Use of videophones for distant caregiving - An enriching experience for families and residents in long-term care

Abstract

The objective of this study was to explore the role of videophone technology in enhancing the distant caregiving experience of and communication between residents of a long-term care facility and their family members. Ten participants-4 residents of an independent retirement facility and 6 family members-were recruited. A videophone was installed in each resident's apartment, and another was mailed to the remote family member. Participants were asked to conduct a videocall at least once per week for 3 months. Exit interviews assessed general impressions of videophone communication, the relationship between residents and family members, stress, burden, and isolation. Participants were enthusiastic and emphasized a sense of closeness, the inclusion of the resident in family interactions, and reduced feelings of guilt and isolation as key benefits. New models of care are needed to challenge the existing paradigm, which often excludes distant caregivers from the care process. Technology can facilitate this process by bridging geographic distance.

Full text

The objective of this study was to explore the role of
videophone technology in enhancing the distant care-
giving experience of and communication between
residents of a long-term care facility and their family
members. Ten participants—4 residents of an indepen-
dent retirement facility and 6 family members—were
recruited. A videophone was installed in each resident’s
apartment, and another was mailed to the remote
family member. Participants were asked to conduct a
videocall at least once per week for 3 months. Exit in-
terviews assessed general impressions of videophone
communication, the relationship between residents
and family members, stress, burden, and isolation. Par-
ticipants were enthusiastic and emphasized a sense of
closeness, the inclusion of the resident in family inter-
actions, and reduced feelings of guilt and isolation as
key benets. New models of care are needed to chal-
lenge the existing paradigm, which often excludes dis-
tant caregivers from the care process. Technology can
facilitate this process by bridging geographic distance.
ABSTRACT
George Demiris, PhD; Debra R. Parker Oliver, PhD; Brian Hensel, PhD;
Geraldine Dickey, MS; Marilyn Rantz, PhD, RN; and Marjorie Skubic, PhD
© 2008 iStock International Inc. /Jaren Wicklund
Use of Videophones for
Distant Caregiving
An Enriching Experience for Families
and Residents in Long-Term Care
50 JOGNonline.com

The decision to move into a long-
term care facility is an emo-
tional struggle for older adults,
as well as their family members. For
families, acknowledging that a loved
one needs more care than can be pro-
vided in a home setting is not easy. This
transition becomes especially stressful
for family members who, due to geo-
graphic distance, become less involved
in the care of their loved one. Informa-
tion technology tools have the poten-
tial to address such geographic barri-
ers; thus, it is essential to explore and
evaluate their use with long-term care
residents and their distant caregivers.
BACKGROUND
The transition of moving a loved
one into a long-term care setting often
results in family members simultane-
ously experiencing loss of control,
guilt, disempowerment, sadness, and
relief (Drysdale, Nelson, & Wineman,
1993; Rodgers, 1997; Whitlatch, Schur,
Noelker, Ejaz, & Looman, 2001). A
prevailing view is that the move into
a long-term care facility dictates the
termination of family caregiving (Kel-
lett, 1999). However, recent literature
has found that when older adults move
to long-term care, family members are
introduced to different, yet still poten-
tially stressful involvement (Dellasega
& Mastrian, 1995; Ross, Rosenthal,
& Dawson, 1993). Although mov-
ing a loved one who needs care into a
long-term care facility relieves some of
the caregivers’ physical and time pres-
sures, caregivers perceive little change
in their well-being after such institu-
tionalization (Dellasega, 1991). In-
stead, perceptions of stress and burden
persist with the same intensity as they
do for those who care for older rela-
tives at home (Dellasega, 1991).
Few published reports address in-
terventions aimed at family members
after their loved one has been insti-
tutionalized (Drysdale et al., 1993).
The distant caregiving experience,
especially for family members who
are geographically separated from the
institution in which their loved one
now lives, has not been investigated
extensively. Although interventions
involving distant caregivers in the
design and delivery of health care ser-
vices to residents are lacking, caregiv-
ers themselves want to continue to be
involved and desire more information
from staff about their loved one’s dai-
ly life (Hertzberg, Ekman, & Axels-
son, 2001).
Sustaining and enhancing relation-
ships and communication between dis-
tant caregivers and residents is impor-
tant not only to the family members
but also to the residents (Bauer & Nay,
2003), as they often struggle with isola-
tion and lack of a social network. The
loneliness resulting from social isola-
tion is significantly higher in nursing
home residents than in community-
dwelling older adults (Pinquart & So-
rensen, 2001). High frequency of social
contact between residents and their
children or grandchildren was found
to have a significant effect on lowering
social isolation (Drageset, 2002).
Geographic distance and time con-
straints often prevent distant caregiv-
ers from frequently visiting their loved
ones. These challenges are even greater
when the caregivers live an extensive
distance from the institution. The use
of videophone technology provides an
opportunity to bridge the geographic
distance between family members
and nursing home residents. Several
studies have indicated the potential of
such technology in the home setting,
for example, for disease management
(Demiris, Speedie, & Finkelstein, 2001),
hospice care (Parker Oliver, Demiris,
& Porock, 2005), and rehabilitation
support (Hauber & Jones, 2002).
Only three studies have investigated
the use of videophones in a long-term
care facility. Mickus and Luz (2002)
conducted a pilot study investigat-
ing the use of videophones to allow
residents to communicate with family
members and found that the technol-
ogy was valuable for both distant fam-
ily and residents. Satisfaction and per-
ception of usefulness were linked to
the individuals’ ability to use the tech-
nology. Another study by Sävenstedt,
Brulin, and Sandman (2003) explored
the use of videophones by residents
with dementia in a nursing home.
With staff supervision and assistance,
residents were able to communicate
via videophone with family members,
despite their cognitive impairments.
The interaction increased the attention
and focus of the residents and gave
family members a greater sense of in-
volvement (Sävenstedt et al., 2003). Fi-
© 2008 iStock International Inc. /Jin Yong
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Journal of GerontoloGical nursinG • Vol. 34, no. 7, 2008

