Family members' experiences in adult intensive care units: a systematic review

Correlates of prolonged grief, posttraumatic stress and depression symptoms in Brazilian COVID-19 bereaved adults

The Coronavirus pandemic has hit Brazil exceptionally hard, with more than 700.000 confirmed deaths due to COVID-19, corresponding to an estimated 6.3 million bereaved people. Yet, the mental health consequences among COVID-19 bereaved Brazilians, and the associated loss-related variables have been largely unexplored. Therefore, we aimed to clarify the associations of loss-related characteristics and circumstances with prolonged grief, posttraumatic stress, and depression symptoms experienced by COVID-19-bereaved Brazilian adults. A sample of 371 Brazilian COVID-19 bereaved adults (90% women) completed an online survey. The loss of a partner or first-degree relative, a positive assessment of the healthcare received by the deceased, and the perceived helpfulness of hospital visits in the grief process significantly correlated with prolonged grief and posttraumatic stress symptoms. The findings suggest that farewell ceremonies and positive hospital care experiences may mitigate distress among COVID-19-bereaved Brazilian adults.

Experiences of the Parents of Children Admitted to PICU

Introduction

A pediatric intensive care unit (PICU) is a highly technological and fast-paced setting in a hospital.

Objective

To explore the experiences of the parents in the critical care area of a selected tertiary care facility.

Materials and methods

In a qualitative study, we interviewed 10 purposively selected parents of the children admitted to PICU using a pre-validated in-depth interview schedule. All parents, whose children were admitted to PICU for more than 5 days, who understood Hindi or English and were willing to participate in the study, were enrolled in the study. Parents of critically ill children having readmission to PICU or prolonged stay of more than 15 days and not accompanied by parents were excluded.

Results

Parents had unmet needs, such as the need for information, counseling and education from the healthcare team (HCT) members, having trusting relationship with the HCT, and expecting receiving orientation of the routines and the protocols of PICU, and empathy from the various levels of PICU team. The majority of subjects expressed the desire to talk to a dedicated person for their queries. The parents had multiple feelings of distress, hopelessness, helplessness, guilt, and the fear of losing the child and used various coping strategies.

Conclusion

Parents of critically ill children in the PICU have unmet needs. Healthcare team members should take initiative in relieving parental distress and improving their coping abilities.

How to cite this article

Kichu S, Joshi P, Bhandari S, Lodha R, Jaykrishnan K. Experiences of the Parents of Children Admitted to PICU. Indian J Crit Care Med 2024;28(7):696-701.

An Exploration of the Supportive Care Needs of Caribbean Families of Critically Ill Adults

ABSTRACT

Nurses care for patients of diverse cultures. Persons in and from the Caribbean region have specific needs and concerns related to the support they need when a family member is admitted to an intensive care unit (ICU). Nurses familiar with Caribbean patient culture can provide these family members with knowledgeable and culturally competent care. However, little research exists about the unique needs of this population. This pilot study explored the nursing support needs of adult Caribbean family members of patients in the ICU.

Family members' experiences of COVID-19 visiting restrictions in the intensive care unit-A qualitative study

OBJECTIVE

To describe how family members of critically ill patients experienced the COVID-19 visiting restrictions in Sweden.

BACKGROUND

In Sweden, the response to COVID-19 was less invasive than in many other countries. However, some visiting restrictions were introduced for intensive care units, with local variations. Although there is a growing body of literature regarding healthcare professionals' and family caregivers' perspectives on visiting restriction policies, there may be inter-country differences, which remain to be elucidated.

DESIGN

This study has a qualitative descriptive design. Focus group interviews with 14 family members of patients treated for severe COVID-19 infection were conducted. The interviews took place via digital meetings during the months after the patients' hospital discharge. Qualitative content analysis was used to interpret the interview transcripts. Reporting of the study followed the COREQ checklist.

