[Modification of nursing practice through reflection: participatory action research]

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.

Main information requests of family members of patients in Intensive Care Units

OBJECTIVE

To compile an inventory of information requests prioritized by the family members, to find out which professionals them consider able to respond these requests, and to explore the differences in perception between family members and professionals.

DESIGN

Qualitative analysis of content validation and descriptive cross-sectional study.

SCOPE

41 Spanish ICU.

PARTICIPANTS

Relatives, physicians and nurses of critical patients.

INTERVENTION

From an initial list of questions extracted from literature review, physicians, nurses, and relatives of critical patients incorporated issues that they considered not included. After analyzing content validity, a new list was obtained, which was again submitted to the participants' assessment to evaluate the level of importance that they assigned to each question and which professional they considered appropriate to answer it.

RESULTS

most important questions for the relatives: concern about the clinical situation, measures to be taken, prognosis and information. There was a coincidence between relatives and professionals in the priority issues for families. There were significant differences in the importance given to each question: between doctors and relatives (72/82 questions), and between nurses and relatives (66/82 questions) (P<.05). For the relatives, 63% of the questions could be answered by doctors or nurses, 27% preferably by doctors and 10% by nurses.

CONCLUSIONS

The most relevant issues for families were prognosis and severity, but also the need for information. Healthcare professionals tend to underestimate the importance of many of the questions that concern families. Relatives feel that most of their concerns can be resolved either by doctors or nurses.

[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.

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.

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.

[Perception of the critical patient on nursing cares: an approach to the concept of satisfaction]

INTRODUCTION

Level of satisfaction is a key indicator of quality of care. There are many tools that measure satisfaction with nursing care, however they do not respond to the reality of the critical care patient or to our context.

OBJECTIVES

To define and to identify the dimensions of the satisfaction of patients admitted to the intensive care unit of a tertiary hospital with nursing cares and to define and identify the dimensions of the concept of satisfaction from their point of view.

MATERIAL AND METHODS

A qualitative research study was conducted according to the Grounded Theory Method in three Intensive Care Units with 34 individual boxes, with theoretical sampling. Nineteen patients remained after data saturation sampling. Data collection was obtained through recorded in-depth interviews and field logbook. Contents analysis was made according to the Grounded Theory. Guba and Lincoln rigor's criteria were followed. There was a favorable report from the Hospital's Ethics Committee and informed consent was obtained from the patients.

RESULTS

Four categories were found: The definition and dimensions of the satisfaction concept, expectations and life experiences. The participants included the following dimensions in their satisfaction definition: professional competences, human, technical and continuous cares. The combination of these elements produces feelings of security, calmness, being monitored, feeling like a person, perceiving a close relationship and trustfulness with the nurse who performs the individualized cares.

CONCLUSIONS

The definition and dimensions of satisfaction concept from the patient's point of view show the important aspects of the person and also clarify their dimensions, allowing the construction of tools more in line with the context and real perception.

[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.

[Needs of the family in the intensive care units: a review of the literature]

Admission to the Intensive Care Units (ICU) is perceived by both patients and their family as a stressful experience. This situation can cause shock, skepticism and anxiety in the patient's setting.

OBJECTIVE

To analyze and present the needs of the family members of the critical patient.

METHODOLOGY

A review was made of the literature in the following data bases: Pubmed, CINAHL, Cuiden and Cochrane Library. Furthermore, three journals specialized in Intensive Cares were reviewed.

RESULTS

After including the articles that met the screening criteria, 30 articles were finally selected. Of these, 11 were reviews of the literature, 7 qualitative studies and 12 more were quantitative investigations. Four groups of needs in the families were identified after the analysis of these articles, these being cognitive, emotional, social and practical.

DISCUSSION

One of the main needs of the family is to receive better information from the professionals followed by the need for closeness with the ill family member. This review proposes that, in order to cover these needs, the information should be protocolized and the visiting hours should be made flexible. Furthermore, incorporation of two familial evaluation tools, the genogram and ecomap, is proposed.

CONCLUSIONS

This work has revealed the importance of having the Intensive Care nurses identify the needs of the family during the admission of the patient in the ICU in order to be able to provide help, support and counseling care that relieves the suffering of the families.

[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.

