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Family and Social Work Roles inthe Long-Term Care FacilityStephanie S. Malench MSW, PLSW aa Social Services , Life Care Center of Bridgeton ,USAPublished online: 24 Sep 2008.

To cite this article: Stephanie S. Malench MSW, PLSW (2004) Family and Social WorkRoles in the Long-Term Care Facility, Journal of Gerontological Social Work, 43:1,49-60, DOI: 10.1300/J083v43n01_05

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Family and Social Work Rolesin the Long-Term Care Facility

Stephanie S. Malench, MSW, PLSW

ABSTRACT. The purpose of this article is to explore current practiceregarding family involvement in long-term care facilities and the rolesocial workers play in these facilities. Questionnaires were receivedfrom 87 long-term care facilities surveyed throughout the Midwest.Family members can provide the long-term care center with an invalu-able resource while assisting the resident with adaptation to this new lifephase. Only 36% of facilities employ a qualified social worker as de-fined by NASW. Future research needs to be aimed at educating ownersand directors of long-term care facilities of the importance of recruitingand retaining qualified, degreed social workers to care for the residentsand families. [Article copies available for a fee from The Haworth Document Deliv-ery Service: 1-800-HAWORTH. E-mail address: <docdelivery@haworthpress.com>Website: <http://www.HaworthPress.com> © 2004 by The Haworth Press, Inc. Allrights reserved.]

KEYWORDS. NASW Standards for Social Work Services in Long-TermCare Facilities, continuum of family roles, long-term care facility, familyinvolvement, qualified social workers

Stephanie S. Malench was Director of Social Services at Life Care Center ofBridgeton and received her Masters in Social Work from Saint Louis University.

Address correspondence to: Stephanie S. Malench, c/o Rose Dobrof, BrookdaleCenter on Aging of Hunter College, 425 East 25th Street, 13th Floor North, New York,NY 10013.

The author gives special thanks to Dr. Donald Linhorst for all his help in completingthe statistical analyses.

Journal of Gerontological Social Work, Vol. 43(1) 2004http://www.haworthpress.com/web/JGSW

© 2004 by The Haworth Press, Inc. All rights reserved.Digital Object Identifier: 10.1300/J083v43n01_05 49

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The twenty-first century is going to be the century of the older per-son. By 2030 it is estimated that 5.3 million elderly will be cared for inlong-term care facilities (Caron, 1997). In 1990, 35-45% of those whoturned 65 will live in a nursing home, at least temporarily, before theydie. As social workers who work with the elderly, there is a natural in-clination to include the families of our long-term care residents in pro-gramming and decision-making. The purpose of this article is to explorecurrent practice in long-term care facilities and where we as practicingresearchers can go from here. This article expands upon the gapspointed out by Janzen (2001) in his review of the literature on family in-volvement from the perspective of facility policies and staff attitudes.

Family and staff roles must be clearly defined in order for the olderperson to be successfully cared for in a long-term care facility (Demp-sey and Pruchno, 1993). The ideal role of the family in long-term care is“to facilitate linkages that will assist the dependent resident’s interac-tion with the nursing home bureaucracy and will buffer the effects of thebureaucracy on the resident” (Buckwalter and Hall, 1987, pp. 178-179).This can be accomplished by utilizing family members as a resource forcare planning and some care provision to the resident, as support per-sons and peer counselors for other families, as resource persons andadjunct therapists within the facility, and as community and public rela-tions liaisons. Family members can provide the long-term care centerwith an invaluable resource while assisting the resident with adaptationto this new life phase. When possible, residents as well as familymembers should be included in the care planning process regularly(Buckwalter and Hall, 1987).

In long-term care facilities there is a continuum of four differenttypes of family roles (Caron, 1997). The disengaged family memberdisappears after placement in a facility. They do not visit the resident,attend care conferences or return staff phone calls. A second role is thatof a consultant. The consultant meets and communicates with staff butno longer includes the elder in the family system. A third role is thecompetitive family member who competes with the facility staff to con-trol how care is given. Staff see these family members as complainerswho look for mistakes during each visit. Finally, collaborating familymembers are partners in care and are supportive of staff, interactingwith them positively.

