Children's thoughts and feelings related to visiting critically ill relatives in an adult ICU: A qualitative study

Experiences of parents visiting an adult family member in the intensive care unit accompanied by their underaged children: A qualitative study

OBJECTIVES

The objective of this study was to explore experiences and needs of parents visiting critically ill family members in intensive care units (ICUs) accompanied by their underaged children (<18 years).

METHODS

Six semistructured interviews with parents were conducted in a qualitative design. Data analysis and synthesis were performed using Braun and Clarke's thematic analysis. This study was conducted in five adult ICUs in Switzerland.

FINDINGS

Parents opted for early and truthful involvement of their children, and the majority initiated the visits themselves. Five themes were identified: feeling of shock by the entire family; crying in front of the children; feeling welcome with the children; knowing that the children can cope with it; and holding the family together. Parents felt only partially welcomed in the ICU when accompanied by their children. In one case, the parents withdrew the child from the visit.

CONCLUSIONS

Parents experienced the visit to a critically ill family member in the ICU with their underaged children as challenging. They were emotionally vulnerable and yet took the initiative to keep the family together. Parents had to mediate between their children, the critically ill family member, and the treatment team. Awareness of the needs of the parents visiting with underaged children is important in clinical practice. There is a need for family-centred structures and processes, including adequate visiting times and rooms suitable for children with books, pictures, and toys.

"We want to include him in that journey": A qualitative descriptive study of parental experiences and considerations for sibling inclusion in the paediatric ICU

OBJECTIVES

Siblings are an important yet often forgotten part of the paediatric intensive care unit (PICU) family experience. Commonly, siblings are supported through the experience by their parents; however, very little is known about parental experiences of providing this support. This study aims to explore parental experiences of supporting sibling inclusion in PICU.

RESEARCH METHODOLOGY/DESIGN

This study utilised a qualitative descriptive approach to conduct semi-structured interviews with 6 parents of 5 children with congenital heart disease who had spent time in PICU. Data were analysed using reflexive thematic analysis.

SETTING

Australian PICUs.

FINDINGS

Parental considerations and experiences for sibling inclusion were identified across three key phases: Pre-inclusion, The PICU visit, and Post-inclusion. Prior to including siblings in PICU, parents considered various ways of sharing information with siblings, and weighed up the risks and benefits of bringing siblings into PICU. Parents also recounted a number of challenges and facilitators to a positive sibling experience in PICU, including supportive staff and fun activities. Finally, parents, identified that siblings require ongoing support after their inclusion in PICU and made suggestions for ongoing availability of information and supportive resources.

CONCLUSIONS

This study has illuminated key parental experiences when supporting sibling inclusion in PICU before, during and after their visit. By understanding these parental experiences, PICU staff can work with and support parents where needed, helping to achieve a positive sibling inclusion experience.

IMPLICATIONS FOR CLINICAL PRACTICE

Parents need ongoing support to explain the PICU to siblings of critically ill children and may benefit from specific visual resources to aid communication. In addition, PICUs should aim to ensure the physical layout is supportive of sibling needs, with dedicated spaces for siblings to play and take time out during their experience.

Family experiences and perceptions of intensive care unit care and communication during the COVID-19 pandemic

INTRODUCTION

In 2020, during the first wave of the COVID-19 pandemic in Melbourne, visitor access to acute hospitals including intensive care units (ICUs) was initially barred, followed by a limit of one person per patient for one hour per day. This study explores the care and communication experienced by family members of ICU patients during this time.

METHODS

This qualitative descriptive study was conducted at an Australian quaternary hospital. Semistructured phone interviews were conducted using an aide-memoire designed to understand participants' experiences as family of a patient during this time. Interviews were recorded, transcribed, and thematically analysed.

FINDINGS

Twenty family members of patients in the ICU participated. Three major themes were identified: 'impact of restricting visiting procedures', 'family experiences of communication', and 'care and support'. Inflexible visiting restrictions had a momentous impact on families. Participants objected to having to nominate only two people to visit during the admission and the short visiting time limit. Some family members suffered extreme stress and anxiety during their absence from the bedside. Additional challenges were experienced by rural families, visitors with disabilities, and the young children of patients who were excluded. Communication with clinicians varied. Telehealth was valued by some but not universally embraced. The relationship between staff members and families and involvement in decision-making were unaffected.

CONCLUSION

Families experienced significant psychological distress from being separated from their critically ill relatives. Patient care and involvement in decision-making appeared to be unchanged, but communication with staff felt to be lacking. Better alternatives to face-to-face communication must be sought to limit the impact of family separation on mental health. Families are a key link between the patient and clinicians and often play a major role in patient support and recovery after discharge. There is an urgent need to support them and facilitate meaningful engagement despite the obstacles.

