Professional Documents
Culture Documents
ScienceDirect
journal homepage: www.elsevier.com/iccn
La Trobe University, Faculty of Health Sciences, School of Nursing & Midwifery, Melbourne, Victoria 3086,
Australia
b
La Trobe University, Faculty of Health Sciences, School of Public Health & Human Biosciences, Melbourne,
Victoria 3086, Australia
c
RDNS Institute, Royal District Nursing Service, St Kilda, Victoria 3182, Australia
d
Deakin University, Faculty of Health, School of Nursing & Midwifery, Melbourne, Victoria 3125, Australia
Accepted 16 June 2014
KEYWORDS
Critical care;
Critical care nursing;
Family care;
Professional-family
relations;
Qualitative studies;
Nursing
Summary
Objective: Nursing is characterised as a profession that provides holistic, person-centred care.
Due to the condition of the critically ill, a family-centred care model is more applicable in this
context. Furthermore, families are at risk of emotional and psychological distress, as a result of
the admission of their relative to intensive care. The families experiences of their interactions
in intensive care have the potential to enhance or minimise this risk. This paper presents a
subset of ndings from a broader study exploring families of critically ill patients experiences
of their interactions with staff, their environment, the patient and other families, when their
relative is admitted to an Australian intensive care unit. By developing an understanding of their
experience, nurses are able to implement interventions to minimise the families distress, while
providing more holistic, person- and family-centred care.
Research design: The study was a qualitative enquiry that adopted the grounded theory
approach for data collection and analysis. In-depth interviews with family members occurred
between 2009 and 2011, allowing the thoughts on interactions experienced by those families, to be explored. Data were analysed thematically. Twelve family members of 11 patients
participated in this study.
Setting: This study was undertaken in a mixed intensive care unit of a large metropolitan
hospital in Australia.
http://dx.doi.org/10.1016/j.iccn.2014.06.005
0964-3397/ 2014 Elsevier Ltd. All rights reserved.
52
P. Wong et al.
Findings: Interactions experienced by families of the critically ill primarily revolved around
seeking information and becoming informed. Further examination of the interviews suggested
that staff interacted in supportive ways due to their communication and interpersonal skills.
However, families also experienced unsupportive interactions as a result of poor communication.
Conclusion: Facilitating communication and interacting in supportive ways should help alleviate
the anxiety and distress experienced by families of the critically ill in the intensive care unit.
2014 Elsevier Ltd. All rights reserved.
Introduction
The importance of close family and friends to the Intensive
care Unit (ICU) patients recovery and outcomes is well
documented. Families of the critically ill provide a source
of social support for the patient, through the provision of a
close and familiar caring relationship (Hupcey, 2001; Olsen
et al., 2009). Critically ill patients are often unresponsive
and unable to contribute to decision-making about their
health care or develop therapeutic relationships with staff.
Consequently, families serve as a valuable resource for
patient care as staff come to know the patient better
through the family (Engstrm and Sderberg, 2007). Families may not only inuence the ability of staff to interact
more effectively with the patient, but are able to clarify the
patients preferences for care and treatment and decision
making about care issues may be facilitated (Davidson,
2009).
The unexpected admission of a family member to ICU in
a life-threatening condition can cause overwhelming stress
and anxiety for families (Jones et al., 2004). Moreover, the
psychological and emotional well being of families is at risk
as a result of this potentially traumatic experience. Family
members have been found to experience high levels of acute
post-traumatic stress disorder (PTSD) symptoms, three to
six months following death or discharge of a family member
from the ICU, placing them at risk for the development of the
condition (Azoulay et al., 2005; Jones et al., 2004). At the
very least, families may experience changes in their sleeping and eating behaviours, their daily activities and family
Background
Family needs in ICU
The needs of families in ICU have been the focus of familyrelated research in this context since the late 1970s. Much
of the research centred on the importance of families
needs, as identied in Molters seminal study (Molter, 1979)
and the subsequently developed Critical Care Family Needs
Inventory (CCFNI). Now universally accepted, we know that
families of critically ill patients require honest, accurate and
up-to-date information; they want to be close to the patient;
they want to be notied of any changes in the patients
condition and they want to be assured that the patient is
being well cared for (Burr, 1998; Davidson, 2009; Lam and
Beaulieu, 2004; Leske, 1986; Molter, 1979; Obringer et al.,
2012). Further studies have compared families needs with
healthcare professionals perceptions of their needs and
53
54
In this study, we sought to explore the families interactions
more broadly and within an Australian ICU context, significantly adding to the body of knowledge around this topic.
This paper focuses on the ndings limited to one major area
within the broader study that highlight the families experiences of their interactions specically with physicians and
nurses in ICU.
