The meaning and importance of vigilant attendance for the relatives of intensive care unit patients

Close relatives' perspective of critical illness due to COVID-19: Keeping in touch at a distance

AIM

To elucidate the meaning of being a close relative of a critically ill person cared for in intensive care during the initial phase of the COVID-19 pandemic.

DESIGN

A narrative inquiry design following the COREQ guidelines.

METHODS

Individual interviews with fifteen close relatives of patients critically ill with COVID-19 were analysed using phenomenological hermeneutics.

RESULTS

The surreal existence of not being allowed to be near was emotionally difficult. While distancing due to restrictions was challenging, physicians' phone calls served as a connection to their relatives and brought a sense of security. Keeping notes helped them remember what happened and brought order to a chaotic situation.

CONCLUSION

Close relatives feel secure when they receive regular information about their critically ill relative, not just when their condition worsens. They wish to be physically near to their critically ill person; when this is impossible, digital technology can provide support, but further accessibility developments are needed.

The needs and experiences of critically ill patients and family members in intensive care unit of a tertiary hospital in Malaysia: a qualitative study

BACKGROUND

Admission to an intensive care unit (ICU) is a stressful experience for patients and their family members. While the focus of management is primarily on medical care, there can be other areas which are overlooked. The purpose of this study was to investigate the needs and experiences of ICU patients and family members.

METHOD

This qualitative study involved four trained researchers conducting in-depth interviews (IDI) based on a semi-structured interview guide. The participants were ICU patients and family members. All IDIs were audio-recorded and transcribed verbatim. Four researchers independently analyzed the data via thematic analysis with the aid of QDA Miner Lite®. The themes and subthemes were generated and confirmed by literature and expert opinion.

RESULTS

Six IDIs were conducted with three patients and three family members, whose ages ranged from 31 to 64 years old. One pair of participants consisted of a patient and his respective family member, while the other four participants did not have a familial relationship with each other. Three main themes emerged from the analysis: (I) critical care services; (II) physical spaces; and (III) monitoring technology. Medical, psychological, physical, and social needs for critical care services were expressed by both patients and family members. Patients' needs in clinical spaces were highlighted as a conducive ICU environment with ambient temperature and controlled noise levels. In non-clinical spaces, family members expressed a need for more chairs in the waiting area. Participants expressed the need for call bells as well as patients' negative perceptions of medical equipment alarms in the ICU when it pertained to monitoring technology.

CONCLUSION

This study provides an in-depth view at the needs and experiences of ICU patients and family members who have a variety of unmet needs. This understanding is critical for guiding ICU personnel and stakeholders in their efforts to humanize ICU care.

Factors influencing family member perspectives on safety in the intensive care unit: a systematic review

PURPOSE

Patient safety has developed as a strong marker for healthcare quality. Safety matters are important in the intensive care unit (ICU) where complex clinical decisions are made, intensive technology is used, and families hold a unique role. The aim of this review was to identify and describe factors that influence family member's perceptions of safety in the adult ICU.

DATA SOURCES

Searches were conducted between September and November 2018 and repeated in July 2020 using CINAHL, MEDLINE (EBSCO), PubMed and PsycINFO databases.

STUDY SELECTION

Published primary studies undertaken in adult ICUs and involving adult family member participants exploring safety or feeling safe. No date restrictions were applied.

DATA EXTRACTION

A data extraction form collected information about sample, study design, data collection methods and results from each paper. Methodological quality was assessed using the QualSyst tools for qualitative and quantitative studies. Narrative synthesis was undertaken.

RESULTS OF DATA SYNTHESIS

Twenty papers were included with 11 papers published since 2010. The majority of papers reported on qualitative studies (n = 16). Four factors were identified that influenced whether family members felt that the patient was safe in ICU: family visiting, information and communication, caring and professional competence.

CONCLUSION

In detailing specific practices that make families feel safe and unsafe in ICU, these review findings provide a structure for clinicians, educators and researchers to inform future work and gives opportunity for the family role in patient safety to be reconsidered.

