Outcomes and experiences of relatives of patients discharged home after critical illness: a systematic integrative review

Recovery from Sepsis: Management beyond Acute Care

Recovery from sepsis is a key global health issue, impacting 38 million sepsis survivors worldwide per year. Sepsis survivors face a wide range of physical, cognitive, and psychosocial sequelae. Readmissions to hospital following sepsis are an important driver of global healthcare utilization and cost. Family members of sepsis survivors also experience significant stressors related to their role as informal caregivers. Increasing recognition of the burdens of sepsis survivorship has led to the development of postsepsis recovery programs to better support survivors and their families, although optimal models of care remain uncertain. The goal of this article is to perform a narrative review of recovery from sepsis from the perspective of patients, families, and health systems.

Postintensive care syndrome family: A comprehensive review

Families of critically ill patients are predisposed to tremendous burdens when their relatives are admitted to the intensive care unit (ICU). Postintensive care syndrome family (PICS-F) can be described as a devastated life, encompassing psychological, physical, and socioeconomical burdens that begin with the emotional impact experienced by the family when the patient is admitted to the ICU. PICS-F was primarily proposed as a clinically significant psychological impairment, but it needs to be extended beyond the psychological impairment of the family to include physical and socioeconomical impairments in the future. The prevalence of physiological problems including depression, anxiety and post-traumatic syndrome is 20-40%, and that of non-physiological problems including fatigue is 15% at 6 months after the ICU stay. Assessment of PICS-F was frequently conducted at 3- or 6-month points, although the beginning of the evaluation was based on different assessment points among each of the studies. Families of ICU patients need to be given and understand accurate information, such as the patient's diagnosis, planned care, and prognosis. Prevention of PICS-F requires a continuous bundle of multifaceted and/or multidisciplinary interventions including providing a family information leaflet, ICU diary, communication facilitators, supportive grief care, and follow-up, for the patient and families from during the ICU stay to after discharge from the ICU. This is the first comprehensive review of PICS-F to address the concept, risk factors, assessment tools, prevalence, and management to prevent PICS-F to facilitate acute care physicians' understanding of PICS-F.

When chronic critical illness is a family affair: A multi-perspective qualitative study of family involvement in long-term care

OBJECTIVE

Those with chronic critical illness (CCI) remain dependent on life-sustaining treatments and increasingly reside in long-term care facilities equipped to meet their needs. The nature of family involvement in care remains undetermined thwarting approaches to mitigate poor family outcomes. The research objective was to explicate family involvement in the care of an individual with CCI who resides in long-term care.

METHODS

In this qualitative research, we used thematic analysis and constant comparative techniques to analyze data from interviews with 38 participants: 11 family members, 6 residents with CCI, and 21 healthcare providers.

RESULTS

Involvement in care entailed family: (1) reorienting their life despite the stress and emotional toll; (2) assuming responsibility for meaningful activities and management of practical matters, yet struggling alone; (3) advocating for care by being present, reminding and pushing, and picking their battles; and (4) figuring out how to contribute to nursing care, but with unclear expectations.

DISCUSSION

The burden of family caregiving was substantial, contrasting the assumption that family are relieved of their caregiver responsibilities when the patient with CCI is in a care facility. Research to address unmet family needs specific to their roles and responsibilities could potentially improve family outcomes and is warranted.

What Are the Care Needs of Families Experiencing Sudden Cardiac Arrest? A Survivor- and Family-Performed Systematic Review, Qualitative Meta-Synthesis, and Clinical Practice Recommendations

INTRODUCTION

Cardiac arrest care systems are being designed and implemented to address patients', family members', and survivors' care needs. We conducted a systematic review and a meta-synthesis to understand family experiences and care needs during cardiac arrest care to create treatment recommendations.

METHODS

We searched eight electronic databases to identify articles. Study findings were extracted, coded and synthesized. Confidence in the quality, coherence, relevance, and adequacy of data underpinning the resulting findings was assessed using GRADE-CERQual methods.