Method
Design
The main study on which this paper is based used the
grounded theory method. The resulting grounded theory
developed in this study will be presented in its entirety
in a follow up paper (Wong, 2014). Grounded theory is a
qualitative methodology that is used to build or develop a
theory (Charmaz, 2006; Creswell, 2013). The intention of
a grounded theory research design is to provide a general
theoretical explanation for a process or action, of which the
participants have been a part. Thus, the theory is considered
grounded in the data because it is shaped by the views
of participants in the study (Creswell, 2013). Grounded theory methods are a set of systematic procedures used to
collect and analyse data to develop theories that are generated from the data, and they may be especially useful
to explain practice or provide the foundation for further
research (Charmaz, 2006; Creswell, 2013).
In this study, qualitative inquiries are essential because
we sought to hear families stories about their experiences
P. Wong et al.
when they interact in ICU. It is through an understanding
of the individuals experiences from their perspective that
clinicians can tailor practice to be more family-centred.
Qualitative research is commonly dened as a form of
inquiry that explores the way people experience and interpret the world in which they live. By understanding a
persons view of the world and how this inuences the way
they act, we can come to know more about human behaviour
(Liamputtong, 2013; Munhall, 2007).
Table 1
55
Participants background information.
Participanta
Days in ICU
at time of
interview
Eileen
Kay
Rita
Sharon
Michael
Jenny
Margaret
Terry
Linda
Carol
Cheryl
George
66
57
58
32
44
43
61
43
44
54
52
54
15
21
14
12
24
25
15
7
38
7
5
13
F
F
F
F
M
F
F
M
F
F
F
M
Mother
Wife
Wife
Wife
Father
Mother
Wife
Husband
Mother
Mother
Daughter
Father
56
P. Wong et al.
Trustworthiness
Methodological rigour in this study was maintained by several strategies. Firstly, memos, as part of an audit trail,
were used to document decision-making processes and how
conclusions were reached, during data analysis. Secondly,
clarication and further explanations from participants
were sought during the interviews or later in follow up phone
calls to ensure the families perspectives were represented
accurately. Thirdly, the authors independently reviewed the
same transcripts developing their own codes and discussions of the similarities and differences ensued. This form
of peer review was used to seek alternative explanations
to the principal researchers propositions, avoiding bias and
any attempts to force interpretations unsubstantiated by
the data (Holloway and Wheeler, 2003).
Findings
Families interactions and experiences with staff were
focused around communication. Communication experienced by families revealed four themes obtaining
information, language of communication, supportive communication and unsupportive communication. Specically,
participants discussed who kept them informed, how
information was delivered, the appropriateness of communication and what communication they found supportive and
unsupportive.
Obtaining information
Families were constantly receiving or seeking information
about their critically ill family member from all healthcare professionals, such as physicians and nurses. However,
ICU nurses most commonly facilitated communication and
kept families informed by passing on important information
from physicians, and other sources, to families. If families
had missed meeting with the physicians, they would ask
the nurses to communicate what the physicians had said
about their family members progress and condition. Sharon
remarked:
Im talking to the nurses and they say Well the doctor
came by and said . . .. and so . . . I dont feel the need to
go looking for a doctor to ask . . . cause I feel Ive got all
the information already.
Some families found it easier to communicate with
the nurses because they were at the bedside around the
57
Theme
Category
Codes
Example quotes
Nurses as
communication
channels
Accessible
Personable
Clarifying
Strategies for
becoming
informed
Asking questions
Being resourceful
Putting the pieces
together
Obtaining
information
Temporality of
being informed
Language of
communication
Supportive
communication
Focused on the
present
Needing
information about
the future
Building trust
Delivering bad
news
Not sugar coating
Using Laymans
Terms
Making the
complex simple
Speaking our
language
Reassurance
Consistent themes
OK to leave
Keeping us
up-to-date
58
P. Wong et al.
Table 2 (Continued)
Theme
Unsupportive
communication
Category
Codes
Example quotes
Responding to
nonverbal cues
Anticipating our
information needs
Comforting
Body language
Poor
communication
Inconsistent
themes
Abrupt
Keeping a distance
Supportive communication
Families experienced interactions around communication
with staff that were considered supportive, while others
were described as unsupportive. Reassurance and responding to nonverbal cues represented communication
strategies that families experienced as supportive while
they were in ICU.