nally, in a case study by Hensel, Parker
Oliver, and Demiris (2007) involving a
nursing home resident and her niece,
the videophone technology was found
to provide social presence for the fam-
ily member, who expressed that the
experience was “almost like being in
the same room” as her aunt.
STUDY PURPOSE
On the basis of the encouraging
findings of these preliminary studies,
we aimed to further explore the role
of videophone technology in enhanc-
ing the distant caregiving experience
and communication between residents
and family members. Specifically, the
purpose of this study was to identify
potential benefits and challenges of
videophone technology for long-term
care facility residents and their family
members and determine whether the
use of videophones can increase or en-
hance communication between these
individuals. In addition, we aimed to
explore potential psychosocial benefits
of videophone communication for both
residents and their family members.
METHOD
Setting
The study setting was an assisted
living retirement facility in the mid-
western United States. The design of
the facility was based on the Aging in
Place model, offering varied services as
needed rather than forcing older adults
to move to more skilled nursing en-
vironments as their health care needs
increase (Marek & Rantz, 2000).
Recruitment
A graduate research assistant (GRA)
(G. Dickey) attended several weekly
resident meetings in the facility and
explained the purpose of the study.
Individuals interested in participating
scheduled to meet with the GRA at a
later point and discuss the consent form
and study procedures. If residents’ fam-
ily members also agreed to be contacted
by the GRA, they scheduled a tele-
phone conference to discuss the study
procedures. Eligibility criteria included
that both residents and family members
had to be mentally competent, have a
regular telephone line in their residence,
and, in instances of hearing impairment,
still be able to carry out regular tele-
phone conversations.
When both parties (residents and
family members) signed their consent
forms, the GRA installed the video-
phone in the residents’ apartments and
mailed a videophone with detailed in-
structions to the family members. The
study was approved by the participat-
ing university’s institutional review
board.
Videophone
The videophone used in this study
was the Beamer™ Videophone (Vialta,
Inc., Fremont, CA), which operates
over regular telephone lines and costs
approximately $150 per unit. During
the authors’ preliminary work, this
model was found to be user friendly
for adults age 65 and older (Demiris,
Parker Oliver, & Courtney, 2006). The
videophone can display three kinds of
real-time images during a videocall:
self, other party, and a combination of
both, depending on user preference. It
plugs into a regular telephone and does
not interfere with its use. A videocall is
possible only when both parties have
videophone units and consent to a
videocall (by pressing the video but-
ton). In all other situations, users can
continue making and receiving regular
calls through their telephone without
activating the video feature.
Data Collection and Analysis
Both residents and family mem-
bers were asked to conduct a video-
call at least once per week (or more
if they chose to do so) and complete
a form after each videocall to docu-
ment its technical quality. We used a
previously developed instrument for
assessing the technical quality of a
“virtual visit” in home care (Demiris,
Speedie, Finkelstein, & Harris, 2003),
a video-based interaction between
health care providers and patients or
caregivers.
The form included the date, start
and end times of the videocall, and the
participants’ initials. The main section
of the form contained five items about
the technical quality of the videocall.
The first two items addressed partici-
pants’ observations regarding the fre-
quency of difficulties they experienced
with the videophone’s audio and im-
age. The next two items addressed
problems with video and sound on the
conversation partner’s end, as reported
to the participants. The last item ad-
dressed possible disconnections and
their frequency.
A percentage score for the over-
all technical quality of each videocall
(100% = perfect technical quality
with no problems or disconnections)
is calculated at the end of this sec-
tion. This instrument has been tested
for reliability and validity and used to
rate the technical quality of videocalls
in home care settings (Demiris et al.,
2003; Hensel et al., 2007). The forms
were collected and entered into SPSS,
version 14, for analysis. We entered the
data twice to ensure accuracy.
Participants (residents and fam-
ily members) were interviewed after
using the videophone for 3 months.
The interview protocol addressed six
domains:
l General impressions of video-
phone communication (e.g., perceived
advantages and disadvantages).
l Affective and cognitive dimen-
sions of conversations between
resident and family member (i.e.,
assessing perceptions of the value
of videophones in conversations
conveying factual information and
description, emotional conversa-
tions and discussions of feelings, and
attempts to persuade or convince
and address conflict).
Participants reported
a sense of closeness
during the videocalls,...
and reduced feelings of
guilt and isolation.
52 JOGNonline.com

