hr. J. Nurs. Stud., Vol. 29, No. 1, pp. 49-57, 1992. 0020-7489/92 SS.OO+O.

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Printed in Great Britain. 0 1992 Pergamon Press plc

Family-focused nursing care of

hospitalized elderly
JO ANN H. COLLIER, Ph.D., R.N.
Associate Professor of Nursing,
College of Nursing,
University of Akron,
Akron, OH 44325-3 701,
U.S.A.

VICTORIA SCHIRM, Ph.D., R.N.

Associate Professor of Nursing,
College of Nursing,
University of Akron,
Akron, OH 44325-3701,
U.S.A.

Abstract-The purposes of this research were to gain an understanding of how

nurses in acute care settings involve families of elderly patients in planning and
giving care, and to determine the extent of that involvement in nursing
documentation. Data were obtained from patient records and interviews with
nurses. Evaluated were characteristics of elderly patients and families,
documentation of family involvement in care, and nurses’ descriptions of family
care. A comparison of data sources indicated that nurses verbalized far more
inclusion of families in care than the written records documented. Results of
this research support the importance of clarifying and promoting acute care-
nurses’ involvement of family members who are central to the care of increasing
numbers of elderly persons.

Introduction
Family-focused care has long been espoused by professional nurses in all specialty groups
(Miller and Janosik, 1980; Clements and Roberts, 1983; Friedman, 1986). The increasing
emphasis on the family in nursing education, practice and research was recently examined
by Wright and Leahey (1990), who found that family related content and associated
assessment methods were common in undergraduate curricula in both the U.S.A.
and Canada. At the graduate level, however, a focus on family was primarily seen in family
nursing specialty programs and specialties aimed at nursing of childbearing or childrearing
49
50 J. A. H. COLLIER AND V. SCHIRM

families. Wright and Leahey also found that clinical practice settings where students learned,
tended to treat families as part of the context of individual clients.
Wright and Leahey (1990) found that nursing research focusing on families was increasing.
However, studies examining clinical nursing practice using a family focus are still few and
they are generally concentrated in the area of families with children (Gilliss el al., 1989).
Gonzalez et al. (1989) recently noted a “near vacuum in the clinical literature describing
interventions for families coping with serious chronic illnesses and disabilities” (p. 69).
Care of the chronically ill has been and is a responsibility of the family (Strauss and Corbin,
1988). Given the aging of the population and the concomitant increase in the prevalence
of chronic illness, policy makers are likely to remain reluctant to reduce familial
responsibility.
The financial, physical and social burdens placed on families who provide care to their
elderly members are well documented (Schirm, 1990). In many families, assuming
responsibility for an elderly relative begins gradually and continues over an extended period
of time. In some cases, however, hospitalization of the elderly person marks the beginning
of a family’s entry into the caregiving role, or brings a precipitous need for more intense
family involvement in the elderly person’s care. Consequently, an acute illness or an
exacerbation of chronic problems requiring hospitalization can have a significant impact
on older persons and their families.
Nurses as major caregivers in the acute care setting are in a unique position to use
hospitalization as a point of access to families of older persons. Effective nursing care during
the older person’s hospital stay can enhance family caregiving resources, increase families’
informal caregiving skills and, thus, facilitate transition to the home environment.
The recent decreases in hospital stays make it even more imperative to understand how
family members can be assisted in their caregiving efforts, since as Lave (1989) indicated,
decreased hospital stays have shifted hospital care to home care. Short hospital stays
ultimately mean that informal carers, usually family and friends, provide the care formerly
provided by the acute care setting. Clearly, if hospital care is to be effective for aged persons
who return home, there is a compelling need to identify ways in which nurses in acute
care settings can promote the caregiving efforts of families. Empirical studies of family-
focused nursing care to hospitalized elderly persons have not, however, been reported.
This study was designed to gain an understanding of how nurses in acute care settings
involve families of elderly patients in planning and giving care, and to determine the extent
of that involvement in nursing documentation.