Families were determined, early in the admission, not to
leave the hospital so they could remain close to their family
member. Some families received reassurance and felt comforted in the knowledge that they could go home and contact
the ICU at any time to get information about their family
member. Families were also reassured by being informed
constantly about the family members progress, treatment
and care. For example, a physician put Kays mind at ease:
One doctor . . . might have been the second day . . . I didnt
know how severe his injuries were and the big picture sort
of thing . . . whether he was going to die from it or whether
he was ever going to come out of the coma . . . but I think
one of the senior intensive care doctors probably picked
Unsupportive communication
In contrast to supportive communication, families experienced poor communication such as staff speaking
abruptly, rudely or providing inconsistent information.
These examples are represented by the theme Unsupportive
communication.
Poor communication was represented by staff who spoke
to them in an abrupt and rude manner. Cheryl experienced
the following interaction with a physician:
I said to him I had a couple of concerns about mum being
operated on this early just for an eye socket, and he said
and who are you, what experience do you have. He
was really rude and, um, it was hard, I nearly burst into
tears over it actually . . . it was like a knife stabbing into
you, it was . . . and from then on I probably was a bit
reluctant to ask too many questions.
When families received inconsistent information, such
as that experienced by Michael in the following excerpt, it
often led to further anxiety and distress for families:
59
Discussion
The ndings from this study are supported by current and
previous literature in this area. The following discussion will
link the ndings to the current literature and the implications for clinical practice.
The results of this study are similar to previous work
in this area, specically the important need families have
for obtaining information. Molters (1979) seminal work
determined one of the most important needs of critically
ill patients family members is information about the
patients prognosis and condition. Previous studies have
substantiated the families desire for information and this
nding is now universally accepted (grd and Harder,
2007; Fry and Warren, 2007; Lee et al., 2000; Plakas et al.,
2009). However, further to those studies that identify what
families need, the ndings of our study frame the provision
of information around a context of time and highlight the
importance of assessing each family for their particular
informational needs and determining the most appropriate
time to provide such information. For example, there was
concern from some families that the nursing staff were
unable, or unwilling, to provide specic information about
what happened in the future after ICU because their focus
was on the day to day care in ICU. Interestingly, two participants whose expectations about future information after
ICU were not met, were both nurses. It raises the question as
to whether family members with a healthcare professional
60
background differ from lay families with regard to their
expectations and experiences of their interactions. There
is some evidence that healthcare professionals who are
also family members of patients in ICU, experience specic
challenges related to their interactions with ICU staff and
their expectations of care (Crunden, 2010; Dockerty and
Dockerty, 2006; Salmond, 2011). Salmond (2011) explored
the experience of being a nurse with a relative in ICU.
As a consequence of having medical knowledge, nurse
family members expected more detailed information such
as assessment ndings and planned care. They were aware
of expected care standards and judged staff competence
and the quality of care based on this knowledge (Salmond,
2011). Likewise, it is possible that the nurse family members
in our study had higher than usual expectations about the
information they should receive and therefore were more
likely to experience unmet informational needs.
The signicance of assessing families for their specic
informational requirements and then determining the most
appropriate time to provide such information is aligned with
the philosophy of a FCC theoretical framework. Inherent
within a FCC model is the provision of timely information
by healthcare professionals that enable families to effectively contribute to decision-making. This is supported by
Henneman and Cardin (2002), who suggest that to implement FCC in ICU, nurses play several important roles in
relation to meeting the families need for information, one
of which is to assess the familys needs and ensure they are
addressed appropriately.
Findings from this study support the assertion that families prefer to seek information from nurses because they
were often easier to approach and friendlier. Additionally,
during the process of obtaining information, ICU nurses were
often the communication channel between the family and
other healthcare professionals such as the physicians. Several studies have reported the important role of both nurses
and physicians in communicating various types of information, however, they acknowledge the important role of the
nurse as the immediate source of information and in communicating information (Maxwell et al., 2007; Sderstrom
et al., 2003). Gutierrez (2012) explored the communication
of prognostic information by physicians and nurses to families in ICU and found that nurses have a signicant role to
play in this type of communication. The ICU nurses often
lled the gaps or interpreted the physicians explanations
ensuring they understood what the physicians had told them
and the implications of the information. Auerbach et al.
(2005) studied interpersonal perceptions of healthcare staff
and found nurses were viewed as more friendly and less
hostile (p. 208) than physicians at admission and discharge.
The authors suggested the reason for this was that bedside
nurses are in continual contact with patients families and
are the families primary source of information and support
until the patients discharge from ICU (p. 208). While it is
true that families are in contact with nurses more often, it is
difcult to support a link between the nurses approachable
and friendly demeanour and their physical accessibility.
