The conflicted surrogate syndrome: implications for nursing facility work force stress, safety, and turnover.

When a loved one is admitted to a nursing facility, family members usually experience a variety of emotions. Feelings of guilt, fear, and distrust are common. The facility staff must make every effort to engage the family and establish trust to forge a constructive collaboration in the care of the nursing facility resident. Even with conscientious and compassionate staff efforts to establish an alliance with family members, however, maladaptive family responses can occur. Kidder and Smith have analyzed maladaptive family responses characterized by excessive complaint behaviors and have proposed that this constitutes a recognizable syndrome they named “The Conflicted Surrogate Syndrome.” This article proposes diagnostic criteria for the syndrome, presents 3 cases meeting the criteria, and offers suggestions for early recognition and intervention. The potential for violence against nursing facility staff by the conflicted surrogate and the impact of the syndrome on work force stress, safety, and turnover are discussed. Licensing and certification agencies, ombudsmen programs, and advocacy groups, as well as nursing facility clinicians, staff, and leadership must acknowledge the potential threat this syndrome contains for nursing facility staff. Although the modern focus is on resident rights, the nursing facility is a community in which all members, including the staff, must be afforded an environment that is free from verbal abuse, intimidation, and threat of physical violence. In 2006, Kidder and Smith1 reported 4 cases of families whose complaints about nursing facility care were deemed unwarranted or excessive, and at times, irrational. The cases were analyzed in psychoanalytic terms and hypotheses were generated about various psychopathologies within the family members or family systems, leading to the abnormal complaint behaviors. They proposed that the cases might represent a recognizable syndrome they labeled “The Conflicted Surrogate Syndrome.” Kidder and Smith1 hypothesized that the excessive complaint behaviors might have a negative impact on care of the nursing facility resident, because of staff withdrawal from care and hesitancy to deal with the unpleasant interactions with