The process of giving information to families of critically ill patients: a field of tension

The process of giving information to families in intensive care units: A narrative review

AIM

Information is one of the most important needs of families of critical patients. Healthcare professionals also identify the great value of communication with families to reduce their anxiety and stress. Despite this, families may feel inadequately informed, causing added suffering. The purpose of this study is to provide an understanding of both families' and healthcare professionals' perspectives on information giving within intensive care units (ICU).

METHOD

A narrative review was conducted using MEDLINE, CINAHL, PsycINFO databases and the Cochrane Library to identify studies published in either English or Spanish from 2002 to 2018.

RESULTS

47 studies were included, and five categories were identified: 1)"the need to know"; 2)family satisfaction with the information received; 3)impact of information on families' experiences in the ICU; 4)nurses and physicians' perceptions of information transmission, and 5)information process in the ICU.

CONCLUSIONS

Providing honest and truthful information to the families of critical patients is essential to reduce family anxiety and increase family control, although this often appears to be inadequately accomplished by staff. Interdisciplinary involvement in information giving may be beneficial for both families and ICU professionals. This review brings new understanding about the process of information to families of ICU patients and it can be used to improve the quality and humanization of care in the ICUs.

Experience of care through patients, family members and health professionals in an intensive care unit: a qualitative descriptive study

BACKGROUND

A patient's stay in an intensive care unit (ICU) can lead to psychological and social alterations in patients and their nearest family circle. Healthcare staff and patients' family members strongly influence patients' stays in ICU.

AIMS

To explore the perceptions about the experiences of patients in the ICU, their family members and nurses who attend them.

METHODS

A descriptive phenomenological design was used to guide the research. A purposive sample of 27 male and female participated. Nine hospitalised patients, nine nurses and nine family members were interviewed in 2016 using a semi-structured, face to face interview. Steps of Giorgi phenomenological method were used to analyse the qualitative data.

FINDINGS

Among the three categorised groups, there is a common point that is the constant of humanization in care and it is very clear on the part of the patient, the patient's family and the nurses whom they attend. In addition, both in the group of patients and in the group of families allude to the fear and anguish that responds to patients, this problem does not appear in the speeches of nurses, who are torn between excessive technology and the performance of their work correctly for better patient welfare.

CONCLUSIONS

A stay in an ICU implies emotional expense for both patients and their families, which leads to a series of changes in their affective and social sphere, manifested by a set of requirements that must be responded by the multidisciplinary team that attends to patients. It would be fundamental to inform the health authorities about these requirements in order to modify the usual conduct habits displayed in ICU, which would help improve all levels for patients, their families and nurses.

Implementation of the evidence for the improvement of nursing care to the critical patient's family: a Participatory Action Research

BACKGROUND

There are many descriptive studies regarding the needs of the family, as well as those regarding nursing care aimed directly at family members. However, there is no widespread application of such evidence in clinical practice. There has also been no analysis made of the evolution of patterns of knowing during the act of improving clinical practice. Therefore, the purpose of the study is to understand the change process aimed at improving care to critical patient's families, and to explore the evolution of patterns of knowing that nurses use in this process.

METHODS

Qualitative study with a Participatory Action Research method, in accordance with the Kemmis and McTaggart model. In this model, nurses can observe their practice, reflect upon it and compare it with scientific evidence, as well as define, deploy and evaluate improvement strategies adapted to the context. Simultaneously, the process of empowerment derived from the Participatory Action Research allows for the identification of patterns of knowing and their development over time. The research will take place in the Intensive Care Units of a tertiary hospital. The participants will be nurses who are part of the regular workforce of these units, with more than five years of experience in critical patients, and who are motivated to consider and critique their practice. Data collection will take place through participant observation, multi-level discussion group meetings and documentary analysis. A content analysis will be carried out, following a process of codification and categorisation, with the help of Nvivo10. The approval date and the beginning of the funding were December 2012 and 2013, respectively.

DISCUSSION

The definition, introduction and evaluation of care strategies for family members will allow for their real and immediate implementation in practice. The study of the patterns of knowing in the Participatory Action Research will be part of the theoretical and practical feedback process of a professional discipline. Also, the identification of the construction and evolution of knowledge will provide decision elements to managers and academics when choosing strategies for increased quality.