RESULTS

In total 4181 studies were screened, and 39 met our inclusion criteria; these studies enrolled 215 survivors and 418 family participants-which includes both co-survivors and bereaved family members. From these studies findings and participant data we identified 5 major analytical themes: (1) When the crisis begins we must respond; (2) Anguish from uncertainty, we need to understand; (3) Partnering in care, we have much to offer; (4) The crisis surrounding the victim, ignore us, the family, no longer; (5) Our family's emergency is not over, now is when we need help the most. Confidence in the evidence statements are provided along with our review findings.

DISCUSSION

The family experience of cardiac arrest care is often chaotic, distressing, complex and the aftereffects are long-lasting. Patient and family experiences could be improved for many people. High certainty family care needs identified in this review include rapid recognition and response, improved information sharing, more effective communication, supported presence and participation, or supported absence, and psychological aftercare.

Being devastated by critical illness journey in the family: A grounded theory approach of post-intensive care syndrome-family

OBJECTIVES

This study aimed to explore the meaning and structure of postintensive care syndrome experienced by families of critically ill patients.

METHODS

This qualitative study applied the constructivist grounded theory approach and conducted one or two interviews with eight participants with postintensive care syndrome-family for a total of 12 interviews. The contents of the interviews were analysed through line-by-line coding, focused coding, and categorisation. Data collection and analysis were iterative, to enable continuous comparative analysis.

FINDINGS

The core category of postintensive care syndrome experienced by families was 'being devastated by the critical illness journey in the family' and comprised the interactions of four categories: 'overwhelming intensive care experience', 'taking responsibility for the recovery trajectory of critical illness', 'life devastated by the trauma of intensive care and family caregiving', and 'balancing and compromising'.

CONCLUSION

Based on this grounded theory approach, postintensive care syndrome experienced by families is a complex and ongoing phenomenon that arises from the recovery trajectory of a critical illness. It involves mental, physical, social and familial aspects, particularly the impact on the patient's family.

IMPLICATIONS FOR CLINICAL PRACTICE

The findings can guide critical care nurses to understand postintensive care syndrome experienced by families in providing patient or family-centred care. To improve the long-term outcomes and quality of life for families, it is necessary to assess their unique needs within the continuum of post-intensive care syndrome experienced by the family and to propose interventions to satisfy those needs.

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.

A Mixed-Methods Feasibility Study: Eliciting ICU Experiences and Measuring Outcomes of Family Caregivers of Patients Who Have Undergone Hematopoietic Stem Cell Transplantation

The impact of an intensive care unit (ICU) admission on family caregivers of patients who have undergone hematopoietic stem cell transplantation (HSCT) has not been well described. Aims of this study were to determine the feasibility of conducting research with family caregivers of HSCT patients during an ICU admission and generate preliminary data about their experiences and engagement in care. Using a mixed-methods, repeated measures design, we collected data from family caregivers after 48 hr in the ICU (T1) and at 48 hr after transferring out of ICU (T2). Enrolling HSCT caregivers in research while in the ICU was feasible (10/13 consented; 9/10 completed data collection at T1); however, data collection at T2 was not possible for most caregivers. Caregiver distress levels were high, and engagement in care was moderate. The three themes that emerged from interviews (n = 5) highlighted that although HSCT family caregivers faced many challenges and received limited support during their ICU experience, they were able to access their own personal resources and demonstrated resilience.

Hospitalisation at Home of Patients with COVID-19: A Qualitative Study of User Experiences

Hospitalisation at Home (HaH) is a new model providing hospital-level care at home as a substitute for traditional care. Biometric monitoring and digital communication are crucial, but little is known about user perspectives. We aim to explore how in-patients with severe COVID-19 infection and clinicians engage with and experience communication and self-monitoring activities following the HaH model. A qualitative study based on semi-structured interviews of patients and clinicians participating in the early development phase of HaH were conducted. We interviewed eight clinicians and six patients. Five themes emerged from clinicians: (1) staff fear and concerns, (2) workflow, (3) virtual closeness, (4) patient relatives, and (5) future HaH models; four themes emerged from patients: (1) transition to home, (2) joint responsibility, (3) acceptability of technologies, and (4) relatives. Despite technical problems, both patients and clinicians were enthusiastic about the conceptual HaH idea. If appropriately introduced, treatment based on self-monitoring and remote communication was perceived acceptable for the patients; however, obtaining vitals at night was an overwhelming challenge. HaH is generally acceptable, perceived patient-centred, influencing routine clinical workflow, role and job satisfaction. Therefore, it calls for educational programs including more perspective than issues related to technical devices.