[Children visiting intensive care units and emergency departments : Kids are welcome!]

In this white paper, key recommendations for visitation by children in intensive care units (ICU; both pediatric and adult), intermediate care units and emergency departments (ED) are presented. In ICUs and EDs in German-speaking countries, the visiting policies for children and adolescents are regulated very heterogeneously: sometimes they are allowed to visit patients without restrictions in age and time duration, sometimes this is only possible from the age of teenager on, and only for a short duration. A request from children to visit often triggers different, sometimes restrictive reactions among the staff. Management is encouraged to reflect on this attitude together with their employees and to develop a culture of family-centered care. Despite limited evidence, there are more advantages for than against a visit, also in hygienic, psychosocial, ethical, religious, and cultural aspects. No general recommendation can be made for or against visits. The decisions for a visit are complex and require careful consideration.

The meaning of being a visiting child of a seriously ill parent receiving care at the ICU

PURPOSE

Children's visits to the ICU are still restricted, and more focus on the child's own needs and experiences are needed. The aim of this study is to illustrate the meaning of being a visiting child of a seriously ill parent receiving care at the ICU.

METHOD

A qualitative descriptive design was used, with open-ended interviews with seven children (6-18 years) performed and analysed using a phenomenological research approach.

FINDINGS

Being a visiting child of a seriously ill parent receiving care at the ICU is described as a life situation taking place in an unfamiliar environment, characterized by a heartfelt, genuine desire to be there, in an interdependence entailing offering a loved one the help they need while at the same time being seen in a compassionate way and being able to share, revealing a sudden awakening of an inner truth of reality and a sense of a healing wisdom of understanding.

CONCLUSIONS

The children felt good when they visited their ill parent, but at the same time not fully involved, and desired a more compassionate, caring approach by the nurses. Improvements are needed in how to approach visiting children in a more individual and caring way.

It's Not Just in the Walls: Patient and Staff Experiences of a New Spatial Design for Psychiatric Inpatient Care

The environment in psychiatric inpatient care is key to patient recovery and staff job satisfaction. In this qualitative study of patient and staff experiences of a new spatial design in psychiatric inpatient care, we analysed data from 11 semi-structured interviews with patients and five focus group discussions with staff using qualitative content analysis. The new design contributed to feelings of safety and recovery, but patients and staff also reported some frustration and added stress. The results lead us to conclude that while the new spatial design improves some conditions for recovery and job satisfaction, the design itself is simply not enough. Changes in care environments require that both patients and staff be informed and involved in the renovation to ensure that patients feel respected and staff feel confident in using the new environment before and during treatment and follow-ups.

Visual arts and drawings to communicate and explore authentic life situations, a data collection method in caring science - a hermeneutic perspective

This methodological article aims to describe three methodological strategies for using drawings as a part of qualitative data collection methods in caring research based on hermeneutics. In some research interview situations, participants may have difficulties to express their experiences and feelings in words. The consequences may be that the descriptions in research reports will become superficial and not authentic, meaning, "telling it as it is". Drawn pictures may facilitate and support reflection related to the deepening of experiences and thoughts, and communicate and express more than words can do. It may also reveal thoughts and feelings the person drawing the picture was not aware of. Three methodological strategies are described: (1) Drawing a picture as an introduction or starting point for an interview, (2) During an ongoing interview, encouraging the participant to draw a picture when further explanation or description is needed for deepening the communication and (3) Drawing something in a pre-existing picture. The theoretical foundation of Gadamer's hermeneutic philosophy is discussed in relation to what a drawing is representing and presents. The interpretation of the drawn picture depends primarily on the creator of the picture, but at the same time the interpretation and understanding is a movement between the interviewer's and the participant's horizons, and thus is open for preunderstanding and new understanding. In contrast to an ordinary interview between two parties, an interview involving a drawing adds something specific to the conversation as it becomes a "trialogue" and not only a dialog. The drawn picture stands on its own. Using the participant's drawing can, therefore, be understood as an ongoing process with three parties involved: (1) the participant, (2) the researcher and (3) the drawing.