RESULTS

Two categories-dealing with uncertainty and being involved at a distance-described family members' experiences of coping with visiting restrictions during the COVID-19 pandemic. These restrictions were found to reduce family members' ability to cope with the situation. Communication via telephone or video calls to maintain contact was appreciated but could not replace the importance of personal contact.

CONCLUSIONS

Family members perceived that the visiting restriction routines in place during the COVID-19 pandemic negatively influenced their ability to cope with the situation and to achieve realistic expectations of the patients' needs when they returned home.

RELEVANCE TO CLINICAL PRACTICE

This study suggests that, during the COVID-19 pandemic, the visiting restrictions were experienced negatively by family members and specific family-centred care guidelines need to be developed for use during crises, including the possibility of regular family visits to the ICU.

PATIENT AND PUBLIC CONTRIBUTION

None in the conceptualisation or design of the study.

The bereavement experiences of families of potential organ donors: a qualitative longitudinal case study illuminating opportunities for family care

OBJECTIVES

To illuminate opportunities for care in the context of deceased organ donation by exploring pre-existing family and healthcare professional characteristics, in-hospital experiences, and ongoing adjustment through the lenses of grief theory, systems theory, meaning-making, narrative, and organ donation literature.

METHOD

Qualitative longitudinal case studies explored individual and family change in five Australian families who had consented to Donation after Circulatory Determination of Death at a single centre. Participants attended semi-structured interviews at four, eight, and twelve months after the death.

FINDINGS

Family values, pre-existing relationships, and in-hospital experiences influenced first responses to their changed lives, understanding of the patient's death, and ongoing family adjustment. Novel behaviour that was conguent with family values was required at the hospital, especially if the patient had previously played a key role in family decision-making. This behaviour and emerging interactional patterns were drawn into family life over the first year of their bereavement.

RECOMMENDATIONS

Training that includes lenses introduced in this study will enable healthcare professionals to confidently respond to individual and family psychosocial needs.

CONCLUSION

The lenses of grief theory and systems thinking highlight opportunities for care tailored to the unique in-hospital context and needs that emerge in the months that follow.

In their absence; intensive care nurses' experiences of communicating and supporting relatives from a distance

BACKGROUND

Having a critically ill family member in the intensive care unit (ICU) is a challenging situation and ICU nurses play an important part in supporting relatives to make sense of the situation. Strict visiting policies inhibited the family's presence in ICUs during 2020-22, and the communication between nurses and families changed drastically. Information and support are at the core of the ICU nurses' profession, and the pandemic backdrop created a split between what intensive care nurses have a professional responsibility to perform and which actions were possible. To get a fuller picture, the aim of this study was: To describe intensive care nurses' experiences of communicating and supporting relatives from a distance while working during visiting restrictions.

METHOD

A qualitative descriptive design using individual and semi-structured interviews with 16 ICU nurses. The interviews were analyzed using inductive thematic analysis. This study followed the consolidated criteria for reporting qualitative research (COREQ).

RESULTS

Due to the visiting restriction during the COVID-19 pandemic, ICU nurses found themselves in a situation where proximity and time to develop an interpersonal connection with relatives disappeared overnight. The nurses' experiences of communicating with and supporting families is described in three themes: "Finding ways to create order out of chaos"; "Guiding the relatives to a fuller picture of the situation"; and "Feeling insufficient in their support".

CONCLUSION

Visiting restrictions in the ICU meant that ICU nurses missed vital information about their patients as a person, which might have had a negative effect on personalizing and centring the patient care. But using a combination of digital and audio tools helped nurses to guide the relatives to a clearer picture of the situation as a whole. The support that nurses were able to provide to relatives was often insufficient due to the visiting restriction and as a consequence, they experienced physical and psychological stress.

Anxiety and Depression in Family Members of Critically Ill Covid-19 Inpatients: Brief Psychological Interventions via Telephone, an Exploratory Study

Purpose

This study aimed to assess the level of anxiety and depression in relatives of critically ill COVID-19 patients admitted to the intensive care unit (ICU), and to perform an exploratory pilot study on the implementation of telephone psychological interventions to reduce the initial levels of anxiety and depression in this population.