[Satisfaction of relatives of the patients admitted to an intensive careunit: Perceptions of relatives and professionals]

OBJECTIVES

To estimate the satisfaction of relatives of critical care patients with regard to the environment, relationship with professionals and visitation and compare it to the perception of professionals.

METHODOLOGY

A descriptive study in two phases. In the first phase validated telephone survey within 15 days of discharge to the relatives of the patients was performed. In the second phase, the same modified questionnaire was self-administered to the professionals. The same variables were studied in both populations.

RESULTS

We interviewed 78 family members and 44 professionals. 95% of professionals vs 67% of the families claimed not to know the name of the nurses (P < .001). Over 70% of professionals and families agreed that the visit protocol is correct and that the information was adequate income. 70% of professionals felt that the information received at admission is not understood by the family although 97% of households claimed to have understood themselves. Statistically significant differences were observed in relation to the location of the unit assessment, the waiting, the aspects of information and comfort, always being the professionals who felt greater dissatisfaction (P < .05).

CONCLUSIONS

The perceptions of relatives and professionals were mostly uneven, making it necessary to continue exploring the differences through qualitative and participatory methodologies.

Patient and family involvement in adult critical and intensive care settings: a scoping review

BACKGROUND

Despite international bodies calling for increased patient and family involvement, these concepts remain poorly defined within literature on critical and intensive care settings.

OBJECTIVE

This scoping review investigates the extent and range of literature on patient and family involvement in critical and intensive care settings. Methodological and empirical gaps are identified, and a future agenda for research into optimizing patient and family involvement is outlined.

METHODS

Searches of MEDLINE, CINAHL, Social Work Abstracts and PsycINFO were conducted. English-language articles published between 2003 and 2014 were retrieved. Articles were included if the studies were undertaken in an intensive care or critical care setting, addressed the topic of patient and family involvement, included a sample of adult critical care patients, their families and/or critical care providers. Two reviewers extracted and charted data and analysed findings using qualitative content analysis.

FINDINGS

A total of 892 articles were screened, 124 were eligible for analysis, including 61 quantitative, 61 qualitative and 2 mixed-methods studies. There was a significant gap in research on patient involvement in the intensive care unit. The analysis identified five different components of family and patient involvement: (i) presence, (ii) having needs met/being supported, (iii) communication, (iv) decision making and (v) contributing to care.

CONCLUSION

Three research gaps were identified that require addressing: (i) the scope, extent and nature of patient involvement in intensive care settings; (ii) the broader socio-cultural processes that shape patient and family involvement; and (iii) the bidirectional implications between patient/family involvement and interprofessional teamwork.

Transforming a conservative clinical setting: ICU nurses' strategies to improve care for patients' relatives through a participatory action research

This study focuses on change strategies generated through a dialogical-reflexive-participatory process designed to improve the care of families of critically ill patients in an intensive care unit (ICU) using a participatory action research in a tertiary hospital in the Balearic Islands (Spain). Eleven professionals (representatives) participated in 11 discussion groups and five in-depth interviews. They represented the opinions of 49 colleagues (participants). Four main change strategies were created: (i) Institutionally supported practices were confronted to make a shift from professional-centered work to a more inclusive, patient-centered approach; (ii) traditional power relations were challenged to decrease the hierarchical power differences between physicians and nurses; (iii) consensus was built about the need to move from an individual to a collective position in relation to change; and (iv) consensus was built about the need to develop a critical attitude toward the conservative nature of the unit. The strategies proposed were both transgressive and conservative; however, when compared with the initial situation, they enhanced the care offered to patients' relatives and patient safety. Transforming conservative settings requires capacity to negotiate positions and potential outcomes. However, when individual critical capacities are articulated with a new approach to micropolitics, transformative proposals can be implemented and sustained.

Resolving Communication Challenges in the Intensive Care Unit

Communication in the intensive care unit (ICU) is challenging because of complexity, high patient acuity, uncertainty, and ethical issues. Unfortunately, conflict is common, as several studies and reviews confirm. Three types of communication challenges are found in this setting: those within the ICU team, those between the ICU team and the patient or family, and those within the patient’s family. Although specific evidence-based interventions are available for each type of communication challenge, all hinge on clinicians being culturally competent, respectful, and good communicators/listeners. Critical care advanced practice nurses promote a positive team environment, increase patient satisfaction, and model good communication for other clinicians. All advanced practice nurses, however, also need to be adept at having difficult conversations, handling conflict, and providing basic palliative care, including emotional support.