Timely Family Feedback to Guide Family Engagement in the Intensive Care Unit

BACKGROUND

Organizations motivated to provide high-quality care in the intensive care unit are exploring strategies to engage families in patient care. Such initiatives are based on emerging evidence that family engagement improves quality and safety of care.

OBJECTIVE

To gather family feedback to guide future nurse-led quality improvement efforts to engage families in the intensive care unit setting.

METHODS

The Critical Care Family Satisfaction Survey, which consists of 20 items rated from 1 (very dissatisfied) to 5 (very satisfied), was paired with open-ended questions and administered to families during the intensive care unit stay from March through December 2017. Content analysis was used to identify themes regarding the family experience.

RESULTS

Responses were collected from 178 family members. The mean (SD) score on the survey was 4.65 (0.33). Five themes emerged regarding the delivery of family care in the intensive care unit: family interactions with the interdisciplinary team, information sharing and effective communication, family navigation of the intensive care unit environment, family engagement in the intensive care unit, and quality of patient care.

CONCLUSIONS

This quality improvement project provided foundational information to guide family engagement efforts in the intensive care unit. Real-time solicitation of feedback is essential to improving the family experience and guiding family-centered care delivery in this practice environment.

Visitor's Experiences of an Evidence-Based Designed Healthcare Environment in an Intensive Care Unit

Objectives:

The objective of the research was to study the visitors’ experiences of different healthcare environment designs of intensive care unit (ICU) patient rooms.

Background:

The healthcare environment may seem frightening and overwhelming in times when life-threatening conditions affect a family member or close friend and individuals visit the patient in an ICU. A two-bed patient room was refurbished to enhance the well-being of patients and their families according to the principles of evidence-based design (EBD). No prior research has used the Person-centred Climate Questionnaire—Family version (PCQ-F) or the semantic environment description (SMB) in the ICU setting.

Methods:

A sample of 99 visitors to critically ill patients admitted to a multidisciplinary ICU completed a questionnaire; 69 visited one of the two control rooms, while 30 visited the intervention room.

Results:

For the dimension of everydayness in the PCQ-F, a significantly better experience was expressed for the intervention room (p < .030); the dimension regarding the ward climate general was also perceived as higher in the intervention room (p < .004). The factors of pleasantness (p < .019), and complexity (p < 0.049), showed significant differences favoring the intervention room in the SMB, with borderline significance on the modern factor (p < .061).

Conclusion:

Designing and implementing an enriched healthcare environment in the ICU setting increases person-centered care in relation to the patients’ visitors. This could lead to better outcomes for the visitors, for example, decreasing post-traumatic stress disorder symptoms, but this needs further investigations.

End of life in acute hospital setting-A systematic review of families' experience of spiritual care

AIMS AND OBJECTIVES

To systematically review qualitative studies exploring families' experiences of spiritual care at the end of life in acute hospital settings.

BACKGROUND

Although there is a widespread belief that the consideration of spiritual and religious needs is outdated in the context of secularism, from a practical perspective patients and families appear to benefit from spiritual support at the end of life.

METHODS

Six key databases, CINAHL, MEDLINE, EMBASE, Global Health Library, Web of Science and Applied Social Sciences Index and Abstracts (ASSIA), were searched, and three reviewers independently extracted the data and coded them into themes and subthemes. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was used as a reporting framework.

RESULTS

Five main themes emerged: anticipating needs; honouring the family by honouring the patient; personal connection; lack of sensitivity; and making space for religious and spiritual practices.

CONCLUSIONS

Families experiencing end-of-life care in acute hospital settings may benefit from spiritual care. While this can also be considered as fundamental care, understanding this through the lenses of spiritual care allows for incorporation of religious and spiritual practices that many seek at this time, irrespective of their faith perspectives.

RELEVANCE TO CLINICAL PRACTICE

Although hospice care is well established internationally, many families experience end-of-life care in acute hospital settings. Nurses usually get to know families well during this time; however, the demands of the clinical environment place restrictions on family care and perceptions of lack of communication, limited support and/or limited sensitivity can compound families' suffering. Consideration of families' spiritual needs can help to support families during this time. Nurses are ideally placed for this and can anticipate and plan for patient and family needs in this regard, or refer to a specialist, such as the Healthcare Chaplain.