Gwyther (2001) discusses a variety of ways to care for and supportthe family who is dealing with placing a loved one in group care. Sherecommends that all staff become involved in “the subjective experi-ence of families of residents with dementia” (p. 66). This includes ask-

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ing the family what they know about the facility experience, as well asgetting to know the resident and his or her family’s story graduallythroughout the resident’s stay. These stories can be recorded by familymembers in a photo album, scrapbook, life story books, or even creatingvideotapes of old home movies.

A coalition of practitioners, educators, and aging advocates fromacross the state of Missouri have defined the role of the social worker ina long-term care facility as “to enable each individual to function at thehighest possible level of social and emotional wellness” (Perrin andPolowy, 1993, p. 6). Today’s social workers face the challenge of tryingto balance family-based social services with completing the other tasksadministrators expect social workers to complete, including arrangingmedical appointments and transportation, searching for lost items, mov-ing residents and utilities between rooms, and shopping for residents(O’Neill, 2002). Lax enforcement of the 1987 Nursing Home ReformAct contributes to the frustration social workers face in providing high-quality social services to residents and their families.

This study looks at how the family is involved in the long-term carefacility and how social workers facilitate family involvement. Thisstudy also looks at which, if any, characteristics such as social workeron staff, number of services offered, or size, influence family involve-ment.

METHODS

A three-page survey and explanatory cover letter were mailed with aself-addressed stamped envelope to the Director of Social Services at163 long-term care facilities throughout the Midwest, using facility listsfrom the Chicagoland, St. Louis, and Heartland chapters of the Alzhei-mer’s Association. Eighty-three facilities responded, for a response rateof 53.4%. The survey was created to explore if differences exist in fam-ily involvement in a variety of long-term care facilities, including As-sisted Living, Special Care Units, for profit, not for profit, large andsmall. The questionnaire format was a combination of multiple choice,checklists, true/false, and essay (Appendix A). Two staff from the Alz-heimer’s Association of St. Louis previewed and made recommenda-tions regarding the survey.

In calculating results, social worker was defined as having a BSW orMSW. Surveys with BS, BA, Designee, or anything other than Bachelorin Social Work or Masters in Social Work were counted as not having a

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social worker. The Encyclopedia of Social Work entry on long-term care(Garner, 1995) states that qualified social workers are often found in met-ropolitan facilities, with social service designees in rural facilities. TheNASW (1981) Standards for Social Work Services in Long-Term CareFacilities defines qualified social worker:

as a social worker who (1) is a graduate of a master’s degree pro-gram from a school of social work accredited by the Council onSocial Work Education, (2) has had two years of postgraduateexperience in long-term or related programs, and (3) meets equivalentstate certification or licensing requirements for social workers, whenapplicable, or, in jurisdictions not having such legal regulation, is amember of the Academy of Certified Social Workers. (p. 8)

Chi-squares were used to analyze relationships between several keyvariables, including social worker on staff, number of services offered,percentage of residents receiving visitors, number of activities per-formed by family members, size, tax status, availability of weekend ac-tivities, presence of support groups, and distribution of newsletters tofamilies.

RESULTS

Figure 1 shows the number of facilities in which family members as-sist with selected activities. The most common activity was bringinggifts (78), and the least common, feeding others (11).

Only 36% of those responding were qualified social workers: 51.6%of the facilities employing a qualified social worker had a BSW on staffand 58.1% had a MSW on staff. Seven of these hold a social work li-cense (LMSW, LBSW, LCSW). Other advanced training responses in-cluded Masters in Gerontology, Masters in Counseling, Masters inCounseling Psychology, and Masters in Public Health. Sixty percent ofrespondents were employed by for-profit facilities. Table 1 providesmore detailed demographic information from the survey.

The most frequent service available to families in surveyed facilitieswas weekend/evening special activities, with an 80% offering rate.Fifty-eight percent of facilities said they offer family counseling. Theleast frequently offered service was materials for checkout, with only33% of facilities offering families this service. Table 2 shows responsesfor all items listed.