l Quality and frequency of com-
munication and quality of relationship
between resident and family member
(and the role of videophone in this
context).
l Stress and burden (e.g., feelings
of stress, nervousness, depression,
general anxiety, tension).
l Assisted living facility place-
ment stress (for interviews with fam-
ily members only).
l Isolation and loneliness (for
interviews with residents only).
The protocol was reviewed by two
experts in gerontology and communi-
cation research to address face valid-
ity. Interviews were audiotaped and
transcribed. Transcript data were then
analyzed using a qualitative approach
by which codes were inductively gen-
erated (Miles & Huberman, 1994). The
thematic data analysis was performed
by two members of the research team
(G. Demiris, D.R. Parker Oliver), and
a third member (B. Hensel) confirmed
the validity of interpretations.
RESULTS
A total of 10 individuals participat-
ed in the study: 4 residents and 6 fam-
ily members (2 residents each partici-
pated with 2 family members). All of
the participating family members were
children of the residents except for
one, who was the niece of the resident.
All residents were older than age 65.
The original study plan focused on
the recruitment of family members re-
siding at least 20 miles from the facil-
ity; however, when one daughter who
lived locally became ill and unable to
visit her father, we discovered the value
of the instrument for families who live
locally as well.
Two residents died before study
completion, resulting in a total of eight
exit interviews (2 residents and 6 fam-
ily members). The average duration
of a videocall was 43 minutes (SD =
11.2), with the shortest call lasting 14
minutes and the longest 1 hour and 14
minutes. The average technical qual-
ity was 94.75% (SD = 7.97); the mini-
mum score observed was 57.1% and
the maximum was 100%, indicating
an overall very good level of videocall
audio and video quality.
All respondents stated that they ap-
preciated being able to see their loved
one’s facial expressions and to have a
sense of closeness. One respondent
stated:
It was great to see Dad, and I think
that one of the times we used it [the
videophone], we gave him some good
news and just being able to see the smile
on his face was really good.
Another respondent pointed out
the value of the visual aid in assessing
one’s condition:
I can remember this one time when
I had the flu…. He [participant’s father]
was worried about me being sick, and it
helped him to be able to see me and re-
alize that I wasn’t on my death bed…. I
felt good because I could see that he had
a smile on his face. He could answer the
phone and have that tone of voice that
I could hear he was just feeling down
and depressed, and we could click on
the videophone, and, especially with
Dad’s personality, he would start to get
a grin on his face and start saying hello
and being a clown on the phone. He en-
joyed it, and it was ideal.
A consistent theme in the responses
of both residents and family mem-
bers was the inclusion of the resident
in family interactions, which was fa-
cilitated by the video component. A
family member described how the
videophone was used when the grand-
children would visit, and on one occa-
sion, the resident was able to watch a
football game with the family:
On special occasions it was nice to
have a visual. When kids gathered at
the house, Dad could see them; they
could see their grandfather. When the
kids visited on holidays, when [football
team] beat [football team] we were all
dressed up and yelling, and it was fun.
I could see him laughing. He could see
me wearing a sombrero and a [football
team] shirt.
Another resident stated:
I was amused that my niece had a
grandchild, and they wanted me to see
the grandchild. So I was ready to visit
and I got a kick out of it because every
time they said, “Say hi to Aunt _____,”
she would take a little peek at the screen
and then hide behind her mother’s
skirt.
Most family members emphasized
the importance of having the resident
see new family members or friends
over the videophone, as this allowed
residents to feel like they are still part
of the family group. One family mem-
ber stated:
With the videophone, he could see
his granddaughter’s new boyfriend. It
did put him more at the center of fam-
ily gatherings. And we tried harder to
physically show items to him, the way
we dressed, people in the background.
Concerns were also expressed re-
garding the use of the technology.
Four respondents identified occasion-
al audio delays as distracting or con-
fusing. Two family members reported
that videocalls can be time consuming
or inconvenient, as the videophone re-
quired them to sit in front of the camera
during the whole conversation rather
than being able to carry out other tasks
in the house during the conversation,
as they would with mobile phones or
handsets.
When commenting on the affective
and cognitive dimensions of the con-
versation, all respondents saw a benefit
in being able to see their loved one’s fa-
cial expressions and part of their resi-
dence. Three respondents believed the
videophone can be useful in conversa-
tions that involve factual information
(i.e., when one is describing symptoms
or an injury). All respondents saw an
advantage in using the videophone over
the regular telephone in conversations
that involved emotions and feelings
or when trying to persuade or con-
vince the conversation partner. Eight
respondents were unsure whether the
videophone would be more or less
appropriate to address conflict, and 2
believed the videophone was more ap-
propriate than a regular telephone, as
one can assess the emotional status and
sincerity of the conversation partner.
One family member stated:
She [her mother] can be stubborn
at times, and if I can see the expression
53
Journal of GerontoloGical nursinG • Vol. 34, no. 7, 2008