Causes and consequences of disproportionate care in intensive care medicine

PURPOSE OF REVIEW

Increased use of advanced life-sustaining measures in patients with poor long-term expectations secondary to more chronic organ dysfunctions, comorbidities and/or a poor quality of life has become a worrying trend over the last decade. This can lead to futile, disproportionate or inappropriate care in the ICU. This review summarizes the causes and consequences of disproportionate care in the ICU.

RECENT FINDINGS

Disproportionate care seems to be common in European and North American ICUs. The initiation and prolongation of disproportionate care can be related to hospital facilities, healthcare providers, the patient and his/her representatives and society. This can have serious consequences for patients, their relatives, physicians, nurses and society.

SUMMARY

Disproportionate care is common in western ICUs. It can lead to violation of basic bioethical principles, suffering of patients and relatives and compassion fatigue and moral distress in healthcare providers. Avoiding inappropriate use of ICU resources and disproportionate care in the ICU should have high priority for ICU managers but also for every healthcare provider taking care of patients at the bedside.

Factors limiting and facilitating changes in caring for the intensive care unit patients' relatives

AIM

To explore how the intensive care unit (ICU) context influenced receptivity to change in clinical practice, in order to improve the care offered to patients' relatives.

BACKGROUND

Families of critically ill patients have unmet needs that are not being addressed. Lack of attention to these needs is related more to the ICU context than to a lack of scientific evidence.

DESIGN

Participatory action research (PAR), a qualitative study conducted in a Spanish ICU.

METHOD

Eleven participants agreed to represent their teams in all scheduled group discussions. Field diaries were kept by the principal investigator and discussion participants, and five in-depth interviews were conducted. Content analysis was performed.

RESULTS

Four factors limited change: (1) Not acknowledging the legitimacy of scientific evidence regarding the families of critically ill patients. (2) Imbalanced power relationships between the members of multidisciplinary teams. (3) Lack of nurse participation in the information flows. (4) The organization of time and physical space in the unit. Three factors facilitated change: (1) A sense of individual and shared commitment. (2) Leadership in day-to-day matters. (3) A process based on reflection.

CONCLUSIONS

PAR can lead to change in clinical practice, although the process is complex and requires substantial input of time and energy. Contextual factors limiting this change were structural whereas facilitating factors were circumstantial and depended upon individuals' characteristics. Professionals working at the bedside are capable of identifying, developing and introducing changes to the context in which they work.

RELEVANCE TO CLINICAL PRACTICE

Knowing these factors and sharing the experience of a successful change process can help others design processes appropriate to their site.

Family Perceptions of Intensive Care Unit Nurses' Roles: A Greek Perspective

This study was done in order to examine the role of the nurse in families with critically ill patients as perceived by family members. A descriptive design was conducted with 93 family members aged 18-53 years from a 6-bed intensive care unit in a Greek Hospital. An anonymous self-completed questionnaire recording demographic data and the questionnaire Family members perception of nurses behavioral role expectation/enactment scale of Hickey and Lewandowski was used. Parametric statistic tests were used to examine the research questions. Intensive care unit (ICU) patients’ family members expect nurses to make them feel they can ask whatever they want whenever they want, placing great emphasis on communicating with one another and on participating in decision making to the progress of patient care. The age seems to correlate with the expectation from nurse to meet the role of training on how to handle the patient. Nurses did well with regard to meeting family members’ expectations. Most family members assessed positively the role of ICU nurse confirming the need for communication, and clear support of families.

[Limiting and facilitating factors of changes in the care of families of the critically ill patient]

INTRODUCTION

Participatory action research (PAR) was conducted in an intensive care unit (UCI), with the general purpose of fostering change in clinical practice so as to improve the care offered to families of critically ill patients. As a result of this process, four change-related initiatives were introduced. One specific additional objective was to explore how the unit's background context limited or facilitated change. This paper presents findings based on this objective.

MATERIALS AND METHODS

Qualitative methodology.