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Because only three of the facilities not employing a BSW or MSW donot offer family related services, a majority of facilities are providingsocial services such as family counseling and support groups withoutproperly trained staff.

Table 3 presents a summary of the results of the chi-squares from var-ious cross-tabulations. Four of the most significant results occurred inthe following pairings: (1) availability of support groups and socialworker on staff; (2) availability of weekend/evening activities with per-

Stephanie S. Malench 53

TABLE 1. Selected Characteristics of Responding Facilities

Characteristics N %

Size5-50 residents51-99100-150151-175176+

Tax StatusFor ProfitNot For ProfitNA

Payment AcceptedMedicareMedicaidPrivate PayLTC Insurance

Social Worker on StaffYes

BSWMSW

No

1413299

22

50361

59738668

31161856

16.315.133.710.325.6

57.541.9

1.1

67.883.998.978.2

36.051.658.164.4

Feed Other (11)Toileting (19)

Assistw/Org.Act.(42)Praying (50)

Reading (53)Attend Rel. Services (54)

Grooming (55)Feeling Loved (56)

Take To and From Activities (60)

Walking (62)Disc. Curr. Events (65)

Disc. Past (66)

Take Trips (68)

Laundry (68)Visit Others (72)

Bring Gifts (78)

0 20 40 60 80 100

FIGURE 1. Activities Performed by Families

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centage of residents receiving visitors; (3) distribution of a newsletterand social worker on staff; and (4) number of services provided by taxstatus.

Support groups/social worker. With alpha equal to .05, a chi-squaretest on these frequencies was statistically significant,χ2 (1, N = 85) =.081, p < .01. Long-term care facilities which employ a social workerare more likely to offer support groups to their family members. Thiscould be related to a prevalence of the ecological systems perspectivetaught in schools of social work compared to other social sciences.

Weekend/evening activities/percentage visitors. With alpha equal to.05, a chi-square test on these frequencies was statistically significant,χ2 (1, N = 85) = .765, p < .01. Facilities with weekend and evening ac-tivities are likely to have a higher percentage of their residents receivingvisitors. Families probably feel more welcomed when activities areplanned around working hours. Activities also eliminate the concernthat family members will not know what to do with their loved ones be-sides sit in the residents’ rooms talking and looking out the window.

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TABLE 2. Services Offered in Facilities

Weekend/Evening Activities 69 (80.2%)

Meeting Rooms 57 (66.3%)

Newsletters 56 (65.1%)

Family Counseling 50 (58.1%)

Support Groups 44 (51.2%)

Materials for Checkout 28 (32.6%)

TABLE 3. Results of Chi-Square Analyses

Categories Asymp.Sig. 2-sided

Support group *Social worker on staff .081

Weekend/evening Activities* %Visited .7645

Newsletters sent *Social worker on staff .069

#Services offered *Tax status .526

%Visited *Social worker on staff .296

#Services offered *Social worker on staff .107

#Services offered *Facility size .009

Social worker on staff* #Activities performed .740

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Newsletter/social worker. With alpha equal to .05, a chi-square teston these frequencies was statistically significant, χ2 (1, N = 85) = .069,p < .01. Facilities employing a social worker are more likely to send anewsletter home to residents’ family members and members of thecommunity.

Of the returned surveys, 49.4% of the essays were completed. Overhalf (52.4%) of the essays contained themes that could be grouped intosix categories: 24-hour a day visiting (7/16.7%), special familyday/nights (5/11.9%), family council meetings (3/7.1%), pets (3/7.1%),intergenerational programs (2/4.8%), and staff “adoptions” (2/4.8%).

Several surveys contained excellent descriptions of innovative waysthey have made their facility family friendly. A Masters’ level socialworker at a 100-150 bed not for profit progressive care facility wrote:

We initiated the Eden Alternative approximately 4 years ago in anattempt to make the nursing home more “home-like.” This intro-duces three new/expanded areas into the home: plants, animalsand children. We own a greyhound who lives on the first floornamed Smiley, a gray cat who also lives on the first floor namedSmokey, an aviary in one dining room, a cockatiel on one of ourdementia units and parakeets in the 2 dayrooms. Families are en-couraged to bring family pets in to visit (as long as they have up-dated shots). This gives visitors something to talk about as well.We have had few complaints about the animals and dander hasnot been a problem.