A national Position Statement on adult end-of-life care in critical care

Patient death in critical care is not uncommon. Rather, the provision of end-of-life care is a core feature of critical care nursing, yet not all nurses feel adequately prepared for their role in the provision of end-of-life care. For this reason, the Australian College of Critical Care Nurses (ACCCN) supported the development of a Position Statement to provide nurses with clear practice recommendations to guide the provision of end-of-life care, which reflect the most relevant evidence and information associated with end-of-life care for adult patients in Australian critical care settings. A systematic literature search was conducted between June and July, 2020 in CINAHL Complete, Medline, and EMBASE databases to locate research evidence related to key elements of end-of-life care in critical care. Preference was given to the most recent Australian or Australasian research evidence, where available. Once the practice recommendations were drafted in accordance with the research evidence, a clinical expert review panel was established. The panel comprised clinically active ACCCN members with at least 12 months of clinical experience. The clinical expert review panel participated in an eDelphi process to provide face validity for practice recommendations and a subsequent online meeting to suggest additional refinements and ensure the final practice recommendations were meaningful and practical for critical care nursing practice in Australia. ACCCN Board members also provided independent review of the Position Statement. This Position Statement is intended to provide practical guidance to critical care nurses in the provision of adult end-of-life care in Australian critical care settings.

Practice Recommendations for End-of-Life Care in the Intensive Care Unit

TOPIC

A substantial number of patients die in the intensive care unit, so high-quality end-of-life care is an important part of intensive care unit work. However, end-of-life care varies because of lack of knowledge of best practices.

CLINICAL RELEVANCE

Research shows that high-quality end-of-life care is possible in an intensive care unit. This article encourages nurses to be imaginative and take an individual approach to provide the best possible end-of-life care for patients and their family members.

PURPOSE OF PAPER

To provide recommendations for high-quality end-of-life care for patients and family members.

CONTENT COVERED

This article touches on the following domains: end-of-life decision-making, place to die, patient comfort, family presence in the intensive care unit, visiting children, family needs, preparing the family, staff presence, when the patient dies, after-death care of the family, and caring for staff.

The impact of visiting the Intensive Care Unit on children's and adolescents' psychological well-being: A systematic review

OBJECTIVES

The visits of children/adolescents in adult intensive care units are increasingly more common. However, few studies examine the psychological impact of visiting. This systematic review aims to summarise the psychological effects that visiting family members has on children/adolescents.

RESEARCH METHODOLOGY

A systematic review of research articles published from 1990 to January 2021 was conducted using PsycInfo, PubMed, and CINAHL. Inclusion/exclusion criteria were applied. Those studies included were evaluated using the Joanna Briggs Institute Critical Appraisal tools. A narrative synthesis of the results was conducted.

SETTING

Adult intensive care unit.

RESULTS

The review identified five studies (three of which qualitative), involving 141 children/adolescents. Although the experience of visiting was potentially traumatic, it enabled children/adolescents to better understand the reality and to preserve their relationships with family members. The impact of visiting was influenced by individual characteristics (e.g., age, past traumatic experiences) and by organisational characteristics (e.g., facilitated visit or not). Regardless of visitation, most children/adolescents presented anxiety and depression symptoms that need to be addressed.

CONCLUSIONS

Child/adolescent visitation seems to have positive effects, provided there is preparation and facilitation. Clinicians should pay attention to individual characteristics and optimise organisational factors (e.g., environment) in order to minimise potentially trauma-inducing aspects.

The enablers and barriers to children visiting their ill parent/carer in intensive care units: A scoping review

AIM

The aim of the study was to identify the enablers and/or barriers to children visiting their ill parent/carer in intensive care units by examining the visiting policies as practiced or perceived by nurses and experienced or perceived by parents and caregivers.

REVIEW METHOD

This is a scoping review following Joanna Briggs Institute Protocol Guidelines.

DATA SOURCES

An extensive literature search of Cumulative Index of Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online, PsychINFO, PubMed, and Excerpta Medica dataBASE databases, using key terms, was conducted between May 2019 and July 2020; studies published between 1990 and 2020 were considered for inclusion. Double screening, extraction, and coding of the data using thematic analysis and frequency counts were used.

RESULTS

Fifteen barriers, 19 facilitators, nine situationally contingent factors, and six personal judgement considerations were identified that influenced children visiting their ill parent/carer in intensive care units. Most barriers (n = 10) were related to organisational factors including restrictive policies, nurses' level of education, age, working hours, nurses' attitudes, and lack of required skills to promote emotional resilience and/or to communicate with children. Family perception factors relating to parents' perceptions, attitudes and concerns of staff/parents, and anticipated behaviours of children were also identified as both barriers and facilitators.

CONCLUSIONS

There is a lack of consistency in the application of policies and procedures to facilitate children visiting their loved ones in an intensive care unit. Without key involvement from the nurses and healthcare team, there may have been opportunities lost to optimise family-centred care practices in critical care settings.

