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Intensive and Critical Care Nursing (2015) 31, 5163

Available online at www.sciencedirect.com

ScienceDirect
journal homepage: www.elsevier.com/iccn

Families experiences of their interactions


with staff in an Australian intensive care
unit (ICU): A qualitative study
Pauline Wong a,, Pranee Liamputtong b,
Susan Koch c, Helen Rawson d
a

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.

Corresponding author: Tel.: +61 3 9479 6734.


E-mail address: p.wong@latrobe.edu.au (P. Wong).

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.

Implications for Clinical Practice


Families need to be assessed for their specic informational needs and the most appropriate time to give this information. Families that are also healthcare professionals may have different informational needs, due to their background,
and this should be a consideration when assessing their needs.
To communicate with families in supportive ways, ICU staff should use nontechnical terms and language that families
can understand. In recognition of the signicant role nurses play in ensuring effective communication with families,
nurses should be present during all family meetings when possible.
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.
Poor communication or providing inconsistent information may cause further distress and anxiety for families in
intensive care. Stafng allocation should aim to provide continuity of care to minimise the risk of families receiving
inconsistent or conicting information.
Staff should remain vigilant to families nonverbal cues, which may indicate a need for further information, clarication or reassurance.

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

functioning while their family member is in ICU (Van Horn


and Tesh, 2000).
It has been suggested that the level of anxiety and distress experienced by families may be inuenced by the
interactions they experience while visiting their family
member in ICU, including the interpersonal relationships
developed with healthcare staff and the process by which
information is communicated (Auerbach et al., 2005;
Davidson et al., 2012). Critical care nurses play a crucial role
in helping families manage their anxiety and their ability to
cope with the stress of the situation and therefore, facilitate
the supportive role families provide for the patient.

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

Families experiences of their interactions with staff in an Australian ICU


found that they often underestimate the families needs,
or level of importance families attribute to those needs
(Kinrade et al., 2009; Maxwell et al., 2007). Furthermore,
ICU nurses may have a good knowledge of what families
need, but this may not be translated into clinical practice
(Buckley and Andrews, 2011). Consequently, studies have
found that unmet families needs have a negative impact on
family satisfaction in ICU (Khalaila, 2012).
Family interactions in ICU
Some studies have suggested that family needs are met by
their experiences, interactions and relationships with staff
such as through the communication of information (Blom
et al., 2013; Engstrm and Sderberg, 2007; Williams, 2005).
For example, ease of communication with staff and the use
of everyday language help families to feel condent that
their family member is well looked after in ICU. In addition, caring interactions provide comfort and help allay fears
(Williams, 2005). Nonverbal interactions such as eye contact
and facial expressions also provide comfort and reassurance
(Fry and Warren, 2007). Nurse behaviours that demonstrate
a commitment to the family and patient, such as treating
them as people, displays of empathy and sharing of information, encourages a connection that reassures and supports
families (Eggenberger and Nelms, 2007).
Conversely, healthcare professionals can cause more distress when they give conicting information. Similarly, if
information is more positive than warranted, families experience false hope and distrust in the healthcare professional
(Verhaeghe et al., 2007). When nurses discourage family
involvement, fail to acknowledge the family or demonstrate
task-oriented attitudes towards care of the patient, families
express distress and feel excluded (Eggenberger and Nelms,
2007).
Further studies that explored interactions with healthcare professionals found family-staff interactions may have
a signicant effect on the family and their involvement in
ICU. Earlier research in this eld has found that nurses use
strategies to hinder the staff-family relationship, by distancing themselves from the patient and the family, at the
expense of focusing on the technological aspects of the
patients care (Chesla, 1996; Chesla and Stannard, 1997;
Hupcey, 1998). Similarly, Sderstrom et al. (2003) found that
nurses, who value the technical and medical aspects of their
role and are unable to provide families with comfort or support, represent noninviting interactions. In contrast, they
also found that nurses who value the development of good
relationships with families and feel condent about supporting them characterise inviting interactions.
Later, the same authors interviewed families and
observed their interactions with staff and concluded that
initial interactions had an impact on the families and
inuenced further interactions families had with staff.
Unambiguous information and open communication that
lead to mutual understanding was important for families
to adjust to the system and impacted on whether they felt
consoled or insulted (Sderstrom et al., 2006)
Family-focused research in Australian ICUs
Most recently Mitchell and colleagues have been researching how Family-Centred Care (FCC) models can be

