Graphical Abstract
Marriage is complicated, and every couple is unique. When a couple — or one spouse — enters a long-term care community, their relationship faces new challenges, and the community’s staff may find themselves pulled into the drama. In addition to helping the couple, it takes teamwork, patience, and creativity to keep marital discord from creating problems for other residents and staff.
Born to Bicker
For some couples, heated arguments and raised voices are par for the course. “If both spouses are alert and cognitively intact, they get to make their own decisions. As long as their arguments don’t disturb others, it is their right to interact the way they want,” said Sherrie Dornberger, executive director of the National Association of Directors of Nursing Administration in Long Term Care (NADONA).
David Smith, MD, CMD, president of Geriatric Consultants in Brownwood, TX, said, “We need to do a bit of diagnosis to determine if the marital discord is new or something that’s always been that way.” If the discord is new, he suggested, “determine what is happening and what may have changed. For instance, if someone is depressed, their spouse might not understand that and be critical of or impatient.”
In fact, there are numerous health changes that can cause marital problems. For example, if one spouse has cognitive impairment or dementia, the other person can get frustrated and impatient. Physical changes and illness can also interfere with a couple’s sex life when one partner no longer wants to be intimate or becomes hypersexual, and this can cause conflicts. However, it’s never acceptable for one spouse to be abusive toward their partner. Ms. Dornberger said, “If you suspect physical, psychological, or emotional abuse, you have to take a prompt assessment of the situation and develop an action plan.”
She stressed, “Physical confrontations are never okay. I’ve had family members say that a couple fought physically all their lives, but we have to tell them that it won’t happen here.” She added, “If someone is being physically or mentally abused by a spouse, you have to follow your policies and procedures. You need to prioritize safety while protecting the rights of the residents.”
“I have found that family members can be pretty helpful in providing some background about what is going on with a couple, and they can help formulate a solution,” Dr. Smith said.
Guilt, Bossiness, Family Antics
Some family dynamics can cause marital problems as well as challenges for staff. According to Barbara Resnick, PhD, CRNP, professor and Sonya Ziporkin Gershowitz chair in gerontology at the University of Maryland School of Nursing in Baltimore, MD, these include guilt on the part the spouse who has always been the caregiver and can’t do it anymore, or domineering spouses who always speak for their partners and are convinced they always know best.
“We really need to support spouses through the process of settling into a long-term care facility. For example, alleviating guilt is a real gift we can give. This also helps them relax a bit and not be as demanding about care,” Dr. Resnick said, adding, “It’s also important to acknowledge what they have accomplished as a caregiver for their spouse.”
Engaging the caregiving spouse also can reduce tensions, guilt, and anxiety. “We need to listen to the caregiver and let them express how they have done things like bathing their spouse or giving them their medications. Give them a voice, while role modeling better ways to do things like optimizing function,” said Dr. Resnick.
Easing a controlling or bossy spouse’s anxiety is key because their words and action can make their partner feel anxious or agitated. “Sometimes it may be helpful to encourage them to get a cup of coffee and step away while staff are working with the resident,” said Dr. Resnick. When the spouse’s bossiness puts the other person at risk, a team leader may need to get involved. For instance, Janet Feldkamp, Esq., a partner at Benesch Friedlander Coplan & Aronoff in Columbus, OH, said, “I’ve seen situations such as someone trying to force their spouse to eat. We have a responsibility to protect residents from such abusive behavior in our buildings.”
When spouses are battling, counseling may help. However, there are times when the best solution is to move them into separate rooms or apartments. “However, if there is abuse involved, you may have to take some additional steps. For instance, it may be necessary to have another person present when spouses meet,” said Ms. Feldkamp.
Educating, Helping Employees
It is important that frontline staff understand that they need to report concerning situations and avoid assuming all responsibility for intervening directly. Good training is key: have a detailed plan and educate everyone on it. “It’s about making sure your staff knows how to communicate and with whom and then making sure there is appropriate follow-through,” said Ms. Dornberger.
If a couple’s arguing is causing an employee anxiety or stress, it is important to address this. “Someone who has experienced a toxic marriage or family situation may be triggered by a constantly fighting couple. We need to respect this and not dismiss their feelings,” said Ms. Dornberger, advising that clinical leaders should do what they can to help. This might mean assigning someone else to care for the couple or having a quiet room where staff can go to regroup and destress.
No Judgment
Ultimately, while we’re working to keep residents safe and maximize their quality of life, it’s important to resist judgmental impulses. “You can’t judge people by your experiences or standards. You just don’t know what the history of a relationship is or what a couple has been through,” said Dr. Resnick.
Senior contributor Joanne Kaldy is a freelance writer in New Orleans, LA.
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Access this article on ScienceDirectRelated Podcast
November 30, 2022
November/December 2022
In this episode, Dr. Karl Steinberg and Dr. Elizabeth Galik discuss our November-December issue, including the oral COVID-19 outpatient treatment known as Paxlovid, the role of professional social workers in the nursing home, the assessment and management of wandering and elopement in nursing homes, and what to do with spousal disagreements impact individuals, other patients, and staff.
https://mcdn.podbean.com/mf/download/i45u3d/COTG-2022-11-09.mp3
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