DESIGN

Participatory-action research (PAR). DATA GATHERING TECHNIQUES: 11 discussion groups incorporating professionals, 5 in-depth interviews with professionals, field diaries kept by the participants, and field diary kept by the lead researcher. Eleven professionals took part in the discussion groups (each one conveyed information made known to them by 3-5 colleagues), 5 professionals were involved in the interviews, and 11 professionals filled in a field diary. A content analysis was performed.

RESULTS

Factors limiting change included: 1) Not acknowledging the legitimacy of scientific evidence regarding the families of critically ill patients; 2) Imbalanced power relationships among the members of multi-disciplinary teams; 3) Nurses' lack of involvement in information flow; 4) The organization of time and physical space in the unit. Factors facilitating change: 1) A sense of individual and shared commitment; 2) Leadership in day-to-day matters; 3) A process based on reflection.

CONCLUSIONS

A process of participatory action research can lead to change in clinical practice, although this is complex and requires substantial input in terms of personal energy. Contextual factors limiting this change are related to the actual structure of the unit, while factors facilitating it are circumstantial ones and are dependent upon individual people. In this sense, professionals working at the bedside are capable of introducing changes to the context in which they work.

Nursing Roles and Strategies in End-of-Life Decision Making in Acute Care: A Systematic Review of the Literature

The objective of this paper is to analyze the literature concerning nurses' roles and strategies in EOL decision making in acute care environments, synthesize the findings, and identify implications for future research. We conducted searches in CINAHL and PubMed, using a broad range of terms. The 44 articles retained for review had quantitative and qualitative designs and represented ten countries. These articles were entered into a matrix to facilitate examining patterns, themes, and relationships across studies. Three nursing roles emerged from the synthesis of the literature: information broker, supporter, and advocate, each with a set of strategies nurses use to enact the roles. Empirical evidence linking these nursing roles and strategies to patients and family members outcomes is lacking. Understanding how these strategies and activities are effective in helping patients and families make EOL decisions is an area for future research.

[Improving the care of critical patient family members: Agreed on strategies]

INTRODUCTION

Within the context of participatory action research (PAR), a 4-stage process was established with the general aim of promoting improvements in the care offered to families of patients in the Intensive Care Unit (ICU). The 4 stages consisted of a situational diagnosis, proposals for change, the design and implementation of the proposals, and an evaluation. This paper presents the first 2 stages.

OBJECTIVES

To define the attention given to families of patients in the Intensive Care Unit. To reach a consensus on areas for action/intervention in the unit.

MATERIALS AND METHOD

A qualitative methodology.

DESIGN

PAR. Data-collection technique: 4 focus groups made up of 10 professionals, and consensus with support groups made up of 30 members. Content analysis was performed. The theoretical saturation point was reached.

RESULTS

Two documents were drawn up: 1) A situational diagnosis, describing the current situation of the attention given to families and 2) 10 proposals for change, 5 of which were given priority. They were: a session to familiarize professionals with evidence concerning families of patients in the ICU and the handing out of informative leaflets, the improvement of (nurse-family and intra-team) informative procedures, more privacy for patients and a reduction in environmental noise, a training plan for professionals, and change in the visiting policy.

CONCLUSION

By using consensus-based methodologies, strategies for change can be prioritized and designed, adapted to the context in which they will be applied.

[Opening the intensive care unit to families: what do the professionals think?]

AIM

A participatory action-research was conducted in an intensive care unit (ICU). A consensus was reached on four proposals for change regarding how to deal with the relatives of the critically ill patients, extending their visiting hours being one of these proposals. This study has aimed to ascertain the contributions of the unit professionals to a new proposal regarding visiting hours.

PARTICIPANTS AND METHODS

The sample included 93 ICU professionals out of 205. A qualitative methodology study that included a two-item open survey was used: 1. Yes, I agree with the proposal (explain how you would improve it); 2. No, I do not agree with the proposal (explain why and how you would improve it). Content analysis and triangulation of researchers and participants were performed. The theoretical saturation point was reached.

RESULTS

Five categories emerged: 1) Modify the initial proposal; 2) Agreement with the proposal; 3) Doubts; 4) Barriers to implementation; 5) Flexibilization.

CONCLUSIONS

ICU professionals are reluctant to open their units, but accept the extension of current visiting hours. The physical structure of the unit is perceived as a major barrier.