Methods
Setting and sample
Data were obtained from patient records and interviews with nurses at two large acute
care hospitals serving a metropolitan area in the Midwestern United States. Both hospitals
are teaching institutions offering a fuil range of medical and surgical services to acutely
ill adults. They report that 50 to 60 per cent of their average caseload is 65 years of age
or older.
Patients whose records were included in the study met the following criteria: (a) age 65
years or older, and (b) discharged alive in the first half of 1988. Random sampling was
used to generate a list of 100 patient records at each hospital. An effort was made to over-
represent the very old in these limits because of their rapidly increasing numbers and the
paucity of reported research on this age group.
 FAMILY-FOCUSED NURSING CARE 51

Sixty nurses, 30 from each hospital, were interviewed. Selection criteria included licensure
as a registered nurse and participation in employee orientation at the study hospitals prior
to March 1988. A list of nurses employed on units routinely caring for elderly patients
was obtained from nursing administration at each hospital. Letters of invitation to participate
in the study were sent to one-third more than the desired number of nurses. Those who
responded were contacted by a member of the research team for an interview.
No attempt was made to link individual patient records to care given by the nurses
interviewed. The record review was retrospective and occurred during the fall of 1988. The
nurse interviews were conducted between November 1988 and February 1989. Procedures
for the protection of human subjects were approved by the Institutional Review Board
(IRB) at the researchers’ academic setting and respective IRBs at the cooperating agencies.

Study variables and their measurement

Characteristics of elderly patients and families. Numerous studies have pointed to
characteristics of elderly patients that should alert professionals to the care needed post-
hospitalization (Inui et al., 1981; Munoz and Mesick, 1979); outcomes that are predictive
of nursing home placement (Robertson and Rockwood, 1982; Wachtel et al., 1984); and
factors that contribute to untimely hospital readmissions (Gooding and Jette, 1985). Using
these studies as a basis for determining variables of interest, a chart review form was
developed to collect data on patients’ age, sex, race, length of stay, insurance coverage,
illness conditions, source of admission, discharge destination, and in-hospital and home
health care referrals. Data collected on family characteristics included marital status, living
arrangements, and nurse-identified family caregiver.
Each of five investigators conducted chart reviews and assigned codes on 40 records.
The coding system mirrored the codes used by the hospitals and the order of presentation
within the chart to minimize errors. The records of the two hospitals were quite similar.
Documentation of family involvement in care. A measure evaluating nurses’
documentation of the involvement of family members in caregiving of elderly patients was
developed for this investigation, on the basis of the Standards of Gerontological Nursing
Practice promulgated by the American Nurses’ Association (ANA, 1987). Statements of
outcome criteria were adapted from the Gerontological Standards for the chart audit
measure, which consisted of 16 criteria (these are listed in Table 1 in abbreviated form).
Content validity of the criteria was determined by two nurses with expertise in gerontological
nursing. Additionally, a quality assurance nurse from each hospital reviewed the audit form
for clarity.
Documentation was reviewed in six sections of the patients’ records to determine the
extent to which nurses had involved the family in planning and giving care. The six sections
were: admission assessment, first 24-hour nursing notes, interim nursing notes, nursing
care plan, discharge summary, and medical progress notes. Each criterion was rated as
being met, partially met, or not met. The chart audits were conducted by the five
investigators. The criteria were pretested in the two hospitals to obtain consensus on the
rating process. Three investigators independently rated the same records at each hospital
until consensus was achieved. This process required the review of four records at one
hospital, and the review of three records at the other hospital.
Nurses’ descriptions of family involvement in care. A semi-structured interview protocol
was used to determine how nurses perceived they involved families in care of hospitalized
elders. The interview consisted of 11 sequential questions based on selected categories of
52 J. A. H. COLLIER AND V. SCHIRM

care in the Standards of Gerontological Nursing Practice (ANA, 1987). Questions were open-
ended and broader in focus than the outcome criteria in the chart audit. The content validity
of the questions was determined by the same gerontological nurse specialists who reviewed
the chart audit criteria. Because of time constraints in the work setting, a 1% to 20-minute
interview length was established. The interview schedule was pretested with registered nurse
students enrolled in a baccalaureate nursing program.
Interviews were conducted either at the worksite or at another convenient location,
according to the preference of the nurse. Most interviews were conducted in the hospital
during the scheduled shift or at the conclusion of the shift. Each of the five researchers
conducted 12 interviews.