53

operationalised in ICUs within an Australian context. Using a


qualitative design, the authors explored the families experiences of providing physical care to their family member
with support of the critical care nurse, and found that the
process improved communication and facilitated a connection between nurses, families and the patient (Mitchell and
Chaboyer, 2010). Another study used FCC models (measured
by respect, collaboration and support) to explore the effects
of having families partner with ICU nurses in providing care.
A quasi experimental design using control and intervention
groups was used and the intervention resulted in a signicant
difference in the level of FCC (Mitchell et al., 2009).
Further studies focused on families in the Australian ICU
setting have explored the experience of patients and their
families, including anxiety and uncertainty, during the time
of transfer from ICU (Chaboyer et al., 2005, 2007; Mitchell
and Courtney, 2004). One study investigated the effect of an
ICU liaison nurse on the anxiety experienced by patients and
their families before leaving ICU (Chaboyer et al., 2007). In
another study, the authors highlighted the signicance of
providing emotional support to patients and their families
during ICU transfer (Chaboyer et al., 2005).
Another main focus of family studies in Australia centers
around end-of life care, withdrawal of treatment and caring
for brain dead organ donor patients. Most of the studies,
however, explore the perspectives of ICU nurses undertaking
this challenging role and very limited attention has been
given to the families experiences in this context (Bloomer
et al., 2010; Halcomb et al., 2004; Pearson et al., 2001;
Ranse et al., 2012).
In summary, there is a plethora of research into what
families need based on the use of the CCFNI. In addition,
there is a signicant body of qualitative studies that explore
the families perceptions of what they need (Bond et al.,
2003; Coulter, 1989; Fry and Warren, 2007; Wilkinson, 1995);
the families overall experiences in ICU (grd and Harder,
2007; Hughes et al., 2005; Jamerson et al., 1996; Lam
and Beaulieu, 2004; Plakas et al., 2009; Ploweld, 1999;
Walters, 1995); the experiences and perceptions of interacting with families in ICU, from the health professionals
perspective (Cypress, 2010; Hughes et al., 2005; Hupcey,
1999; Sderstrom et al., 2003) and less frequently explored,
the interactions between families and healthcare professionals from the families perspective (Sderstrom et al.,
2006). Whilst these studies provide insight into what families need and their overall experiences, as well as staff and
family perceptions of their interactions, studies with the
specic aim of understanding the families perspective of
their experiences when they interact with staff, as well the
patient, other ICU families and the environment is limited
in the literature.
The study on which this paper is based provides a broader
exploration of the families perceptions of their interactions
in ICU. In addition to interactions with staff, we also examined the families interactions with the patient, other ICU
families, interactions within their own family and the environment which included the surrounding technology, the
waiting room and the ICU per se. Although we now have an
understanding of what families need and the impact that
interactions with staff have on them in the US, UK and the
Northern European ICU context, the experiences of families
with regard to their overall interactions is largely unknown.

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.

Family-centred care: theoretical framework


The theoretical framework upon which this study is based
is family-centred care (FCC). In response to family needs
research conducted over the preceding three decades,
FCC has emerged as an approach to delivering care to
patients and their families that many organisations include
in their unit policies and guidelines. Yet, although it is
widely practised in the neonatal ICU setting in Australia,
its implementation is yet to be fully realised in the adult
ICU context. A FCC model considers the patients family
to be the unit around which care delivery should be organised. However, more than simply a model of care delivery,
it is considered a philosophical approach based on the principal that patients are part of a larger whole (Henneman
and Cardin, 2002). A collaborative team approach, whereby
members support and value the FCC philosophy, is essential in its implementation (Damboise and Cardin, 2003).
Patient- and family-centred care is dened by the Institute for Patient- and Family-Centred Care as an approach
to the planning, delivery, and evaluation of health care
that is grounded in mutually benecial partnerships among
health care providers, patients, and families (Institute
for Patient- and Family-Centered Care, 2010b, para 1).
Among the key concepts central to this framework are collaboration; respect and dignity; information sharing and
participation. The institute recognises the signicant contribution families provide in promoting the health and well
being of their family members of all ages (Institute for
Patient- and Family-Centered Care, 2010a).

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).

Setting and sample


This study was conducted in an ICU at a major metropolitan hospital in Australia. It is one of the largest ICUs in
the country and admits over 2000 critically ill patients per
year with various life-threatening conditions. The ICU is a
combined general unit with various sub-specialties including
trauma and cardiothoracic surgery. There is an open visiting policy, although families are sometimes discouraged
from visiting during medical rounds and nursing handover.
However there is some exibility dependent on the patient
situation. Generally, visitors are limited to two at the bedside at any one time, and again this varies dependent on the
patient context. A one spokesperson policy is supported in
ICU, whereby one family member is nominated as the liaison between medical and nursing staff and the rest of the
family. Generally, medical and nursing staff will communicate information about the patients progress and condition
to the spokesperson, who will then update the wider family
members.
Participants who had a family member admitted to ICU no
earlier than 4872 hours following admission were invited
to participate. A family member was dened as anyone
related to the patient by blood, marriage, adoption or a
non-traditional family relationship that was considered the
patients support system, or anyone who considered themselves a part of the family. Inclusion criteria were families
of patients admitted unexpectedly (e.g. due to road trauma
or cardiac arrest), as opposed to a planned, elective admission; any family member over the age of 18 years old and
English speaking. Families of patients admitted unexpectedly to ICU are not given information about what to expect
or how to prepare for what could potentially go wrong. We
were interested in exploring the impact of this situation on
the families experiences of their interactions. Exclusion
criteria were family members who were particularly distressed, as deemed by the Social Worker, that approaching
them about the study may cause further emotional distress.
Families of patients at end-of-life or classied as brain dead
were also excluded from the study.
Based on the grounded theory approach we used theoretical sampling by selecting participants and collecting data on
the basis of its contribution to the conceptual and theoretical development of our analysis (Charmaz, 2006; Creswell,
2013). A theoretical sampling strategy directed us to act
on developing codes and categories by posing questions in
further interviews that tested propositions and themes to
elaborate meaning and discover variation within them
(Charmaz, 2006, p. 108). Therefore, an iterative process
of data collection, analysing then theoretically sampling
to guide further data collection occurred (Charmaz, 2006).