Effects of COVID-19 Outbreak on Children's Mental Health: A Comparative Study with Children Diagnosed and Isolated from Their Parents

OBJECTIVE

The COVID-19 outbreak has negatively affected children in many ways. This study aimed to compare the psychological responses of children exposed to different levels of stress during the COVID-19 outbreak.

METHODS

The anxiety levels, negative thoughts, and quality of life of COVID-19-positive children with COVID-19-positive parents (Child+ group, n=17), COVID-19-negative children who are separated from COVID-19-positive parents (Parent+ group, n=59), and a control group (n=64) were compared. The participants completed the Screen for Child Anxiety and Related Disorders (SCARED), Children's Negative Cognitive Errors Questionnaire (CNCEQ), and Pediatric Quality of Life Inventory (PedsQL).

RESULTS

The statistical analysis revealed that the Parent+ group recorded higher SCARED and CNCEQ scores and lower PedsQL scores in comparison with the control group. No statistically significant difference was found between the scores of the Child+ and control groups. Furthermore, high CNCEQ scores and low PedsQL scores in the Parent+ group predicted an increase in their SCARED scores.

CONCLUSION

Our study indicates that separating children from their parents during the COVID-19 outbreak negatively influences their mental health and increases their anxiety levels.

Visit of minors in an intensive care unit. What is the opinion of health staff?

AIM

To determine the opinion of healthcare staff (HS) on the presence of minors in an adult intensive care unit.

METHOD

Transversal descriptive research study in an adult intensive care unit with 62 people, between September/December 2017. The Knutsson questionnaire was used with 10 closed questions with space for comments, and 2 open questions. Selection of the respondents was by means of convenience sampling. Descriptive statistics with absolute frequencies and percentages. Chi-squared-test or Fisher. Significance p<.05.

RESULTS

61 questionnaires were collected: 70.5% nursing staff (NS). Fifty percent of medical staff (MS) would restrict the entry of 0 to 6-year old minors versus 76.2% NS (p=.04). Of the MS, 16.7% would restrict the visits of minors between the ages of 7 and 12 versus 46.5% NS (p=.02). Seventy-five percent of HS thought that minors' access could entail a risk of infection for the children. Of the survey respondents, 60% believed that the environment could intimidate the minor, and 66.7% thought that the patient's condition could affect the child. They would permit 0-6-year-old minors to access the ICU if the patient was dying (70.6% MS/41% NS, p=.04), awake and alert (77.8% MS/57.5% NE) and close relatives (parents) (66.7% MS/60% NS).

CONCLUSIONS

HS support minors visiting an adult adult intensive care unit if they are>6 years old. HS show a more positive attitude towards visits in special circumstances such as close relatives, awake patient, and death regardless of their age. The reasons for restriction of visits are: environment, patient's condition and risk of infection. NS show a less positive attitude in relation to visits.

Family members' experiences of waiting in intensive care: a concept analysis

AIM

The aim of this study was to explore the meaning of family members' experience of waiting in an intensive care context using Rodgers' evolutionary method of concept analysis.

METHOD

Systematic searches in CINAHL and PubMed retrieved 38 articles which illustrated the waiting experienced by family members in an intensive care context. Rodgers' evolutionary method of concept analysis was applied to the data.

FINDINGS

In total, five elements of the concept were identified in the analysis. These were as follows: living in limbo; feeling helpless and powerless; hoping; enduring; and fearing the worst. Family members' vigilance regarding their relative proved to be a related concept, but vigilance does not share the same set of attributes. The consequences of waiting were often negative for the relatives and caused them suffering. The references show that the concept was manifested in different situations and in intensive care units (ICUs) with various types of specialties.

CONCLUSIONS

The application of concept analysis has brought a deeper understanding and meaning to the experience of waiting among family members in an intensive care context. This may provide professionals with an awareness of how to take care of family members in this situation. The waiting is inevitable, but improved communication between the ICU staff and family members is necessary to reduce stress and alleviate the suffering of family members. It is important to acknowledge that waiting cannot be eliminated but family-centred care, including a friendly and welcoming hospital environment, can ease the burden of family members with a loved one in an ICU.

[Children visiting as an integral part of patient- and family-centered care of adult critical care patients]

Children are relatives and should also be included even at the end of life. From the point of view of adult patients, involving children in this way means helpful assistance and care. From the point of view of children, who are often confronted for the first time with dying and death, integration facilitates the processing of an existentially threatening situation. Depending on certain factors and circumstances, children also carry a substantial burden. In addition to professional psychological support, they also need assistance from adult caregivers. Children are thus an integral part of patient- and family-centered care of adult intensive care patients.

