.

To avoid potential conflict, families should be educated early on about opportunities for collaboration and have roles and expectations of both families and staff clearly defined.

How do families perceive their own role in care?

Bauer says it’s a mistake to think of families as a homogenous stakeholder, as attitudes to their involvement in care range from overprotective to absent.

“Many families want a continued role in the care of their family member, whereas others are quite happy to relinquish responsibility,” he says.

For some, assuming the responsibility of care monitor or evaluator was considered their most important role.

The attitudes of residents are similarly diverse. There are some residents who don’t want relatives involved in care decision-making and it is incumbent on the facility to determine the role, if any, of families in their care, he says.

Factors influencing staff-family interaction:

The quality of staff family relationships is shaped by both positive influences and destructive patterns of behaviour.

Staff were criticised for being cold, insensitive and belittling, while families used negative strategies such as complaining and demanding to assert their influence.

Unaddressed feelings of guilt, loss and grief were perceived as contributing to the demanding nature of some relatives.

Facilities are also not impervious to the effects of internal family conflict and power dynamics, which staff must learn to negotiate.

Organisational factors such as high staff turnover, large numbers of casual staff and inflexible routines all impact the quality of staff-family relationships.

The active promotion of psychosocial engagement will encourage more collaborative partnerships, says Bauer. The foundation of a constructive relationship is the development of familiarity and trust. Staff were just as likely to expect compassion and understanding to be reciprocated from families in a shared empathy.

While these characteristics were highly valued by both family and staff, interactions are complex and conflict is inevitable in highly emotional environments.

“Even when these factors were present there was the undeniable finding that sometimes staff and family are simply unable to get along,” says the review.

Current evidence suggests involving multidisciplinary teams in collaboration with families is most successful.

The benefits of increased collaboration is an under-researched area and further trials are needed to understand how collaboration can best be utilised to promote resident wellbeing.

Bauer and co-authors Emily Haesler and Rhonda Nay recently published their review in the International Journal of evidence-based healthcare.

Most important factors for constructive staff family relationships

1. Openness to sharing personal information about the resident.

2. Good communication and having documented processes of interaction. including clear expectations, set goals and responsibilities.

3. Effective initial orientation and providing ongoing feedback to families.

4. A sense of familiarity, trust and mutual respect.

5. Reciprocated recognition of their role in care.

6. Collaborative partnerships involving a multi-disciplinary team of professionals

7. Respect for the wishes of residents regarding family involvement in care.