A vulnerable population: families of patients in adult critical care

Striving for a safe ground-A lifeworld approach of family members' experiences of the critical illness trajectory

AIMS AND OBJECTIVES

To explore the experiences of family members after they have lived through a close one's illness trajectory starting with critical illness and intensive care treatment, throughout hospitalisation and after their return home, and describe what was important and challenging for them during this time.

BACKGROUND

Being family during and after critical illness and intensive care treatment may be traumatic and challenging. An in-depth understanding of family members' lifeworld throughout a close one's illness trajectory is needed.

DESIGN

A qualitative design with a phenomenological approach.

METHODS

We held ten interviews with eleven next of kin, nine of which were individual and one with a parent couple. The interviews lasted 90 minutes, on average, and were transcribed verbatim. Giorgi's phenomenological method guided the analysis.

RESULTS

The overall structure was 'striving for a safe ground for themselves and their close one', which was dependent on the three constituents of 'in need of care', 'to take on responsibility' and 'to create new understanding'. Throughout the illness trajectory, the family members required care to increase their feelings of safety in the context of their close one being unsafe. They described taking on responsibility for their close one-a responsibility that increased after hospital discharge-as demanding new knowledge which they were often unable to obtain.

CONCLUSIONS

Families of critically ill patients need to be seen on their own behalf. Moreover, when taking on responsibility for their close one, they regularly need more knowledge than they get. There seems to be an absence of a support system for families with caring responsibilities after their relatives are discharged from hospitals.

RELEVANCE TO CLINICAL PRACTICE

This study shows the importance of family carers being considered in their own right, as well as their individual needs throughout a close one's illness trajectory. There seems to be a gap in the knowledge of what family members require when their close one is discharged. Indeed, a better support system is essential for families following a hospital discharge.

Vulnerability: A concept synthesis and its application to the Emergency Department

AIM

The aim of this concept synthesis was to add clarity to the concept of vulnerability with application to the Emergency Department (ED) by critiquing, analysing and amalgamating published concept analyses.

BACKGROUND

The concept of vulnerability has been used widely, however it has various meanings. A clearer understanding of vulnerability and application to the ED may help healthcare professionals provide high quality care responsive to the needs of vulnerable individuals.

METHOD

Nine concept analyses of vulnerability were retrieved using Medline, CINAHL, and PsycINFO databases. After extracting data on each analysis, Walker and Avant's concept synthesis method was used to structure this synthesis, with a thematic synthesis approach used in the analysis.

FINDINGS

Four themes associated with vulnerability emerged from the synthesis. The first theme, vulnerability as a journey, reflected elements within an individual's life that perpetuate and exacerbate vulnerability. The second theme, vulnerability as susceptibility and risk, highlighted intrinsic and extrinsic elements that contribute to a state of risk. The third theme, positive and negative repercussions, emphasised lessons that can be learned from experience, with the fourth theme of a shared understanding indicating the importance of understanding the concept of vulnerability for patient care.

CONCLUSION

Findings from this synthesis highlight the multiple elements associated with a vulnerable state, evident in the context of the ED. With multiple ED-specific elements contributing to vulnerability, clarity of the term is important to inform ED-specific interventions designed to meet the needs of vulnerable populations.

The Impact of Social Support Networks on Family Resilience in an Australian Intensive Care Unit: A Constructivist Grounded Theory

PURPOSE

This article discusses the findings of a grounded theory of family resilience in an Australian intensive care unit (ICU) with a specific focus on families' experiences of their interactions with other members within their own family, and the families of other patients in the ICU.

DESIGN

A constructivist grounded theory methodology was adopted. Data were collected using in-depth interviews with 25 family members of 21 critically ill patients admitted to a tertiary-level ICU in Australia.

FINDINGS

The core category regaining control represents the families' journey toward resilience when in ICU. The major categories represent facilitators for, and barriers to, regaining control. One of the main facilitators is drawing strength, and it explains the manner with which families receive social support from their own and other family members to help them cope.

CONCLUSIONS

This study offers a framework to improve patient- and family-centered care in the ICU by facilitating families' ability to manage their situation more effectively. Social support offered by family members facilitates the families' ability to regain control. An ICU family resilience theoretical framework, situated within the context of the Australian healthcare system, adds to what is currently known about the families' experiences in the ICU.