A 176+ bed for profit skilled nursing facility without a social workerdescribed their innovative program:

All Dept. Heads “Adopt” new residents and are responsible fororienting resident and family to facility and follows resident carethroughout stay in facility. This gives family a “face” to go to w.concerns, problems, compliments and makes both res. and familymore welcome to the facility.

The Masters level social worker at another 176+ bed for profit skillednursing facility explained:

We have Ethics Committee meetings quarterly and have familymembers as representation. We also have resident council meet-ings once a month to discuss family concerns.

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DISCUSSION

This study looked at 163 long-term care facilities to see how familiesare involved in these facilities and what social workers in these facilitiesdo to involve the family.

Families need to be educated when they bring their loved one into along-term care facility about what social services are available to themand what services it is acceptable for family members to assist theirloved one and facility staff in completing. This can be accomplishedwith a “Rights and Responsibilities” table in the admission materials forboth resident and family separate from the Resident’s Rights books pro-vided by corporations and state Ombudsman offices. The admissionmaterials should also include proper grievance procedures should theresidents or their family run into any problems during their time in thelong-term care facility. This should include name and telephone num-bers for department heads, administrators, owners and state hotlines.

There are several limitations to this study. First, family members’opinions were not sought in this study. A separate or parallel study ofjust families in these facilities could yield different information as towhat family members do in long-term care facilities and what servicesthey perceive as being offered. In addition, social work staff may not beaware of everything family members do for their loved one, especiallyon evenings and weekends.

Second, a complete list of possible services was not provided on thesurvey. If the director of social service did not take the time to fill out theessay on the last page, a complete picture of the facility could not be ob-tained. A facility may offer excellent services that are not reflected inthe list alone.

Third, the sample is limited to facilities in the Midwest. Although thesample consisted of urban, suburban, and rural facilities, the entire sam-ple was contained in three states. Different states tend to place differentguidelines on long-term care facilities, such as licensing requirements,staffing rates, and specialized training, which could affect services of-fered and what activities families are allowed to participate in within fa-cilities.

Fourth, respondents were not asked to state the location of their facil-ity (urban, suburban, or rural). Although this could be an entirely differ-ent study, it would be interesting to explore the relationships betweenlocation of facility and services offered, activities performed, socialworker on staff, and visitors. This information would provide a nice ex-

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tension to Garner’s (1995) entry on long-term care in The Encyclopediaof Social Work.

Finally, the question on family-related services asked about what thefacility offers, not the social service department. Services such as news-letters, weekend/evening special activities, and materials for checkoutcould be overseen by the activities department if the facility is largeenough to have two separate departments. Family counseling could bedone by social services, pastoral counseling, or an independent coun-selor that has a contract with the facility.

CONCLUSION

Overall, social workers in long-term care facilities appear to be doinga good job offering a variety of high-quality services to their residentsand families. Care needs to be taken to hire only the most qualified so-cial workers. Other members of the nursing home staff also need to beeducated on the role of the professional social worker.

The lack of trained social workers in long-term care facilities doesimpact the type of support services available to family members. Socialservice designees and other non-social work degreed social service pro-viders are not as likely to have training in the skills needed to provide di-rect services to residents and may not be as knowledgeable aboutresources located in the community.

Just as licensing regulations are enforced for nursing and dietary de-partments in long-term care facilities, the NASW Standards for SocialWork Services in Long-Term Care Facilities (1981) need to be taken se-riously. Therefore, professional social workers working in long-termcare facilities and those who want to work in long-term care must advo-cate for themselves with their employers and state legislators. Masterslevel social workers possess a unique skill set critical to the care of theelderly person as a whole person who is still an integral part of his or herfamily and the family as a system and not as a collection of ill or dam-aged parts.