on her face, I know how to go with my
conversation and I know how to get the
point across.
In terms of the quality of com-
munication and frequency of interac-
tion, 4 respondents believed that these
factors did not change because of the
videophone, whereas the remaining
6 respondents stated that the video-
phone made the communication more
personal and comforting. Interest-
ingly, these 6 respondents had also ex-
perienced the highest level of technical
quality of the videocalls, as reported
in the technical quality forms. One
respondent stated that conversations
lasted longer with the videophone and
were more fulfilling.
Three family members stated they
did feel guilt about their loved one mov-
ing into a retirement community and
that the videocalls played a role in re-
ducing this guilt. One participant said:
We don’t live together, and some-
times I could feel guilty about that. This
[the videophone] took away some of
the guilt because I could actually see
him [his father]. I felt very much like I
was closer in proximity, and if he had
taken a turn for the worse…this would
have given me a better way to assess
how he is.
Another family member com-
mented on the sense of connectedness
the videophone provided and wished
she had used that tool for another par-
ent who had passed away in a nursing
home:
The connectedness was great with
the videophone. I wish I had one for
Dad, if I knew they existed, I would
have purchased one for him and me. It
would have so reduced my stress.
The videophone communication
also contributed positively in reducing
feelings of isolation and loneliness for
residents. One resident stated:
I think the videophone was a help
in fighting feelings of depression. Time
just changes depression, it just reduces
it overall, you come to the conclusion
that this is where you are. The visual as-
pect helped me to feel like I was visiting
when we spoke.
Another participant commented:
Oh, yes, the videophone contrib-
uted positively to our relationship. We
developed a way of kind of kissing each
other over the phone or giving each
other a hug over the phone. We would
both always leave it with a big smile
on our face. And a couple of times, my
sons were at my house when we were
having conversations, and they got in
the picture as well, and we were like
three clowns trying to cheer him [her
father] up. But we did it.
DISCUSSION
This was an exploratory study
with a limited sample and, as such,
has limited generalizability. However,
the findings do indicate the potential
of videophone technology to improve
quality of life for long-term care fa-
cility residents and distant family
members. All participants were en-
thusiastic about their ability to con-
duct videocalls. Although technical
issues and challenges were identified,
respondents emphasized the sense
of closeness and the inclusion of the
resident in family interactions as key
benefits of this technology. The vid-
eophone contact could play a role in
reducing social isolation and loneli-
ness of residents in long-term care.
In addition, these experiences sup-
port an earlier finding by Hensel et al.
(2007) that the videophone promotes
a social presence for the resident and
family member. This finding indicates
a need for further exploration of the
relationship between social presence
and social support for long-term care
residents.
The successful implementation of
these commercially available, low-
cost tools needs to be further ex-
plored (Parker Oliver, Demiris, &
Hensel, 2006). For example, such a
video-based tool can also allow staff
to communicate with the family mem-
bers, enhancing their relationship
with distant caregivers. A long-term
care facility may use this technology
to connect family members not only
with their loved ones but also with
the entire care team, allowing distant
KEYPOINTS
Videophones for distant
CaregiVing
Demiris, G., Parker Oliver, D.R., Hensel, B., Dickey, G., Rantz, M., & Skubic, M. (2008). Use
of Videophones for Distant Caregiving: An Enriching Experience for Families and
Residents in Long-Term Care. Journal of Gerontological Nursing, 34(7), 50-55.
1 The decision to move into a long-term care facility is an emo-
tional struggle for older adults, as well as their family members.
2 Enhancing communication between long-term care residents and
distant caregivers is important not only to the family members
but also to the residents, as they often struggle with isolation and
lack of a social network.
3 Long-term care residents and their distant caregivers were greatly
satisfied with regular use of videophones for their communica-
tion and emphasized a sense of closeness, the inclusion of the
resident in family interactions, and reduced feelings of guilt and
isolation as key benefits.
4 New models of care are needed to challenge the existing para-
digm, which often excludes distant caregivers from the care pro-
cess; technology can contribute to this process by bridging geo-
graphic distance.
54 JOGNonline.com