Surrogate consent for genomics research in intensive care

Surrogate decision makers may be poorly prepared to give informed consent for genomics research for their loved ones in intensive care. A review of the challenges and strategies associated with obtaining surrogates' consent for genomics research in intensive care patients revealed that few well-controlled studies have been done on this topic. Yet, a major theme in the literature is the role of health care professionals in guiding surrogates through the informed consent process rather than simply witnessing a signature. Informed consent requires explicit strategies to approach potential surrogates effectively, educate them, and ensure that informed consent has been attained.

[Analysis of the literature on the relatives of the critical patient: research in effective care needs to be performed]

AIM

To explore the nature of studies on families and the Intensive Care Unit context and the issues they deal with.

DESIGN AND METHODS

This is a qualitative, methodological study that makes a documental analysis of 24 articles (between 1993-2004) located by descriptors in journals and databases. A double analysis was conducted: quality assessment and content analysis.

RESULTS

The articles analyzed were mainly descriptive and reviews of the literature. Six categories were found: environment hostility, family needs, design of interventions, nursing care, experience of the families, and decision making autonomy.

CONCLUSIONS

The nursing staff wants to establish care aimed at the patient's family. To do so, they need to be trained in psychological aspects such as handling of emotional stress, strategies and skills for coping and communication strategies and skills. Research should change its focus from being description to proposing and evaluating intervention strategies. Research findings should translate into recommendations for this change.

Short- and long-term impact of critical illness on relatives: literature review

AIM

This paper is a report of a literature review undertaken to identify the short- and long-term impact of critical illness on relatives.

BACKGROUND

Patients in intensive care can experience physical and psychological consequences, and their relatives may also experience such effects. Although it is recognized that relatives have specific needs, it is not clear whether these needs are always met and whether further support is required, particularly after intensive care.

DATA SOURCES

The following databases were searched for the period 1950-2007: Medline, British Nursing Index and Archive, EMBASE, CINAHL, PsycINFO and EMB Reviews--Cochrane Central Register of Clinical Trials.

SEARCH METHODS

Search terms focused on adult relatives of critically ill adult patients during and after intensive care. Recurrent topics were categorized to structure the review, i.e. 'relatives needs', 'meeting relatives' needs', 'interventions', 'satisfaction', 'psychological outcomes' and 'coping'.

RESULTS

Studies have mainly identified relatives' immediate needs using the Critical Care Family Needs Inventory. There are few studies of interventions to meet relatives' needs and the short- and long-term effects of critical illness on relatives.

CONCLUSION

Despite widespread use of the Critical Care Family Needs Inventory, factors such as local or cultural differences may influence relatives' needs. Relatives may also have unidentified needs, and these needs should be explored. Limited research has been carried out into interventions to meet relatives' needs and the effects of critical illness on their well-being, yet some relatives may experience negative psychological consequences far beyond the acute phase of the illness.

Close relatives in intensive care from the perspective of critical care nurses

AIM

The aim was to describe critical care nurses' experiences of close relatives within intensive care.

BACKGROUND

There is a lack of research describing critical care nurses' experiences of the significance of close relatives in intensive care. Knowledge in this area will support critical care nurses to develop good nursing care for the critically ill person and their close relatives.

DESIGN AND METHOD

The design of the study was qualitative. Data collection was carried out through focus group discussions with 24 critical care nurses in four focus groups during spring 2004. The data were subjected to qualitative thematic content analysis.

RESULTS

The focus groups discussions showed that the presence of close relatives was taken for granted by critical care nurses and it was frustrating if the critically ill person did not have any. Information from close relatives made it possible for critical care nurses to create individual care for the critically ill person. They supported close relatives by giving them information, being near and trying to establish good relations with them. Close relatives were important. Critical care nurses lacked forums for reflection and discussion about the care given.

RELEVANCE TO CLINICAL PRACTICE

This study indicates that close relatives are a prerequisite for critical care nurses to give good nursing care to meet the needs of the critically ill person. A communication based on mutual understanding is necessary if critical care nurses are to be able to support close relatives. Dealing constantly with situations that were ethically difficult without any chance to reflect was an obstacle for critical care nurses to improve their work with close relatives.