Education for Support of Nursing Home Residents

While Extension doesn't provide direct services to elderly nursing home residents, Extension can play a significant role in educating family members and facility caregivers about how to support and interact with those they care for. Each year a growing segment of the elderly population is faced with chronic physical and mental impairments that leave them unable to care for themselves. Over one million individuals currently reside in long-term care facilities. Estimates project an increase to two million by the year 2000.1

Family members of these individuals, many of whom once aided the elderly in maintaining their independence in the community, have now turned to nursing home care as a necessary alternative. The severity of the elderly's condition and/or the depletion of the caregiver's physical, emotional, or financial resources can make home-based care very stressful and burdensome.2 When family members are no longer able to care for frail elderly at home, their desire to remain part of the elderly person's life continues. Family members want to know what services facilities provide, how they can relate to these services, and ways to continue a relationship with their loved one in an institutional setting.3 Extension can provide education on these issues.

A primary goal for long-term care facilities in recent years has been to improve the quality of care by integrating attention to the residents' physical health and safety with a psychosocial focus on quality of life.4 While National Initiatives such as the Nursing Home Reform Act, part of the 1988 Omnibus Act (OBRA), try to strengthen care facilities' ability to provide quality health care, a need exists for comprehensive training of staff and family members in other areas that could lead to improving the resident's quality of life. Such training should aim to increase residents' personal satisfaction, enhance self-concept, and maintain positive interaction with others. It's the facility staff's attitude when interacting with the elderly that can make a difference and is the aspect of care that residents value most.5

Family and facility caregivers can work together to improve the elderly resident's quality of life in the nursing home setting. Both caregiver groups need a greater understanding of the elderly and more effective interaction skills to use with this group. Education for understanding and skills development is being provided by Extension home economics in Atlantic County, New Jersey.

The initial step in developing a program for the two caregiver groups was the establishment of an ad hoc advisory council. Representatives from area long-term care facilities as well as county and state agencies constituted the seven-member council. Through council support, the target audiences' educational needs and program delivery methods were established. Group interaction, together with a review of the literature, resulted in the development of the "Understanding and Interacting with the Elderly in a Long-Term Care Facility" program objectives:

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1. Identify the physical, mental, social, and spiritual needs and changes of the institutionalized elderly.
   
2. Understand the relocation adjustment period as it affects the elderly and family members.
   
3. Use effective communication techniques with the elderly. Choose activities that address residents' needs.

Objectives particular to the family caregiver included:

1. Increase knowledge of the long-term care facilities' services and responsibilities.
   
2. Become more comfortable in the long-term care facility setting.

Grants were essential in the development of the project's instructional tools. Funds for this project were provided through the Home Economics Department, Rutgers Cooperative Extension, and a Rutgers Cooperative Extension Junior Faculty Grant. To meet objectives for the two target audiences, a set of five publications, a 47-minute videotape, and a curriculum manual were developed as program components. Five publications, each two to four pages long, addressed such issues as the needs and changes of the elderly, care facility services and responsibilities, the relocation adjustment period, communication, and activities. The video, which was designed to be used in a classroom setting or viewed individually, explores these topics in greater detail. The curriculum manual includes a section on program use and provides seven discussion guides and corresponding evaluations.6

Eight of the 11 area long-term care facility administrators answered letters about the program. Two of these facilities were asked to host a variety of program pilot tests. At each of the eight facilities, a group meeting was arranged with the social services director, nursing director, and facility administrator. At the meetings, facility directors offered input concerning program delivery methods that would best meet their needs. Delivery methods included: inservice for staff and volunteers, distribution of publications to family caregivers, and development of family support groups.

Staff inservice has been offered in various forms. The most prevalent has been four one-hour classes on consecutive weeks. Other facilities have elected to offer certain sections of the four-part series on a monthly basis. The video, discussion guides, and three of the five publications were used as teaching tools in this instance.

Publications have been distributed during resident intake or family orientation procedure by social work staff. Several facilities have elected to mail the publications' advertisement to their clientele's family members. Each nursing home received a copy of the videotape and has been encouraged to make the presentation available to family caregivers. In addition to distributing the publications through nursing homes, the Medicaid section of the Atlantic County Division of Welfare also distributed the publications' advertisement to all individuals applying for nursing home related Medicare benefits.