Effectiveness of the implementation of an evidence-based nursing model using participatory action research in oncohematology: research protocol

AIM

To generate changes in nursing practice introducing an evidence-based clinical practice (EBCP) model through a participatory process. To evaluate the effectiveness of the changes in terms of nurse-sensitive outcome (NSO).

BACKGROUND

For international nursing science, it is necessary to explore the reasons for supporting EBCP and evaluate the real repercussions and effectiveness.

METHODS

A mixed methods study with a sequential transformative design will be conducted in the bone marrow transplant unit of a tertiary-level Spanish hospital, in two time periods >12 months (date of approval of the protocol: 2006). To evaluate the effectiveness of the intervention, we will use a prospective quasi-experimental design with two non-equivalent and non-concurrent groups. NSO and patient health data will be collected: (a) impact of psycho-social adjustment; (b) patient satisfaction; (c) symptom control; (d) adverse effects. All patients admitted during the period of time will be included, and all staff working on the unit during a participatory action research (PAR). The PAR design will be adopted from a constructivist paradigm perspective, following Checkland's "Soft Systems" theoretical model. Qualitative techniques will be used: 2-hour group meetings with nursing professionals, to be recorded and transcribed. Field diaries (participants and researchers) will be drawn up and data analysis will be carried out by content analysis.

DISCUSSION

PAR is a rigorous research method for introducing changes into practice to improve NSO.

[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.

[Development of an attention guideline for the critical patient's family]

INTRODUCTION

Within the context of participatory action research (PAR) at an Intensive Care Unit (ICU), 4 proposals for change were agreed by consensus to improve the attention given to families of critical patients. One proposal was the creation of a guideline for attending to family members, inspired by the participants' desire to improve the attention given to this group of users.

OBJECTIVES

1) To design a guide that would meet the needs of professionals and users. 2) To reach an agreement on the minimum requirements for attention given to families of critical patients.

MATERIALS AND METHODS

Qualitative methodology, based on PAR. For each of the initiatives, a working group was created, composed mainly of professionals from the ICU coordinated by a researcher. In the case of the guide, an online community was also created as a working tool to speed up communications among the participants, reducing the number of face-to-face sessions. Participation was voluntary. To draft the guideline, a Clinical Practice Guideline for support the family was made available, which had been translated into Spanish, together with an up-to-date bibliography.

RESULTS

Twenty four professionals were involved. We developed a guide that contained the following sections: introduction, objectives, the experiences and needs of families of patients in the ICU, strategies for action, specific procedures, and hospital resources. We designed strategies for the diffusion and implementation of the guide.

CONCLUSIONS

The guide is a useful tool that offers the professionals greater assurances and unifying criteria for action. During subsequent stages of the PAR project, an assessment will be made of the impact on professionals and users.

[Needs of the families in a Critical Care Unit]

OBJECTIVES

To identify the needs of the family of admitted patients in the Critical Care Unit (CCU), and their level of satisfaction with the attention that they received.

DESIGN

Cross-sectional, observational study.

SETTING

Critical Care Unit, Virgen Macarena University Hospital, Seville. SUBJECTS OF THE STUDY: Two-hundred and sixty-eight families were selected through a random sampling system.

INSTRUMENTS

A survey was developed using bibliography as reference.

RESULTS

According to information, it was observed that receiving information after visiting hours and its access was difficult in regards to unforeseen changes in the patient's course. On the other hand, there were high levels of satisfactions with the attention received and with the nursing cares. Nevertheless, several deficiencies were observed in the identification of all the professionals, the visiting hours, the physical conditions of the waiting room, and privacy within patient's care environment.

CONCLUSIONS

One of the principal needs of the relatives was to spend more time with the patients. Regarding to the information, access after visiting hours, and on that regarding unforeseen changes in the patient's evolution should be reviewed. Regarding satisfaction, in general, families were highly satisfied with the attention received, especially with the nurse's care. Nevertheless, these professionals should encourage the participation of the families in the patient's care. Moreover, all the areas of improvement observed should be dealt with urgently, mainly the visiting hours.

[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.

[What is important for the family of patients in the intensive care unit?]