Patients and Methods

Family members of COVID-19 inpatients at ICU answered GAD-7, PHQ-9 and questions on socio-demographic data. A brief psychological intervention was applied via telephone based on the needs of the participants (with adequate adaptation, with symptoms of anxiety, depression, or both). After intervention, participants completed the Patient Global Impression of Change Scale.

Results

A total of 1307 relatives were included (66.5% female), 34% and 29% had anxiety and depressive symptoms, respectively. These symptoms were associated with female gender, unemployment, and being the parent or partner of the patient. After intervention, 57.9% reported felt better, 31.3% a little better and 6.6% much better; and with emotional regulation techniques and psychoeducation, higher percentages of feeling better or much better were reported.

Conclusion

Brief interventions to reduce the psychological impact of inpatient family members could be effective but will need to be explored further in future studies.

Perspectives and wishes for patient and family centred care as expressed by adult intensive care survivors and family-members: A qualitative interview study

OBJECTIVES

To explore perspectives and wishes for patient and family centred care among adult patients and family-members with recent experience of admission to an adult intensive care unit.

RESEARCH DESIGN

An explorative descriptive study using an inductive thematic analysis. Semi-structured interviews with adults (≥18 years) who had experienced admission ≥48 hours to an adult intensive care unit as a patient or family-member within the previous three months. Interview data were analysed used the six phases of thematic analysis, described by Braun and Clarke. Semi-structured interviews with adults (≥18 years) who had experienced admission ≥48 hours to an adult intensive care unit as a patient or family-member within the previous three months. Interview data were analysed used the six phases of thematic analysis, described by Braun and Clarke.

SETTING

Participants were recruited from six general (mixed surgical and medical) units in the Capital Region of Denmark.

FINDINGS

From fifteen interviews a total of 23 participants (8 patients and 15 family-members) described their perspectives and wishes for patient- and family-centred care. Three main themes were identified: 1) Ongoing dialogue is fundamental. Both scheduled and spontaneous information-sharing is important. 2) Humanizing. High-quality treatment was especially evident for participants when staff maintain a humanized attitude. 3) Equipping family to navigate. We found a range of specific suggestions of attention that may help patients and family-members to navigate during admission.

CONCLUSIONS

We found that patients' and family-members' perspectives and wishes for PFCC centred around ongoing dialogue with staff and the importance of humanizing the ICU environment. Patients and family members needed to share and have their knowledge, concerns and perspectives brought forth and acknowledged by staff. Participants emphasized the pivotal role staff have in equipping patients and family-members to cope in the unit and supporting specifically family-members in fulfilling their role as advocates and supporters of the patient.

Adaptation of the Quality of Communication Questionnaire for Family Members and Its Validity Evidence for Use in Brazil

Assessment of communication between physicians and patients' family members is essential to improving healthcare quality. To adapt the Quality of Communication Questionnaire (QoC) for family members and to analyze its validity evidence for use in Brazil. Data were collected between 2017 and 2019, with family members of patients in intensive care (IC) and palliative care (PC) from five public hospitals in the South Brazil. The QoC was adapted for family members for use in Brazil, and its cross-cultural adaptation was carried out. The clarity and cultural appropriateness of the pre-final version were evaluated by 30 family members of patients in IC. The final version was responded by 198 family members of patients. All items were considered clear, and appropriate to Brazilian culture. The goodness of fit index for proposed model had CFI 0.96 (CI95%: 0.94 - 0.98), TLI 0.95 (CI95%: 0.92 - 0.97), RMSEA 0.07 (CI90%: 0.06 - 0.08), and χ²/df 2.18. Cronbach's alpha coefficient (α) among family members of patients in PC was 0.88 for the general communication (first subscale) and 0.80 for the end-of-life communication (second subscale). However, among family members of patients in IC, α was 0.86 for the first subscale and only 0.53 for the second subscale. The QoC for family members and its cross-cultural adaptation were carried out successfully. It has strong validity evidence among those with loved ones in PC, but only the QoC general communication subscale has strong validity evidence among those with loved ones in IC.

