Effectiveness of interventions to improve family-staff relationships in the care of people with dementia in residential aged care: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The objective of this review is to identify and appraise existing evidence regarding the effectiveness of interventions designed to enhance staff-family relationships for people with dementia living in residential aged care facilities.More specifically, the objectives are to identify the effectiveness of constructive communication, cooperation programs, and practices or strategies to enhance family-staff relationships. The effectiveness of these interventions will be measured by comparing the intervention to no intervention, comparing one intervention with another, or comparing pre- and post-interventions.Specifically the review question is: What are the most effective interventions for improving communication and cooperation to enhance family-staff relationships in residential aged care facilities?

BACKGROUND: In our aging world, dementia is prevalent and is a serious health concern affecting approximately 35.6 million people worldwide. This figure is expected to increase two-fold by 2030 and three-fold by 2050. Although younger-onset dementia is increasingly recognized, dementia is most commonly a disease that affects the elderly. Among those aged 65 to 85, the prevalence of dementia increases exponentially, and doubles with every five-year increase in age.Dementia is defined as a syndrome, commonly chronic or progressive in nature, and caused by a range of brain disorders that affect memory, thinking and the ability to perform activities of daily living. While the rate of progression and manifestation of decline differs, all cases of dementia share a similar trajectory of decline. The progressive decline in cognitive functions and ultimately physical function that these people face affects not only the person with the disease but also their family caregivers and health care staff.The manifestation of dementia presents unique and extreme challenges for the family caregiver. Generally it causes great physical, emotional and social strain because the caregiving process is long in duration, unfamiliar, unpredictable and ambiguous. In the later stages of dementia, many family caregivers relocate their relative to a residential aged care facility, most often when the burden of care outweighs the means of the caregiver. This is especially likely when the person with dementia ages, and has lower cognitive function increased limitations in activities in daily living and poorer self-related health. As a result, approximately 50% of all persons aged 65 years or over admitted into residential aged care facilities have dementia.The relocation of a relative into a residential aged care facility can be complex and distressing for family caregivers. While relocation alleviates many issues for the family caregiver, it does not consequently reduce their stress. The stress experienced by the family caregivers who remain involved post-relocation often continues and may even worsen. This is because family caregivers are uncertain about how to transition from a direct caregiving role to a more indirect, supportive interpersonal role, and may be provided with little support from care staff in this regard. Although family caregivers experience a new form of stress post-relocation, family involvement in residential aged care settings has been shown to be beneficial to residents with dementia, their families and care staff.Family involvement is widely acknowledged to provide the resident physical and emotional healing, optimal well-being, and the sustainment of quality of life. Family caregivers benefit from improved satisfaction with the facility and experiences of care, and greater well-being. Care staff benefit from enhanced job satisfaction and greater motivation to remain in their job. The key to these positive outcomes is effective communication and strong relationships between care staff and family caregivers.Effective communication between care staff and family caregivers is crucial for residents with dementia. This is because residents with cognitive impairment may have difficulties articulating their needs, concerns and preferences effectively. Family caregivers rely on staff for information about their relative's behavior in the residential aged care facility; however they themselves have in-depth information about the resident's physical, psychosocial and emotional histories that are necessary for developing individualized care support plans. Family involvement can support care staff in reducing residents' behavioral symptoms by assisting to identify social and emotional needs, or unmet medical needs. Ineffective communication from family caregivers in conveying information to care staff may be disruptive in the caregiving process, and may lead to disagreement regarding respective roles and approaches to caring for the resident. Consequently, family caregivers may withhold information that may support care staff and improve care. They may also be concerned about negative repercussions for the resident.Care staff and family caregivers generally have differing needs and expectations. Care staff are usually in the position where they have to manage a relationship with the family, which is based on multiple roles. Perceptions of family caregivers by care staff include seeing them as colleagues, subordinates, or people who themselves may be in need of nursing care. These different perceptions lead to role ambiguity and result in separate approaches to the caregiving process.Cohen et al. suggest in their study that family involvement can benefit people with dementia in residential aged care settings, their family carers and staff; however further research is required. The relationship between care staff and family caregivers is often challenging due to problems with communication, role ambiguity of both care staff and family carers, and differing approaches to caring for the resident. These problems highlight the need for interventions to constructively enhance the quality of family-staff relationships. For example, one intervention called Partners and Caregiving has been reported as being designed to increase cooperation and effective communication between staff and family. In this study, staff and family members were randomly subjected to treatment and control conditions. The treatment group received parallel training sessions on communication and conflict resolution techniques, followed by a joint meeting with the facility administrators. The results of the study demonstrated improved outcomes in the form of improved attitudes of staff and family members towards each other, less conflict between family and staff, and fewer intentions of staff to quit. Further research is vital in order to identify effective family-staff intervention studies that can provide directions for implementation in residential aged care facilities. Furthermore, it is equally important to identify interventions that are ineffective, so as to provide insights into potential pitfalls to avoid in order to improve staff and family members' relationships and the provision of care to people living with dementia in the future.Previous systematic reviews have focused on factors associated with constructive family-staff relationships in caring for older adults in the institutional setting and the family's involvement in decision making for people with dementia in residential aged care facilites. This review will however specifically investigate interventions for improving communication and cooperation that promote effective family-staff relationships when caring for people with dementia living in residential aged care facilities.