Findings

Characteristics of elderly patients

Two records from the 200 selected were excluded because the data were unusable. The
analysis was done on 198 records. Twenty-nine per cent of the sample were 65 to 74 years
old, 30% were 75 to 84 years old, and 41% were 85 years old and over. The average age
was 80 years, with a median of 81 years. Fifty-six per cent were female and 44% male.
Seventy-nine per cent were white; the remaining subjects were either non-white, or race
was not specified on the record. All but eight persons were covered by Medicare; only 17
persons had Medicaid. About 73% had additional private insurance. A second private
insurance carrier was identified on seven records.
The majority of subjects were widowed (53%); 36% were married, 8% were not married
and, for 3%, marital status data were not available. Some 33% of the subjects lived alone.
Almost 29% lived with a spouse only; 38% fell into the “other” category, which meant
that they either lived with relatives or friends (sometimes in conjunction with their spouse),
or the living situation was not identified. Most of these elderly persons were admitted from
their home (80.3%) and eventually returned there (75.3%).
In 22% of the cases, the nurse identified on the record that a spouse was the caregiver
to the hospitalized person, while about 18% of the time a child was identified as the
caregiver. Siblings, other relatives, or friends were identified as caregivers for 23% of the
elderly. On 37% of the records no caregiver was identified by the nurse.
In-hospital referrals were made most often to social services (5607o),followed by physicians
(55Vo), dietitians (30%), and physical therapists (17%). The mean number of in-hospital
referrals for all services was 1.9, with a range of 0 to 7. Even though a large number of
the elderly persons were discharged to home, in only about 23% of the cases were referrals
made for home health services. Nursing was the most frequent type of home service
requested.
Illness conditions were classified according to the International Classification of Diseases
(9th Revision) and Diagnosis Related Groups (DRG). A wide range of diagnoses was
reported with both classification systems. An average of five medical diagnoses per patient
were reported. The most common principal medical diagnosis was pneumonia (n = 16).
The next most frequent principal diagnoses were congestive heart failure (n = 11) and
coronary atherosclerosis (n = 8). Heart failure and shock (n = 14), followed by pneumonia
with complications (n = 11) were the most frequent DRG categories. Length of stay varied
widely, from 2 to 111 days. Excluding three patients who stayed more than 70 days, the
mean hospital stay was 10.1 days, and the median was 8 days.
 FAMILY-FOCUSED NURSING CARE 53

Using Pearson’s Correlation Coefficient, a positive relationship was found between the
number of medical diagnoses and age (r= 0.14, P= 0.05) and length of stay (r= 0.39,
P=O.OOOl). Age was also significantly associated with marital status (x2 = 23.6, df=4,
PC 0.001) and type of living arrangement (x2 = 22.53, df =4, P< 0.001). The very old
tended to be widowed and, if not living alone, to live with children, other relatives, or
in a nursing home.
Chi-square analysis indicated that persons entering the hospital from home were likely
to return there. Also, persons living alone or with only their spouse at admission tended
to return home. Those admitted from institutions were likely to return to a similar setting
(x2 = 52.58, df= 1, P< 0.001).
Family involvement in care
The patient records showed few instances where criteria for family involvement in care
were even partially met. Therefore, responses of met and partially met were combined for
the analysis. The criteria and the six parts of the patient records used to assess documented
family involvement are given in Table 1. The percentages shown are the proportion of
criteria evaluated as met or partially met.
Table 1. Percentages of met/partially met audit criteria by section of record (n = 198)

Section of record

Admission 1st 24br Interim Medical

nursing nursing nursing Nursing Discharge progress
Abbreviated criteria notes notes notes care plan plan notes

1. Family members participate in

data collection 11.6 1.6 9.6 5.6 7.6 25.8
2. Health status info shared with
family 5.1 8.1 17.1 6.6 15.7 24.2
3. Nursing diagnoses shared with
family 4.0 4.5 6.6 6.1 5.1
4. Affirmation of diagnosis
sought 4.0 4.0 5.6 4.5 4.0 -
5. Elder, family and health team
participate in planning 3.0 2.5 13.1 9.1 17.7 33.3
6. Care plan initiated in 24 hours - - - 59.6% -
I. Care plan accompanies patient
at discharge - - - 62.1’ -
8. Family involved in discharge
planning 2.0 2.5 12.1 3.5 21.7 22.2
9. Family encouraged to promote
elder’s self-care 2.5 3.0 9.1 4.5 7.6 9.6
10. Family encouraged to give
additional care 2.5 3.5 2.5 4.5 7.6 10.6
11. Nursing interventions clearly
documented 54.0 73.1 81.3 48.5 52.5 -
12. Responses of elders and family
documented 13.6 26.3 48.0 19.2 24.2
13. Elder and family show
understanding of aging/health
care needs 1.0 4.5 18.7 17.7 23.7
14. Nurse, patient and family revise
priorities 2.0 2.0 10.1 6.1 5.6 -
15. Nurse, patient and family revise
goals 1.5 1.5 6.6 8.6 5.6 -
16. Nurse, patient and family
revise interventions 2.5 3.5 19.2 10.1 8.6 -

*Yes/no response option.