CLINICAL RELEVANCE

The relationships that develop between families in the ICU may provide a source of social support; however, not all families welcome interactions with other ICU families, and it may cause further emotional distress. Further research is warranted to determine whether families suffer a secondary stress reaction from incidental interactions with other patients' families in the ICU. Furthermore, when family members pull together and offer social support to each other, they are better able to regain control. This process contributes to an ICU family resilience framework.

Searching for meaning: A grounded theory of family resilience in adult ICU

AIM

To explore families' experiences of their interactions in an Australian adult intensive care unit (ICU) to develop a grounded theory that can be used by critical care nurses to improve patient- and family-centred care (PFCC).

BACKGROUND

Families in ICU play an important role in the patient's recovery and outcomes. However, families are at risk of significant psychological morbidity due to their experiences in ICU. Although many ICU patients can make their own decisions, a large proportion are unconscious or chemically sedated and unable to contribute to decisions about their care, leaving the decision-making role to the family. Therefore, the families' psychosocial and emotional well-being must be supported by implementing evidence-based interventions that align with a PFCC approach. This study describes the findings of a grounded theory of family resilience in ICU, of which the core category is Regaining control. The focus of this paper is on the major category: Searching for meaning.

METHODS

We adopted a constructivist grounded theory method. Twenty-five adult family members (n = 25) of 21 patients admitted unexpectedly to an ICU in metropolitan Australia were recruited. In-depth interviews were used to collect the data, and the analytical processes of constructivist grounded theory underpinned the development of a core category and related subcategories.

RESULTS

When adult family members experience the unexpected admission of a relative to ICU, they move towards a state of being beyond emotional adversity and regaining control when facilitated to search for meaning in their situation. When families were able to make sense of their situation and find a purpose by contributing to their relative's recovery, it encouraged them to cope and be resilient.

CONCLUSIONS

Our findings can be used to promote PFCC in ICU, which considers a collaborative approach to meet the patient's needs while providing emotional and psychosocial support to their families.

A Randomized Controlled Pilot Study of a Manualized Intervention for Caregivers of Patients With Traumatic Brain Injury in Inpatient Rehabilitation

OBJECTIVE

Investigate effectiveness of a 5-session manualized intervention for addressing needs of caregivers of persons in acute traumatic brain injury (TBI) rehabilitation.

DESIGN

Prospective, pilot randomized controlled trial.

SETTING

Inpatient brain injury rehabilitation unit, level 1 trauma center.

PARTICIPANTS

Patients (N=93) with moderate-to-severe TBI and their family members were enrolled in the study with 42 randomized to the treatment group, 51 to the control group.

INTERVENTION

Five-session manualized caregiver intervention with educational, stress and anxiety self-management, coping, and emotional support components.

MAIN OUTCOME MEASURES

Family Needs Questionnaire-Revised, knowledge assessment, Zarit Family Burden Scale, and Brief Symptom Inventory-18 were collected at pretreatment, posttreatment, and 3-month follow-up.

RESULTS

Treatment group caregivers showed an increase in met needs for emotional, instrumental, and professional support, and brain injury knowledge from baseline to posttreatment, whereas controls did not. Between-group differences were significant for only emotional support needs. Treatment effects were not sustained at 3-month follow-up.

CONCLUSIONS

Caregivers of persons undergoing acute TBI rehabilitation may benefit from interventions that target their unique needs. Caregivers may require additional and longer-term supports to sustain treatment benefits.

Family Presence During Resuscitation After Trauma

The purpose of this study was to examine the effects of family presence during resuscitation (FPDR) in patients who survived trauma from motor vehicle crashes (MVC) and gunshot wounds (GSW). A convenience sample of family members participated within three days of admission to critical care. Family members of 140 trauma patients (MVC n = 110, 79%; GSW n = 30, 21%) participated. Family members ranged in age from 20-84 years (M = 46, SD = 15, Mdn = 47). The majority were female (n = 112, 80%) and related to the patient as spouse (n = 46, 33%). Participating in the FPDR option reduced anxiety (t = -2.43, p =.04), reduced stress (t = -2.86, p = .005), and fostered well-being (t = 3.46, p = .001). Results demonstrate the positive initial effects of FPDR on family members of patients surviving trauma injury.

Family members' satisfaction with care and decision-making in intensive care units and post-stay follow-up needs-a cross-sectional survey study

Aim

The aim of this study was to explore family members' satisfaction with care and decision‐making during the intensive care units stay and their follow‐up needs after the patient's discharge or death.