The development of a family support group has been the most satisfying program outreach experience. Support groups are designed so education, training, and support are all components of group meetings. Meetings every other month focus on one of the program's topics.

Through extensive interaction with care facilities, the following points have been crucial to the success of the project:

1. Communication. Facility crisis situations, staff turnover, and poor interdepartmental communication can undermine the project's success. A detailed follow-up on facility responsibilities is essential.
   
2. Attendance. Requesting that inservice be a requirement for staff has increased attendance. A certificate of completion awarded to those attending all four sessions has been one effective incentive of the course.

The program has been evaluated considering three factors: knowledge gain, attitude change, and behavior change. Of the 331 who either attended inservice, received written material, or attended support group meetings, 242 returned the post evaluation. Individual distribution of evaluations at facilities and follow-up cards to those obtaining information through the mail were methods used to increase the response rate. Participants were asked to indicate, on a Likert-type scale, the extent to which new information was gained. On a four-section scale of "very much," "some," "a little," and "none," 76% indicated they'd learned "very much," while 24% indicated they'd learned "some."

Behavior changes were recorded by 94% of respondents in one or more of the following areas: improved sensitivity to needs and changes of institutionalized elderly, improved quality of visits, promotion of interaction with the elderly, and planned creative activities. A brief summary of program results indicated that participants helped the elderly compensate for visual impairment (42%), engaged in a planned activity with a resident (66%), and encouraged elderly to interact with others (53%). Sixty-five percent of those responding to the evaluation felt more confident when interacting with residents. Communication was promoted by using the active listening technique (66%) and speaking in a lower pitched voice (63%).

Attitudes of both target audiences changed as a result of the program. Fifty-five percent of the participants felt more confident about providing high quality interaction. Over 80% of facility staff indicated that their attitude toward the institutionalized elderly was more positive and 57% felt their attitude toward family members had changed.

Extension can have a critical and significant role in educating family and facility caregivers. Although Extension provides limited direct services to elderly nursing home residents, skills used and attitudes changed as a result of caregiver education benefit all those involved in institutional life, including the elderly resident.

1. U.S., Senate Special Committee on Aging, Aging America (Washington, D.C.: U.S., Department of Health and Human Services, 1988), pp. 118-20.

2. R. A. Pearlman and M. Ryan-Dykes, "The Vulnerable Elderly," Journal of Gerontological Nursing, XXII (No. 9, 1986), 14-18; F. Beland, "The Decision of Elderly Persons to Leave Their Homes," The Gerontologist, XXIV (Spring 1984), 179-85; R. Morycz, "Caregiving Strain and the Desire to Institutionalize Family Members with Alzheimer's Disease," Research on Aging, VII (Fall 1985), 329-61; and Clara Pratt and others, "The Forgotten Client," in Aging, Health, and Family: Long-Term Care, Timothy H. Brubaker, ed. (Newbury Park, California: Sage Publications, 1987), pp. 197-213.

3. Sandra P. Hirst and Barbara J. Metcalf, "Learning the Needs of Caregivers," Journal of Gerontological Nursing, XXII (No. 4, 1986), 24-28; Kristen F. Smith and Vern L. Bengton, "Positive Consequences of Institutionalization: Solidarity Between Elderly Parents and Their Middle-Aged Children," The Gerontologist, XIX (No. 5, 1979), 438-47; and Jonathan L. York and Robert J. Calsyn, "Family Involvement in Nursing Homes," The Gerontologist, XVII (No. 6, 1977), 500-505.

4. Anne P. Gallagher, "A Model for Change in Long-Term Care," Journal of Gerontological Nursing, XII (No. 5, 1986), 19-23.

5. National Citizen's Coalition for Nursing Home Reform, A Consumer Perspective on Quality Care: The Residents Point of View (Washington, D.C.: National Citizens Coalition for Nursing Home Reform, 1985).

6. To obtain information about the "Understanding and Interacting with the Elderly in a Long-Term Care Facility" program packet, contact Anne-Michelle Marsden, Rutgers Cooperative Extension of Atlantic County, 1200 West Harding Highway, Mays Landing, New Jersey 08330.