Chronic illness and critical care-A qualitative exploration of family experience and need

BACKGROUND

People with chronic illnesses such as cancer and cardiovascular disease are living longer and often require the support of critical care services. Current health care provision means patients may be discharged home once clinically stable despite still having high care demands including social, emotional, or physical needs. Families are often required to assume caregiving roles. Research into family burden using quantitative methods has increased awareness, however, little qualitative work exists and the development of support interventions for families is required.

AIMS

To explore the experience and needs of family members of people with an existing chronic illness who are admitted to the Critical Care Unit (CCU), and to identify the desired components of a family support intervention in the form of a resource toolkit.

STUDY DESIGN

A qualitative exploration of family experience and need, and content development for a resource toolkit using focus group methodology. Two focus groups and one face-to-face interview were conducted involving nine adult (≥18 years) family members of adult patients with chronic illness admitted to critical care in the preceding 9 months across two specialist hospitals in the UK. These were digitally recorded, transcribed, and thematically analysed.

FINDINGS

Four themes were identified: importance of communication, need for support, trauma of chronic illness, and having to provide "Do-it-Yourself" care. The immense responsibility of families to provide care throughout the illness trajectory is highlighted. Understandable information is essential for a family support toolkit.

CONCLUSION

Family members often view a critical care episode broadly from diagnosis through to recovery/rehabilitation. Basic communication training skills within critical care should be ensured, alongside coordination of simple solutions. The potential traumatic impact on families should be highlighted early within the pathway, and positive aspects used to harness essential family support. A simple and coordinated approach to a toolkit is preferred.

RELEVANCE TO CLINICAL PRACTICE

This study highlights that a critical care experience may impact broadly beyond CCU, and the importance of informing patients and families of this potential experience, prior to or on admission, to aid preparation. Further highlighted is the need for contemporaneous and accurate information from clinicians involved in care. Families report a better experience when there is good collaboration across critical care services and admitting clinical teams. Early involvement of families in overall discharge planning is essential to allow patients and families to adjust and plan for recovery.

Professionals' narratives of interactions with patients' families in intensive care

Background: ICU patients’ family members are in a new, uncertain, and vulnerable situation due to the patient’s critical illness and complete dependence on the ICU nurses and physicians. Family members’ feeling of being cared for is closely linked to clinicians’ attitudes and behavior.

Aim: To explore ICU nurses’ and physicians’ bedside interaction with critically ill ICU patients´ families and discuss this in light of the ethics of care.

Research design: A qualitative study using participant observation, focus groups, and thematic narrative analysis.

Participants and research context: Data were gathered from July 2017 to August 2019, in four ICUs in Norway through 270 h of fieldwork and seven focus groups with ICU nurses and physicians.

Ethical considerations: The Regional Committee for Medical and Health Research Ethics and the Norwegian Centre for Research Data approved the study. Findings: Quality of ICU family care depends on nurses’ and physicians’ attitudes, behavior, and personality traits. Three main themes were identified: being attentive, an active approach, and degree of tolerance.

Discussion: The findings are discussed in light of the ethics of care and empirical research from the intensive care environment.

Conclusions: This study shows that attentive, active, and tolerant clinicians represent a culture of ethical care that gives families greater freedom of action and active participation in patient care. Clinicians must not bear sole responsibility for this culture; it must have a firm basis in the hospital and ICU and be established through training, interprofessional reflection, and support of clinicians.

The evidence base of nurse-led family interventions for improving family outcomes in adult critical care settings: A mixed method systematic review

BACKGROUND

The COVID-19 pandemic has exacerbated the consequences of a patient's admission to critical care settings, causing families to face more psychosocial issues than in previous years. Thus, nurses and other clinicians need to keep abreast of interventions that support the families of critical care patients.

OBJECTIVE

To provide evidence of nurse-led family interventions and their family outcomes in adult critical care settings.