The abundant bibliography shows us that the family plays a fundamental paper in the recovery of the hospitalized patients, and the patients in the intensive care units (ICU) are no exception. Several authors have demonstrated that a stress-free and calm setting helps in the care process. Thus, the family needs must be considered to improve their well-being. In this way, their attitude will help in the patient's recovery. Health care personnel must be aware of these needs and make up for their deficit as far as possible. The first study that evaluated this question used the CCFNI questionnaire (Critical Care Family Needs Inventory) that measures the degree of importance given by the relatives to the needs of safety, support, information, comfort and proximity. This study has aimed to detect the degree of importance given by the relatives of the patients in the ICU of the Hospital Dr. Josep Trueta of Girona, using the CCFNI questionnaire. All the relatives of the patients in said unit during the autumn of the year 2003 were interviewed and the needs considered to be most important were compared with the sociodemographic variables of the relatives. The total sample was made up of the 132 people interviewed. The need considered to be most important was safety with 50.3% followed by need for support with 47.2%. In the results, some differences were observed depending according to age and studies of those surveyed and according to the diagnosis and the origin of the hospitalization. The collected data did not differ with the reviewed bibliography. All the study was very valuable for the health care professionals of the unit and was taken into account to improve the deficiencies of the ICU of the hospital of Girona.

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

We conducted research to study nurses' views on factors that influence their relationship with patients' relatives in intensive care units in three hospitals in Mallorca (Balearic Islands, Spain). This article focuses on the findings related to the process of giving information to the family. We used a post-structuralist theoretical framework and data were collected through observations and interviews. The analysis revealed that nurses thought information eases relatives' worries, but they felt that in order to avoid conflicts with physicians they should restrain themselves from providing it. We propose that the existing power relationships in intensive care units should be challenged if we expect health care professionals to offer patients' relatives a planned information process.

A preventative health education programme for osteoporosis

BACKGROUND

Osteoporosis is a preventable disease that is usually not managed until the disease becomes evident, although it places huge economic and social burdens on societies worldwide. It is predicted that this burden will grow if left unchecked. Despite this, evidence suggests that osteoporosis prevention activity is given a low priority, and services often only provide biomedically-based programmes, in which resources are predominantly allocated to screening and pharmacological treatments. Referral to these services mostly occurs when a client is already known to have osteoporosis or to be at risk, rather than as an early preventative intervention.

AIM

This paper reports an action research project with one hospital osteoporosis service. The aim of the project was to assess the current service, identify areas where change was needed, and evaluate the implementation of such changes.

METHOD

Participatory action research was used, with group meetings and reflective journals to collect data for analysis. The process involved assessment of a preventative osteoporosis service, and determination of clinical issues and problems, and it aided decisions on an appropriate course of organizational reform and evaluated any change processes as they occurred. It also encouraged participants to reflect on and evaluate their experiences of using a participatory framework.

CONCLUSION

A change programme was implemented that focused on preventative health education activity in a range of clinical settings. Over the two and a half years of the project, the osteoporosis service expanded its programme to include a wide range of preventative activities, running alongside other organizational reforms.

¿Qué perspectiva tienen las enfermeras de unidades de cuidados intensivos de su relación con los familiares del paciente crítico?

Introduction and aim. Nursing professionals in intensive care units (ICU) face situations of uncertainty and anxiety, above all in patients' relatives. In the literature, we find that the way in which the family and their needs are valued by professionals in the unit is not very systematical, even though there are instruments that have been validated for this purpose. Therefore, we decided to value what perspective ICU nurses have of the relationship they establish with patients' relatives, in order to find possible explanations for this situation. Material and methods. A qualitative study with a critical-social orientation. This was carred out in three ICUs in three state hospitals in Mallorca. Research techniques: 8 observations of the visit of relatives to the unit and 6 semi-structured interviews with nurses from the three hospitals. The transcripts of the interviews were analysed and codified in significance units. Sources and methods were triangulated.Results. Categories of the relationship process: 1) who the social actors are; 2) what the actions of the nurses with respect to the relatives are; 3) what the relationships are like between both; and 4) expectations of the nurses regarding this relationship.Conclusions. a) It is necessary to establish quality standards for attending the relatives of critical patients. b) Continuous nursing training is necessary in order to provide emotional support to families and to protect nurses from the added stress involved in providing this emotional support.