Bearing witness and being bounded: The experiences of nurses in adult critical care in relation to the survivorship needs of patients and families

AIM

To discern and understand the responses of nurses to the survivorship needs of patients and family members in adult critical care units.

BACKGROUND

The critical care environment is a demanding place of work which may limit nurses to immediacy of care, such as the proximity to death and the pressure of work.

DESIGN

A constructivist grounded theory approach with constant comparative analysis.

METHODS

As part of a wider study and following ethical approval, eleven critical care nurses working within a general adult critical care unit were interviewed with respect to their experiences in meeting the psychosocial needs of patients and family members. Through the process of constant comparative analysis, an overarching selective code was constructed. EQUATOR guidelines for qualitative research (COREQ) were applied.

RESULTS

The data illuminated a path of developing expertise permitting integration of physical, psychological and family care with technology and humanity. Gaining such proficiency is demanding, and the data presented reveal the challenges that nurses experience along the way.

CONCLUSION

The study confirms that working within a critical care environment is an emotionally charged challenge and may incur an emotional cost. Nurses can find themselves bounded by the walls of the critical care unit and experience personal and professional conflicts in their role. Nurses bear witness to the early stages of the survivorship trajectory but are limited in their support of ongoing needs.

RELEVANCE TO CLINICAL PRACTICE

Critical care nurses can experience personal and professional conflicts when caring for both patients and families. This can lead to moral distress and may contribute to compassion fatigue. Critical care nurses appear bounded to the delivery of physiological and technical care, in the moment, as demanded by the patient's acuity. Consequentially, this limits nurses' ability to support the onward survivorship trajectory. Increased pressure and demands on critical care beds have contributed further to occupational stress in this care setting.

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.

Relationships among Climate of Care, Nursing Family Care and Family Well-being in ICUs

BACKGROUND

Frequent exposure to ethical conflict and a perceived lack of organizational support to address ethical conflict may negatively influence nursing family care in the intensive care unit.

RESEARCH AIMS

The specific aims of this study were to determine: (1) if intensive care unit climate of care variables (ethical conflict, organizational resources for ethical conflict, and nurse burnout) were predictive of nursing family care and family wellbeing and (2) direct and indirect effects of the climate of care on the quality of nursing family care and family wellbeing.

RESEARCH DESIGN

A cross-sectional, correlational design was used.

PARTICIPANTS AND RESEARCH CONTEXT

Convenience sample of 111 nurses and 44 family members from five intensive care units at a Midwest hospital in the United States.

INSTRUMENTS

The Ethical Conflict Questionnaire-Critical Care Version, Maslach Burnout Inventory-Human Services Survey and Hospital Ethical Climate Scale were used to measure climate of care. The Family-Centered Care-Adult Version and Nurse Provided Family Social Support Scale were family measures of the quality of nursing family care. The Family Wellbeing Index was used to measure family wellbeing.

DATA ANALYSIS

Hierarchical regression and mediation analysis were used to answer the study aims.

ETHICAL CONSIDERATIONS

The study was approved by the Institutional Review Board at the study site.

FINDINGS

In separate regression models, organizational resources for ethical conflict (β = .401, p = .006) and depersonalization (β = -.511, p = .006), a component of burnout, were significant predictors of family-centered care. In simple mediation analysis the relationship between organizational resources for ethical conflict and family-centered care was mediated by depersonalization (β = .341, 95% confidence interval (.015, .707)).

DISCUSSION

Inadequate organizational resources and depersonalization may be related to family care delivery, and present obstacles to family-centered care in the intensive care unit.

CONCLUSION

Further research to explicate the relationships among organizational resources, ethical conflict, burnout, and family-centered care is needed to guide the development of effective interventions that enhance the quality of nursing family care in the intensive care unit.