A protocol for exploring patients' and support peoples' experiences after prolonged critical illness

BACKGROUND

Improved survival of critically ill people has increased the number of patients who experience an extended stay in intensive care units (ICU). Evidence suggests the complexities, vulnerabilities, and traumas created by critical illness are substantial for both patients and their support people with a number experiencing devastating impairments across multiple domains of health and function including physical, mental, cognitive, and social health. However, research on survivors predominantly focuses on those who have experienced a relatively short length of stay; only a limited number of studies seek to explore the experiences of survivors and their support people who have had a prolonged stay in intensive care.

AIMS AND OBJECTIVES

To describe the experiences of survivors of prolonged critical illness (invasively mechanically ventilated in ICU for ≥eight days) and their support people during the first 12 months following hospital discharge in New Zealand.

DESIGN

This research will be a multi-centre study recruiting from three intensive care units in New Zealand. A narrative inquiry methodology will be used to interview 6-8 former long stay patients and 6-8 support people of a former long stay patient. Each participant will be interviewed at 3-, 6-, 9-, and 12-months following hospital discharge.

METHODS

Data will be collected via narrative inquiry interviews. Data analysis will combine two theoretical frameworks: the Clandinin and Connelly narrative inquiry three-dimensional space and the Fairclough situation, discourse and context framework.

RESULTS

The phenomenon of investigation will be experiences after prolonged critical illness explored longitudinally across the first-year post-hospital discharge.

RELEVANCE TO CLINICAL PRACTICE

This protocol provides a methodological framework for exploring the lived experiences of survivors of prolonged critical illness and their support people. Data analysis will support understanding of the human journey of ICU survivorship and add to the body of knowledge on how to support post-ICU recovery in this population. The barriers and enablers of survivorship at the micro, meso, and macro levels of the health service will also be illuminated.

Relationships among Demographic, Clinical, and Psychological Factors Associated with Family Caregiver Readiness to Participate in Intensive Care Unit Care

Rationale: There has been a paradigm shift to partner with family caregivers by actively involving them in the direct care of the patient throughout the critical illness trajectory. Before effectively engaging family members in patient care, clinicians must assess characteristics and circumstances that may affect caregiver readiness to assume a caregiving role in the intensive care unit (ICU). Objectives: To determine how demographic, clinical, and psychological factors are related to characteristics of family caregiver readiness to engage in ICU patient care. Methods: A convenience sample of ICU family caregivers of both adult and pediatric patients in the ICU was recruited for this cross-sectional study. Participants completed the following measures: PROMIS-29 (Patient-Reported Outcomes Measurement and Information System); HADS (Hospital Anxiety and Depression Scale); CaSES (Caregiver Self-Efficacy Scale); Prep Scale (Preparedness for Caregiving Scale); Patient Activation Measure for Caregivers; and FCMFHS (Family Caregiver's Motives for Helping Scale). Data were collected via self-report at a single time point while the caregiver was visiting the critically ill patient in the ICU. Data analysis consisted of descriptive statistics and bivariate correlations. Results: Caregivers (N = 127) were primarily White (82.7%), females (77.2%), with a mean age of 51.8 (standard deviation [SD], 15.6). Most were either spouses (37.8%) or parents (32.3%) of the patient in the ICU. Patients were primarily adult (76.4%) with a mean APACHE (Acute Physiology, Age, Chronic Health Evaluation) III of 45.9 (SD, 22.5). There were significant (P < 0.05) negative correlations between depression, anxiety, and fatigue and all subscales of self-efficacy (resilience r = -0.18 to -0.30; self-maintenance r = -0.44 to -0.63; emotional connectivity r = -0.27 to -0.41; instrumental giving r = -0.34 to -0.46). Caregiver depression was negatively correlated with caregiver activation (r = -0.199) and caregiver preparedness (r = -0.300). Social satisfaction was positively correlated (P < 0.05) with caregiving preparedness, motivation, and all subscales of self-efficacy (preparedness r = 0.19; motivation r = 0.24; resilience r = 0.21; self-maintenance r = 0.49; emotional connectivity r = 0.29; instrumental giving r = 0.36). Conclusions: We found that caregiver symptoms of depression, anxiety, and fatigue are inversely related to caregiver preparation, motivation, and self-efficacy. To develop effective interventions for ICU family caregivers, further research is needed to understand the relationship between caregiver well-being, caregiving readiness, and caregiver involvement in patient care.