Design

A cross‐sectional survey study was conducted.

Methods

Family members of patients recently treated in an ICU were participating. The questionnaire contented of background variables, the instrument Family Satisfaction in ICU (FS‐ICU 24) and questions about follow‐up needs. Descriptive and non‐parametric statistics and a multiple linear regression were used in the analysis.

Results

A total of 123 (47%) relatives returned the questionnaire. Satisfaction with care was higher scored than satisfaction with decision‐making. Follow‐ up needs after the ICU stay was reported by 19 (17%) of the participants. Gender and length of the ICU stay were shown as factors identified to predict follow‐up needs.

Consolation or confrontation when interacting through an ICU diary - A phenomenological-hermeneutical study

OBJECTIVES

Exploring relatives' experience of interaction with other relatives when writing a diary for the critically ill patient.

RESEARCH METHODOLOGY

Qualitative interview data were analysed using a phenomenological-hermeneutical approach building on the theory of Ricoeur.

SETTING

Seven relatives, who had written a diary when their close relative was admitted to the intensive care unit at a regional hospital in Denmark, were interviewed after the patient had been discharged.

FINDINGS

Writing a diary for the critically ill patient implied creating the story together, which impacted the relationships of the relatives. However, the relationship between relatives determined who might author the diary and also the content of the diary. Authoring the diary could be both a powerful position to shape the story unfolding in the diary or a burdensome responsibility.

CONCLUSION

Authorship of the diary provided relatives with the power to influence the narrative in the diary. Co-authoring the diary allowed the relatives to incorporate the illness experience into a personal narrative, thereby influencing the formation of a family narrative. However, difficult relationships kept relatives from sharing emotions and understandings and could cause suffering among relatives and co-creation of the diary to fail.

ICU Bedside Nurses' Involvement in Palliative Care Communication: A Multicenter Survey

CONTEXT

Successful and sustained integration of palliative care into the intensive care unit (ICU) requires the active engagement of bedside nurses.

OBJECTIVES

To describe the perspectives of ICU bedside nurses on their involvement in palliative care communication.

METHODS

A survey was designed, based on prior work, to assess nurses' perspectives on palliative care communication, including the importance and frequency of their involvement, confidence, and barriers. The 46-item survey was distributed via e-mail in 2013 to bedside nurses working in ICUs across the five academic medical centers of the University of California, U.S.

RESULTS

The survey was sent to 1791 nurses; 598 (33%) responded. Most participants (88%) reported that their engagement in discussions of prognosis, goals of care, and palliative care was very important to the quality of patient care. A minority reported often discussing palliative care consultations with physicians (31%) or families (33%); 45% reported rarely or never participating in family meeting discussions. Participating nurses most frequently cited the following barriers to their involvement in palliative care communication: need for more training (66%), physicians not asking their perspective (60%), and the emotional toll of discussions (43%).

CONCLUSION

ICU bedside nurses see their involvement in discussions of prognosis, goals of care, and palliative care as a key element of overall quality of patient care. Based on the barriers participants identified regarding their engagement, interventions are needed to ensure that nurses have the education, opportunities, and support to actively participate in these discussions.

Benefit to Family Members of Delivering Hand Massage With Essential Oils to Critically Ill Patients

BACKGROUND

In intensive care environments, patients' families are often encouraged to participate in their loved one's care; however, many family members feel anxious, depressed, and unsure about how to help patients.

OBJECTIVES

To determine (1) the feasibility of teaching family members a simple intervention combining hand massage with essential oils in a trauma intensive care unit and (2) an effect size for use in designing a more powerful trial.

METHOD

A quasi-experimental pilot study of the effect of a family-delivered touch treatment on anxiety and depression of family members of patients. Fifteen family members were assigned to a treatment group, and 15 family members were assigned to a control group. The treatment consisted of the application of hand massage with essential oils for 6 sessions. Each session lasted 5 minutes and was presented twice a day for 3 days.

RESULTS

The 5-minute intervention was associated with positive change in anxiety and depression scores on the Hospital Anxiety and Depression Scale (HADS) among family members visiting patients. The magnitude of change (improvement) in anxiety scores within the group of treated family members was significantly greater than within family members in the control group.

CONCLUSION

Administering a brief hand massage using pleasant-smelling oils to patients in an intensive care unit may reduce anxiety of family members who administer the treatment.