Findings from this study suggest the way staff deliver bad
news to families is important and families want the truth
about their family member despite the serious nature of
their condition. Information delivered in an open and honest way and with a caring and empathetic approach help
P. Wong et al.
families become informed and reduce anxiety. However, it
must be recognised that there is often a need for tactful
communication, when delivering bad news; and for balancing the requirement to be realistic while maintaining
cultural sensitivity and hope, as well as considering the individual differences in the family members ability to take in
information.
Despite the overwhelming need for families in this study
to receive open and honest information, there are several reports in the literature that raise important questions
around this issue and how bad news is communicated by
healthcare professionals. Engstrm and Sderberg (2007)
reported that although ICU nurses understand the importance of being honest about the gravity of the situation,
they nd it difcult to do this while still maintaining hope
for families. The importance of communicating effectively
with family members in the ICU, especially during end-of
life care is well recognised (Nelson et al., 2006; Shannon
et al., 2011). Jurkovich et al. (2000) investigated families
of trauma patients who died in ICU or Emergency Departments, and found that the most important characteristic in
the communication process of giving bad news, along with
provision of clear information, was the attitude of the person delivering the information. This was found to be more
important than the persons level of knowledge or whether
they could respond to questions.
Furthermore, recent attention has been focused on communication with patients and families from a non-English
speaking background (NESB), with at least one study suggesting they may be at increased risk of receiving less
information and emotional support from healthcare professionals due to language and cultural barriers (Thornton
et al., 2009). Similarly, Lee et al. (2000) highlighted a
cultural concern related to Chinese families, who traditionally avoid saying bad things or speaking negatively
about the patient for fear of causing bad luck and how
this may impact on the need to be honest with families.
Thornton et al. (2009) suggest further research is required to
identify ways of improving communication and support for
families from NESB. Respect and dignity for the patients
and families values, beliefs and cultural background, is
a core concept underpinning the FCC theoretical framework. Healthcare professionals must listen and respect the
families perspectives and choices when planning and implementing care for their relatives (Institute for Patient- and
Family-Centered Care, 2010b). Language and cultural barriers may challenge the staffs ability to practice a FCC
philosophy in this context.
In direct contrast to supportive communication experienced by families when healthcare staff provided
reassurance and consistent information, families in our
study also found communication unsupportive when there
was inconsistency of information among healthcare professionals. grd and Harder (2007) found that knowing about
the patients condition and progress, provided reassurance
and was essential in helping families adapt and cope with
the uncertainty of their situation. However, inconsistent or
conicting information causes unnecessary confusion and
distress, therefore strategies to minimise or prevent families
from receiving inconsistent messages need to be considered.
Nelson et al. (2005) investigated the informational needs of
patients and families of chronic, critically ill patients and
61
Conclusion
When nurses are working in the busy and highly technological
ICU environment, their priority is to maintain the critically ill
patients physiological stability. At times the families need
for emotional and psychological support become secondary,
attended to if, and when, time permits. Families, however,
play an important role in providing the patient with psychosocial support, and are also at risk of emotional distress
if they are not well supported. FCC is currently recognised
as a philosophical approach to care delivery that considers the patient and families perspectives, values and beliefs
when planning, delivering and evaluating care (Institute for
Patient- and Family-Centered Care, 2010b). It is a model
that can be implemented in ICU to ensure families emotional, psychosocial and other needs are met. The ndings
from this study can be used towards operationalising a FCC
framework in ICU. Facilitating communication by interacting
in supportive ways through reassurance and being responsive
to families cues while promoting strategies that minimise
unsupportive communication may help alleviate the anxiety and distress experienced by families of the critically ill.
Hence we recommend the clinical implications for practice
as presented in the Clinical Implications as necessary for
providing improved family-centre care.
Funding
The authors have no sources of funding to declare.
Conict of interest
The authors have no conict of interest to declare.
Acknowledgements
Limitations
The ndings from this study will add to the knowledge base
of families experiences of their interactions with staff in
ICU. Although not detracting from the study and its ndings, we do acknowledge some limitations. The majority of
participants were white Anglo-Saxon. In 20102011, only
2% of trauma patients admitted to this ICU were from a
NESB. Hence, the data presented in this paper represent
the voices of white Anglo-Saxon participants more than
those from ethnic minorities. Future research should aim
to replicate the study and include a greater proportion
from non-English speaking backgrounds. This would allow
us to apply conclusions to clinical practice and be condent that the perspectives of these groups have been
represented. Another limitation of this research is the fact
that it is only a single study and therefore we need to
be cautious about inferring conclusions based on this one
study. Furthermore, this study was conned to unexpected
admissions and so the ndings might not reect the experiences of families of electively admitted patients. Finally,
as identied previously, families of patients at end-of-life
or who were particularly distressed were excluded from
the study, and this could be considered a limitation of this
study.
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