Family Caregiver Preferences and Contributions Related to Patient Care in the ICU

Guided by Individual and Family Self-Management Theory, the purpose of this cross-sectional study was to describe patient care activities that family caregivers endorsed and performed while visiting their family member in the ICU. We found that caregivers wanted to be involved in ICU patient care and had preferences for the care they wanted to perform with their critically ill family member. More than 80% preferred to perform tasks related to daily grooming, communication, and education. Of note, many caregivers expressed interest in holistic healing activities (i.e., music and art), and yet, less than 50% of caregivers reported participating in these activities. The discrepancy between the number of care activities that respondents desired to perform compared to the number of care activities they reported performing represents an important opportunity to shift research and practice improvement efforts toward more tailored family engagement interventions and recognition of family caregivers as essential partners in care.

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.

Stressors and strains of next of kin of patients with ARDS in intensive care: A qualitative interview study using a stress-strain approach

OBJECTIVES

This study aims to explore and analyse the stressors and strains of next of kin of acute respiratory distress syndrome (ARDS) patients during their stay in the intensive care unit utilising the stressors and strain approach as a theoretical framework.

METHODS

Data collection was performed as semi-standardised qualitative interviews. 35 families of patients with ARDS were approached when visiting the intensive care unit. Participants were recruited until thematic saturation was reached; finally, 17 persons (age ranging from 26 to 71 years, nine women) took part. Systematic content analysis was conducted on the theoretical foundations of the stressors and strain approach.

FINDINGS

Numerous stressors were identified; they can be divided into three main categories: in relation to organising the visit, occurring during the visit and arising at home. These stressors were reported highly consistently throughout participants. However, the strains resulting from these stressors were varying in manifestation and level.

CONCLUSIONS

This study explores the manifold stressors and strains of next of kin of a critically ill patient. Some stressors are inherent to the life-threatening condition of a family member; others arise from the health care system and could be modified. The level of strain experienced depends on social support, individual coping skills and life circumstances.

Family Health Conversations create awareness of family functioning

BACKGROUND

The whole family is affected if one family member is critically ill. The Family Health Conversation Intervention may give the family tools that support healthier family functioning.

AIMS AND OBJECTIVES

The aim of this study was to identify which components of family function are affected when families participate in Family Health Conversations.

DESIGN

A secondary analysis was performed of existing qualitative interviews. The Family Health Conversation is an intervention where nurses ask the family reflective questions, and reflection is made possible in three conversation sessions.

METHODS

This study included transcribed data from 13 follow-up interviews from seven families attending Family Health Conversations after three and 12 months. Data were analysed with narrative analysis, focusing on family function.

RESULTS

Three themes were identified. The families' family functioning had been supported with: improved understanding of each other-there was an understanding of being in the same situation but still having totally different experiences; more concern for each other-they talked about their different experiences and felt they had become closer to each other; and a process of working through-they had experienced working through various experiences, standing by and supporting, and then being able to move on.

CONCLUSIONS

The Family Health Conversation Intervention is provided to families, accompanied by nurses. The families in this study gained an awareness of their family function that brought the family closer because of improved understanding of each other and the situation. The families experienced openness, and the family members spoke more freely with each other, which facilitated the progress of working through the experience of critical illness and helped to maintain healthy family functioning.

RELEVANCE TO CLINICAL PRACTICE

It is important to have an overall perspective and to recognize the patient and the family as equally important within the family for awareness of family function.