54 J. A. H. COLLIER AND V. SCHIRM

The medical progress notes contained the most information about family involvement
in the care of hospitalized elders. However, the medical progress notes were an appropriate
source for data on family involvement on only six of the 16 criteria. Even for these six
criteria where documentation would be expected, at most only one-third of the progress
notes contained information on the inclusion of family as a participant in care. Yet, these
notes provided far more information about how the family was involved compared to the
other data sources (nursing admission assessment, first 24-hour nursing notes, interim nurses
notes, care plans, and discharge summaries).
Family participation in data collection was documented infrequently by nurses. Likewise,
sharing information with family members about the elderly persons’ health status or nursing
diagnoses was not generally part of the nursing record.
In the majority of cases (60%), the nursing plan of care was initiated in the first 24 hours
after admission, and a care plan accompanied 62% of the elderly persons upon discharge.
Having a care plan initiated within 24 hours of admission was significantly associated with
having a care plan accompany the person at discharge (x2 = 14.12, df = 1, P c 0.001).
Documentation of nursing care was found primarily on the interim nursing notes.
Documentation about the patient’s response to care was sparse, and emphasis was on the
patient’s reaction to medications or treatments. Family responses were rarely noted.

Nurses’ descriptions of family involvement

When nurses were asked how they involved family members in care of hospitalized elderly,
they gave diverse examples which included inviting the spouse of a patient to give physically
intimate care, telling family members to telephone during the night if they were concerned,
and requesting food from home to bolster appetite. Discharge planning and assessment
of homegoing needs were also frequently mentioned as ways nurses involved families. The
responses conveyed themes of evaluation and communication. Nurses indicated that
interactions with families were aimed at evaluating present and future abilities as caregivers
as well as assessing family needs. Communication was evident in nurses’ descriptions of
keeping family members aware of what was going on, teaching about care provided,
preparing for home care, and answering questions.
Nurses were asked to identify what differences, if any, in their involvement of the family
could be attributed to the medical diagnosis, patient characteristics, or family characteristics.
While specific diagnoses were identified, most nurses placed greater emphasis on the elderly
person’s functioning and the seriousness of the illness as factors influencing their tendency
to involve families.
When asked to identify the kinds of families they did not involve in care of an elderly
patient, nurses mentioned two types: families who were unwilling or undesirable caregivers,
and families who were willing caregivers but were unavailable or incapable. Examples of
undesirable families included those with abusive or alcoholic members, families who were
chaotic or could not get along, and families who wanted the elderly member placed in a
long-term care facility. The nurses’ responses suggested that these family types clearly
demonstrated a lack of willingness to be involved. Families described as willing but unable
to be caregivers included those living outside the geographic area, and those with excessive
work and family responsibilities. In discussing these families, nurses frequently mentioned
problems with transportation and an elderly spouse’s ill health.
When asked to describe specific situations where the nurses’ inclusion of a family
member improved care of the elderly patient, numerous and diverse examples were given.
 FAMILY-FOCUSED NURSING CARE 55

Family assistance with physical care and monitoring the timeliness of procedures were
frequently cited. The family’s presence with the patient was mentioned as having a helpful
calming effect.
When asked if they sought out family members for answers to health-related assessment
questions, over one-third of the nurses responded “yes”. Nurses made it clear, however,
that the patient was viewed as the primary source of information. Physical incapacitation
or impaired cognitive abilities were frequently cited reasons for turning to family members
for information.
When health status information was shared with family members, nurses indicated that
it was the family who generally initiated the interaction. Information such as condition
or health status reports, progress of procedures, and information related to preparation
for discharge were frequently shared. In discussing the kinds of information they gave to
families, several nurses identified territorial issues with physicians. “If it’s information
the physician wants the patient to know”, “Must take care not to preempt the doctor”,
or “Will not share diagnostic test results with the patient”, were some typical responses.
Nurses were asked if the written record would accurately reflect their involvement with
family members of the patient. Of the 60 nurses, 29 said “no”, 10 said “yes”, and the
remainder gave equivocal responses. When asked where one could look in the record for
documentation of family involvement, areas mentioned as most appropriate were: admission
assessments, daily notes, care plans, and discharge summaries. Nurses attributed this lack
of documentation of family-focused practice to not having enough time, and the necessity
of documenting the patient’s condition in the record. As one nurse said, “getting it done
is more important than writing about it”. Nurses also said that the legal or liability concerns
of routine practice mandated a focus on individual patients and their medical condition.