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 multicase study of prolonged critical illness in the intensive care unit: Families' experiences

BACKGROUND

It is widely acknowledged a critical illness is a stressful life event for not only the patient but also their family members; when an illness becomes prolonged, the impact is profound. It is suggested that as medical technologies advance, the number of days patients stay in an intensive care unit will increase. Therefore, it is important nurses understand how families experience a prolonged critical illness of their family member in an intensive care unit.

OBJECTIVE

To explore the trajectory of a prolonged critical illness in the intensive care unit from the experiences of family.

METHODS

A qualitative, longitudinal, multi-case design consisting of six cases from New Zealand intensive care units. Findings presented in this article only relate to the family's experiences, although patients and healthcare professionals formed part of each case. Data collection methods included observation, conversations, interviews and document review. Analysis was undertaken using thematic analysis, vignette development and trajectory mapping.

FINDINGS

Relentless uncertainty dominated all phases of the trajectory for the family during a family member's prolonged critical illness in the intensive care unit. When faced with a critical illness, family shifted rapidly into a world of unknowns. Family worked hard to navigate their way through the many uncertainties that dominated each phase of their family member's illness.

CONCLUSIONS

Nurses need to understand the levels of uncertainty families endure in order to provide care that meets the philosophical underpinnings of family centred care.

Vigilant attentiveness in families observing deterioration in the dying intensive care patient: A secondary analysis study

BACKGROUND

Family support in intensive care is often focussed on what information is communicated to families. This is particularly important during treatment withdrawal and end of life care. However, this positions families as passive receivers of information. Less is known about what bereaved family members actually observe at end of life and how this is interpreted.

AIM

Secondary analysis study was conducted in order to explore the concept of vigilant attentiveness in family members of adult patients dying in intensive care.

METHOD

Secondary analysis of eight interviews sorted from two primary data sets containing 19 interviews with 25 bereaved family members from two intensive care units in England was undertaken. Directed content analysis techniques were adopted.

FINDINGS

Families are observant for physiological deterioration by watching for changes in cardiac monitors as well as paying attention to how their relative looks and sounds. Changes in treatment/interventions were also perceived to indicate deterioration.

CONCLUSION

Families are vigilant and attentive to deterioration, implying that families are active participants in information gathering. By clarifying what families notice, or do not notice during the dying trajectory in ICU, health care professionals can tailor information, helping to prepare families for the death of their relative.

Critical illness trajectory for patients, families and nurses - a literature review

BACKGROUND

In the 21st century, we are starting to discover and understand the longer term sequelae of critical illness from both patient's and family members' perspectives. The consequential effects on physical and psychological function and the social landscape are being slowing realized. We are beginning to understand the long-term legacy of critical care, with survivorship possibly the greatest challenge within the critical care setting.

AIM

To draw together research that has appraised the experience of surviving critical illness from the holistic, triadic perspectives of survivor, relative and critical care nurse. In doing so, knowledge of the complexities of the critical care trajectory is enhanced.

SEARCH STRATEGY

Using Medline; Assia; CINAHL Plus; SCOPUS; Web of knowledge searches from 2000 to 2015 were conducted utilizing the terms 'critical care'; 'intensive care', ITU; patient*; relative*; family member*; experience*; nurse*, and trajectory. Relevant exclusion criteria were applied to provide a generalist adult critical care perspective.

RESULTS

Following a process of constant comparative analysis of the literature and thematic synthesis, seven themes were highlighted. Facing mortality, critical junctures, physiological sequelae, psychological sequelae, family presence, beyond meeting the needs of family members and technology versus humanity were all emergent themes.

CONCLUSION

As humans, we do not live an isolated life; we are interdependent upon each other. This inclusive review of literature has highlighted the lacunae and areas of dissonance both in the literature and in clinical practice in relation to the critical care trajectory as experienced by survivors of critical illness and their families.

RELEVANCE TO CLINICAL PRACTICE

Critical care nurses can and should play a role in preparing and supporting patients and families beyond the critical care unit. In turn, Registered Nurses needed to be supported to fulfil this important role in enabling the process of moving patients and their families from surviving to thriving (survivorship).