caregivers to be included in the deci-
sion making process.
As Kellett (1999) pointed out, new
models of care are needed that will
challenge the existing paradigm, which
often excludes distant caregivers from
the care process. The ability of fam-
ily caregivers to redefine their caring
roles within the long-term care facility
context will depend on the degree to
which the institutions support family
involvement. Information technology
can contribute to this process by bridg-
ing geographic distance and enriching
existing communication channels and
introducing new ones.
NURSING IMPLICATIONS
This study shows that information
technology can provide useful tools
for nurses as they aim to improve ser-
vices provided to long-term care resi-
dents and assess issues of social iso-
lation. In many cases, commercially
available, low-cost tools can be pow-
erful in including distant caregivers in
the design and delivery of health care
services. Long-term care administra-
tors and nurses can use such technol-
ogy to include distant caregivers in
the decision making process and to
facilitate teamwork. Nurses can re-
define the caring roles of family care-
givers in the long-term care facility
context by empowering residents and
their families and bridging geographic
distance.
SUMMARY
This study explored the role of
videophone technology in enhancing
the communication between residents
of a long-term care facility and their
remote family members. Ten par-
ticipants—4 residents and 6 family
members—were recruited. A video-
phone was mailed to the remote fam-
ily members and installed in residents’
apartments. Participants were asked
to conduct a videocall at least once per
week for 3 months and at completion
of the study discuss their experience
with and impression of videophone
communication. Participants reported
a sense of closeness during the video-
calls, the inclusion of the resident in
family interactions, and reduced feel-
ings of guilt and isolation. Technology
can help redefine the role of distant
caregiving in long-term care facilities.
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About the Authors
Dr. Demiris is Associate Profes-
sor, Biobehavioral Nursing and Health
Systems, School of Nursing, University
of Washington, Seattle, Washington; and
Dr. Parker Oliver is Associate Professor,
Family and Community Medicine, School
of Medicine, Dr. Hensel is Postdoctoral
Fellow of Health Management and Infor-
matics, School of Medicine, Ms. Dickey is a
predoctoral student, School of Social Work,
Dr. Rantz is Professor, School of Nurs-
ing, and Dr. Skubic is Associate Profes-
sor, School of Engineering, University of
Missouri-Columbia, Columbia, Missouri.
This study was supported in part by
the U.S. Administration on Aging (Grant
90AM3013, Marilyn Rantz, Principal
Investigator).
Address correspondence to George
Demiris, PhD, Associate Professor,
Biobehavioral Nursing and Health Sys-
tems, University of Washington, BNHS
Box 357266, Seattle, WA 98195; e-mail:
gdemiris@u.washington.edu.
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Journal of GerontoloGical nursinG • Vol. 34, no. 7, 2008