DESIGN

A mixed method systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis checklist.

DATA SOURCES

The search included both a screen of relevant databases (PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature, and the Cochrane Library) and the screening of citations in relevant articles. Studies published in the English language between January 2010 and October 2020 were considered. The final database searches were performed on 20 October 2020.

METHODS

Screening and eligibility assessment were conducted using the Rayyan software. Studies describing the family outcomes of nurse-led interventions in adult critical care settings through either qualitative or quantitative methods were included, i.e., the mixed method synthesis permitted the inclusion of either qualitative or quantitative findings. Article quality was evaluated by three authors using the Joanna Briggs Institute's critical appraisal tools.

FINDINGS

A total of 15 studies - two trials, eight quasi-experimental studies, four qualitative, and one mixed method met the inclusion criteria. The described interventions were organized into five categories: educational/informational; family involvement in care; diary; communication; and bundled interventions. These categories varied in terms of elements, delivery, and family outcomes. Nurse-led interventions that resulted in small to medium improvements in family outcomes included educational interventions with digital storytelling, a bundled approach, informational nursing interventions, and nurse-driven emotional support. The included studies (n = 2) that investigated family rounds in the ICU reported that this approach did not noticeably influence family outcomes.

CONCLUSION

The differences in the intervention elements, tools, and outcomes evaluated in this review reflect the diversity of family needs, and that numerous interventions have already been developed to promote family health in critical care settings. The evidence suggests that interdisciplinary nurse-led family interventions can improve family outcomes. Tweetable abstract: Interprofessional nurse-led family interventions draw on diverse approaches and improve family outcomes in adult critical care settings.

Humanization of care for adult ICU patients: a scoping review protocol

OBJECTIVE

The objective of this review is to review and map data from studies on the humanization of care in intensive care units based on a conceptual framework.

INTRODUCTION

The critical context of adult patients in intensive care units directs the focus on clinical medical interventions, drawing attention away from the humanization of care. Rethinking intensive care is imperative and the humanization of care is an absolute priority. Literature on this topic is scattered under umbrella terms such as "patient-centered care" or specific terms referring to target interventions. A scoping review based on a conceptual framework could map the literature on humanization in intensive care units.

INCLUSION CRITERIA

The review will consider studies on the humanization of care, or on one of the seven components of the conceptual framework (communication, visiting hours, patients' and health care professionals' well-being, family involvement and satisfaction, post-intensive care unit syndrome, and physical environment) focusing on adult patients in intensive care units. Studies on co-existing states or end-of-life care will be excluded.

METHODS

A search of Embase, PubMed, and CINAHL will be conducted to identify relevant studies in English or French on the humanization of care, holistic care, or person-centered care in an adult intensive-care environment. The time period covered will be January 1, 2010 to the present. An iterative team approach will be used to screen and select studies and extract data. Data will be charted according to study design, distribution in time, cultural context, concepts, use of theoretical models, and intervention. The results will be summarized and reported, identifying the implications for policy, practice, and research.

The meaning of caring touch for healthcare professionals in an intensive care unit: A qualitative interview study

BACKGROUND

The way health care professionals touch patients and relatives in the intensive care unit plays a significant role. A negative feeling can be caused by being touched in the wrong way, this is why a holistic approach with respect for the patient is important for the ability to make the patient and their relatives feel secure, avoiding unnecessary suffering.

AIM

The aim of the study was to describe the meaning of caring touch that is given in the ICU from the health care professionals perspective.

METHOD

Qualitative interview study with health care professionals in the intensive care unit, analysed using inductive content analysis, resulting in two themes and four main categories.

FINDINGS

Two themes emerged: Imperative touch and emotional touch and four main categories: touch as a natural tool, create a prerequisite for touch, empathetic touch and conversant touch.

CONCLUSION

Caring touch can be used as a natural tool in the daily work in order to bring comfort and calm to the patient in the intensive care unit.