Identification of Children as Relatives With a Systematic Approach; a Prerequisite in Order to Offer Advice and Support

The purpose of this study was to elucidate conditions at all system levels in a specific health care service to develop practices for identification of children as relatives. An interactive research approach with the intention to create mutual learning between practice and research was used. The participating health care service cared for both clinic in- and outpatients with psychiatric disorders. Health care professionals from different system levels (micro, meso, macro) participated, representing different professions. At the first project meeting, it was obvious that there was no systematic approach to identify children as relatives. At the micro level, activities such as a pilot survey and an open house activity were carried out. At the meso level, it was discussed how to better support collaboration between units. At the management (macro) level, it was decided that all units should appoint at least one child agent, with the aim to increase collaboration throughout the whole health care service. To change focus, in this case from only parents to inclusion of children, is an important challenge faced by health care services when forced to incorporate new policies and regulations. The new regulations contribute to increased complexity in already complex organizations. This study highlights that such challenges are underestimated.

Children's and young people's experiences of a parent's critical illness and admission to the intensive care unit: A qualitative meta-synthesis

BACKGROUND

Little is known about how children and young people experience and manage the critical illness of a parent and a parent's admission to the intensive care unit (ICU).

OBJECTIVE

The aim of this study was to search and interpret the existing literature describing children's and young people's experiences of a parent's illness trajectory in the ICU.

METHOD

A qualitative meta-synthesis was conducted based on a systematic literature search of online databases.

FINDINGS

Four main themes were identified and synthesised to describe the integrated experiences of children and young people: (a) the parent-child bond, (b) the unfamiliar environment, (c) the impact of the illness and (d) the experience of being overseen as close family members.

CONCLUSION

Experiencing a parent's critical illness and admittance to the ICU is overwhelming. The bond between the parent and child is exposed by the separation from the ill parent. To comprehend and manage the experience, children and young people seek information depending on their individual capacities. They express a need to be close to their ill parent and to be seen and approached as close members of the family. However, children experience being overseen in their needs for support during their parent's ICU illness with the risk of being left in loneliness, sadness and lack of understanding of the parent's illness.

RELEVANCE FOR CLINICAL PRACTICE

Children and young people as relatives need to be acknowledged as close members of the family, when facing the illness trajectory of a parent, who is admitted to the ICU. They need to be seen as close family members and to be approached in their needs for support in order to promote their well-being during a family illness crisis. Early supportive interventions tailored to include children of the intensive care patient are recommended.

Contextualisation of patient-centred care: A comparative qualitative study of healthcare professionals' approaches to communicating with seriously ill patients about their dependent children

Patients' family relations play an important part in the provision of patient-centred cancer care, not least when healthcare professionals encounter seriously ill patients with dependent children. Little is known about how children are perceived and dealt with in clinical encounters. In this qualitative comparative study, we explore the influence of medical contexts in three Danish hospital wards, haematology, oncological gynaecology and neuro-intensive care, on communication with patients about their children. In exploring the degree to which the inclusion of children in clinical encounters is dependent on context, we took a comparative approach based on fieldwork in wards either exclusively focusing on cancer treatment or partially involved in critical phases of cancer treatment. We conducted 49 semi-structured, in-depth interviews with doctors and nurses, and 27 days of participant observation. The thematic analysis was based on Bateson's conceptualisation of communication. We found that healthcare professionals' approach to children in clinical encounters and the ways in which children were positioned on each ward were influenced by aspects specific to the ward, including the diagnosis and treatments that related specifically to the patient. Our findings suggest the need to explore further the influence of medical contexts on the inclusion of children in patient communication.

Children as relatives to a sick parent: Healthcare professionals’ approaches

An illness or injury sustained by a family member affects all family members. It is consequently important that a child’s need to be involved in a family member’s care is clearly recognized by healthcare professionals. The aim of this study was to describe healthcare professionals’ approaches to children as relatives of a parent being cared for in a clinical setting. A web-based study-specific questionnaire was sent and responded to by 1052 healthcare professionals in Sweden. Data were analysed using descriptive statistics and qualitative analysis. The results show that guidelines and routines are often lacking regarding involving children in the care of a parent. Compared to other areas, psychiatric units seem to have enacted routines and guidelines to a greater extent than other units. The results indicate that structured approaches based on an awareness of the children’s needs as well as a child-friendly environment are vital in family-focused care. These aspects need to be prioritized by managers in order to support children’s needs and promote health and wellbeing for the whole family.