Discussion
The nurses’ responses to the interview questions indicate that more detailed and diverse
interactions occurred between nurses and family members of hospitalized elderly than the
charts described. Data from interviews suggest that nurses are including families in care
of the hospitalized elderly. The extent of this involvement is unclear, however. Written
records showed very low percentages of family involvement in almost all categories of care
assessed; while the self-report interview data probably give an overly optimistic view. It
seems reasonable to assume that the written record understates the extent of family-focused
nursing practice. At the same time the interviews, while providing rich detail, do not yield
quantitative estimates of the extent of nurses’ involvement of families. The extent of family-
focused nursing practice with hospitalized elderly cannot be established using written
records; and yet, there is compelling evidence that families are included in care.
The greatest involvement of the family occurred in skills training to meet needs at home.
Additionally, there was an emphasis in both the chart audit and the nurse interviews on
discharge planning, either for home-going or transfer to another institutional environment.
However, most activity related to discharge was noted just prior to the discharge. Given
the characteristics of this patient population-the number of medical diagnoses, the presence
of numerous chronic conditions with acute illness superimposed, and the high incidence
of discharge to the home-greater attention should be given to earlier discharge planning.
Social workers provided the most detailed accounts of interactions with families in the
medical progress notes section of the patient records. However, this was most often done
56 J. A. H. COLLIER AND V. SCHIRM

in relation to transfer to a long-term care facility. Three-quarters of the elderly in this study
were discharged to home. Yet, neither institutions’ records included any format or evidence
of systematic evaluation of resources in the home environment. Further, neither hospital
included an assessment of functional capabilities as a routine part of nursing care, though
the assessment of, and interventions related to, functional capability are well established and
are described in the nursing literature on care of the elderly (Lekan-Rutledge, 1988; Miller,
1990). Of note is that functional assessments of elderly patients have been incorporated
in routine care at the study hospitals since completion of this investigation.
Beliefs about the role of the family in providing emotional and instrumental support
were apparent in the nurse interviews. Yet, there was no mention of a family caregiver
on 37% of the records in the nursing sections of the chart. There was also no agreed-upon
language or system of assessing families. Nurses used terminology to talk about assessment
categories and care planning that focused on the individual patient and physical condition.
These findings suggest that the elderly patient is considered the unit of care in the acute
care setting. Although this situation is not inappropriate, there is an urgent need to broaden
the conception of the family role in the acute care setting and to build a better bridge to
the family who manages illness care in the home. As Strauss and Corbin (1988) pointed
out, the family is central to chronic illness management.
Responses of nurses show dividend opinions as to whether the forms in use invited, or
even permitted, notation of family involvement. This finding is especially troublesome in
light of the widespread use of written records as indicators of practice in utilization review
and quality assurance. We questioned staff development instructors about orientation to
institutional charting protocols and were assured that family-focused practice was to be
documented in the record. Clearly, there is a crucial need to promote documentation of
the actual implementation of family-focused care which is an integral part of the standards
of professional gerontological nursing practice.
Contemporary discussions of the ethical dimensions of nursing practice focus on the
paradox of individually-focused care embedded in a relational context of caring (Davis,
1990). This seems to parallel some of our findings about family-focused nursing. The lack
of consensus among nurses about a language to describe families and their relationships
to the patient and health problems, the questions about appropriateness of viewing family
as client, and the references to liability issues related to documentation suggest that continued
efforts to refine our understanding of family-focused nursing are appropriate. Families
are increasingly being called upon to manage more and more care for chronically ill elderly
relatives and they will be well served by further work to clarify family-focused nursing.

Acknowledgements-This study was funded by an Ohio Board of Regents’ Research Challenge Grant Number
OBRS-3400. The authors acknowledge the contributions of Drs V. Ruth Gray, A. Jeanne Hoffer, and Sandra
A. Jones to the project.

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(Received 8 February 1991; accepted for publication 19 September 1991)