Family involvement in the intensive care unit in four Nordic countries

BACKGROUND

Relevance to clinical practice The findings from the study highlighting family involvement, high-quality communication and flexible visiting policy as central aspects of family care may inspire clinicians to identify aspects of everyday family care in their ICUs calling for further improvement.

AIMS AND OBJECTIVES

To describe family involvement, communication practices and visiting policies in adult ICUs.

DESIGN

A cross-sectional survey.

METHOD

A questionnaire consisting of 11 sections was developed, pilot tested and e-mailed to 196 ICUs. The participants were intensive care nurses in adult ICUs in four Nordic countries.

RESULTS

The survey was conducted in October to December 2019. The response rate was 81% (158/196) of the invited ICUs. Most of the units had fewer than 11 beds. Family participation in patient care, including involvement in ward rounds and presence during cardiopulmonary resuscitation, varied between the countries, whereas most families in all countries were involved in decision-making. Family conferences were generally initiated by staff or family members. Children under 18 did not always receive information directly from the staff, and parents were not advised about how to inform their children. Although most respondents described open visiting, restrictions were also mentioned in free-text comments.

CONCLUSIONS

The level of family care in ICUs in the four Nordic countries is generally based on nurses' discretion. Although most Nordic ICUs report having an open or flexible visiting policy, a wide range of potential restrictions still exists. Children and young relatives are not routinely followed up. Family members are included in communication and decision-making, whereas family involvement in daily care, ward rounds and family-witnessed resuscitation seem to be areas with a potential for improvement.

Stakeholders' perceptions of family-centred care in the intensive care unit: An associative group analysis

AIM

To explore different stakeholders' including nurses, health care professionals and family member's perceptions of ideal family-centred care in an intensive care unit.

RESEARCH DESIGN AND METHODS

We used a mixed method approach to identify perceptions of family-centred care with 60 stakeholders of equal numbers who voluntarily participated in the study. Data were collected over one month using an associative group analysis method. The responses were ranked, scored, thematically themed and weighted.

SETTING

A 23 bed adult intensive care unit in an urban private hospital in South Africa.

FINDINGS

According to the stakeholders' responses, ideal family-centred care should be built around communication based on expectations and engagement. In addition, the physical environment should allow for overall comfort and spiritual care must be incorporated.

CONCLUSION

Stakeholders had similar perceptions on the main themes however; nuances of different perspectives were identified showing some of the complexities related to family-centred care. Spiritual care was highlighted by the family members, revealing the need to broaden the care perspectives of healthcare providers.

The enablers and barriers to children visiting their ill parent/carer in intensive care units: A scoping review

AIM

The aim of the study was to identify the enablers and/or barriers to children visiting their ill parent/carer in intensive care units by examining the visiting policies as practiced or perceived by nurses and experienced or perceived by parents and caregivers.

REVIEW METHOD

This is a scoping review following Joanna Briggs Institute Protocol Guidelines.

DATA SOURCES

An extensive literature search of Cumulative Index of Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online, PsychINFO, PubMed, and Excerpta Medica dataBASE databases, using key terms, was conducted between May 2019 and July 2020; studies published between 1990 and 2020 were considered for inclusion. Double screening, extraction, and coding of the data using thematic analysis and frequency counts were used.

RESULTS

Fifteen barriers, 19 facilitators, nine situationally contingent factors, and six personal judgement considerations were identified that influenced children visiting their ill parent/carer in intensive care units. Most barriers (n = 10) were related to organisational factors including restrictive policies, nurses' level of education, age, working hours, nurses' attitudes, and lack of required skills to promote emotional resilience and/or to communicate with children. Family perception factors relating to parents' perceptions, attitudes and concerns of staff/parents, and anticipated behaviours of children were also identified as both barriers and facilitators.

CONCLUSIONS

There is a lack of consistency in the application of policies and procedures to facilitate children visiting their loved ones in an intensive care unit. Without key involvement from the nurses and healthcare team, there may have been opportunities lost to optimise family-centred care practices in critical care settings.

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.