In light of this research, two actions must be taken immediately.First, owners and directors of long-term care facilities must be educatedon the importance of recruiting and retaining qualified, degreed socialworkers to care for the residents and families. Also, policy advocatesneed to press for an amendment to the 1987 Nursing Home Reform Actto require qualified social workers in all facilities, not just those with120 residents or more.

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Future research needs to focus on why nursing home administratorsdo not feel qualified social workers are a worthwhile investment in theirfacilities. Unless we receive full backing from the federal governmentin educating nursing home administrators of our skills, long-term carefacilities will be staffed by underqualified social service designees, andfamilies and residents will not receive the full set of services they de-serve.

REFERENCES

Buckwalter, K.C., & Hall, G.H. (1987). Families of the institutionalized older adult: Aresource. In T.H. Brubaker (Ed.), Aging, health, and family: Long-term care (pp.176-196). Newbury Park (CA): SAGE Publications.

Caron, W.A. (1997). Family systems and nursing home systems: An ecosystemic per-spective for the systems practitioner. In Hargrave & Hanna (Eds.), The aging fam-ily: New visions in theory, practice, and reality. New York: Brunner/Mazel (pp.235-258).

Garner, J.D. (1995). Long-term care. In The encyclopedia of social work (Vol. 2, pp.1625-1634). Washington, DC: NASW Press.

Gwyther, L.P. (2001). Family caregivers and long-term care: Caring together. Alzhei-mer’s Quarterly, 2 (1) 64-72.

Janzen, W. (2001). Long-term care for older adults: The role of the family. Journal ofGerontological Nursing, February, 36-43.

National Association of Social Workers (1981). Standards for social work practice inlong-term care facilities. Washington, DC: Author.

O’Neill, J.V. (2002, April). Nursing home social workers in doldrums. NASW News.Perrin, N., & Polowy, J. (Eds.). The role of the social worker in the long-term care fa-

cility. Warrensberg, MO: Central Missouri State University.Tobin, S.S. (1987). A structural approach to families. In T.H. Brubaker (Ed.), Aging,

health, and family: Long-term care (pp. 42-55). Newbury Park (CA): SAGE Publi-cations.

RECEIVED: 03/22/02SENT FOR BLIND REVIEW: 03/25/02

ACCEPTED: 08/14/02

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APPENDIX ASurvey–Family Role in the Long-Term Care Facility

Demographics

1) Facility size:(a) 5-50 residents, (b) 51-99 residents, (c) 100-150 residents,(d) 151-175 residents, (e) 176+ residents

2) Facility Type:(a) Residential Care , (b) Intermediate Care, (c) Skilled Care,

(d) Special Care Unit, (e) combined3) Tax Status:

(a) For profit (b) Not For Profit4) Payment Accepted: (check all that apply)

(a) Medicare, (b) Medicaid, (c) Private Pay, (d) Long-Term Care In-surance

5) Social Worker on Staff:yes noLevel of Degree Held ____________________

Family Involvement

1) What percentage of your residents receive regular visits from familymembers?

a) 10% or less d) 34-50% g) 76-90%b) 11-25% e) 51-66% h) Above 91%c) 26-33% f) 67-75%

2) Please check all the activities family members perform in your facility:___ Grooming loved one ___ Feeding others___ Feeding loved one ___ Visiting with others___ Taking loved ones to

and from activities/meals___ Laundry for loved one___ Assisting w/ organized activities ___Taking loved one on trips___ Toileting/changing loved one ___ Bring gifts for loved___ Discussing the past

with loved one ___ Walking loved one___ Praying with loved one ___ Reading with loved one___ Attend onsite religious services

with loved one

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3) Please check all of the family related services your facility offers:

___ Family counseling ___ Support groups___ Meeting rooms ___ Weekend/evening special activities___ Newsletters ___ Materials for checkout

Facility Attitudes

1) Staff goes out of their way to meet the needs of family members.True ___ False ___

2) Staff follows up on family complaints/concerns in a timely fashion.True ___ False ___

3) Staff keeps in regular contact with all residents’ family members.True ___ False ___

Innovative ProgramsPlease use this page to describe any innovative ways that you have madeyour facility family friendly.

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