Families experiences of their interactions with staff in an Australian ICU


This process occurred over a period of approximately 12
months.
Participants were recruited via the registered nurse (RN)
caring for the patient, following an initial assessment of
the family members emotional state by the social worker.
The purpose of this initial assessment was to ensure the
family member was not too overly distressed before being
approached to participate in the study. The nurse unit managers in ICU expressed concern about the RNs making an
assessment of family members emotional state as they were
deemed as not having the relevant experience in this area.
Consequently, ethics requirements for this study stipulated
that the social worker must determine the families emotional suitability prior to being approached for participation
in this study. Social workers are commonly a part of the multidisciplinary team in ICUs throughout Australia. The primary
role of the social worker in ICU is focused on crisis intervention, psychosocial assessment, support and counselling as
well as providing practical assistance (Hartman-Shea et al.,
2011). This is similar in the Australian ICU context. Participants were then approached by the RN who briey explained
the study. If the family member was interested in participating, their contact details were forwarded to the researchers.
The family were then contacted and a follow up meeting
organised, during which further details of the study were
claried, questions answered and written consent sought.
Twelve family members of 11 patients admitted to ICU
participated. Average length of stay (LOS) in ICU, for the
patients of the families interviewed, was 19 days, with a
range of 538 days. The high average LOS may be explained
by the nature of the ICU in which the study was performed.
The ICU is considered a level three tertiary referral unit
and provides comprehensive critical care including complex
multi-system life support. A level three ICU is classied as
the highest of three levels by the Australian Institute of
Health and Welfare and therefore manages patients that are
among the most severely critically injured in the country
(Australian Institute of Health and Welfare, 2013).
Background information about the participants, such as
their age and relationship to the patient is presented in
Table 1.

Data collection and analysis


In-depth interviews were used to collect information
between 2009 and 2011. Interviews were conducted on the
hospital site, external to ICU. A location independent of the
ICU was necessary to make it clear to participants that there
was no connection between the care of their family member in ICU and the study. Interviews occurred on site at the
hospital as most families spent the majority of their time in
hospital. At the time of interview, four patients had been
transferred out of ICU to the wards, with the remaining
patients still in ICU. Each interview was audio recorded and
transcribed verbatim and lasted between 30 and 88 minutes.
An interview schedule was used as a guide for the interview
with initial questions being developed from a review of the
literature, however participants were encouraged to discuss
in depth, any aspect of their experience interacting in ICU.
The interview guide varied at each interview to reect the
need to explore themes and concepts that arose from the

Table 1

55
Participants background information.

Participanta

Age Gender Relationship


to patient

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

a The actual participants names have been substituted with


pseudonyms to maintain their anonymity.

analysis of previous interviews in line with the nature of


theoretical sampling.
Ethics approval to conduct this study was granted by
the University Human Ethics Committee and the hospitals
research ethics committee. Written consent was also sought
from participants. Anonymity was assured by de-identifying
participants with the use of pseudonyms when transcribing
the recorded interviews.
Data were analysed using thematic analysis based on the
principles of the grounded theory method of data analysis
(Liamputtong, 2013). Grounded theory research is often situated within a symbolic interactionism framework, which is
concerned with the subjective meanings that people have
for their actions and environments. This framework is based
on the premise that individuals construct their perceptions
and meanings as a result of their interaction with others
(Liamputtong, 2013). In our broader study, we examined
how families interacted with healthcare staff, their environment, the patient and other families. The partial data
analysis presented in this paper relates to the interactions
between families and healthcare staff only. Data analysis occurred by reading and re-reading each transcript and
making sense of what the participants said about their
experiences. According to Charmaz (2006), initial coding
in grounded theory involves naming segments of data and
constructing codes to represent what is seen in the data
and dene meanings within it. Our initial coding produced
multiple codes and concepts that represented different
experiences of families as they interacted in ICU. Focused
coding follows initial coding during which decisions are made
about categorising larger amounts of data. This involves synthesising the most signicant or frequent earlier codes into
categories and themes that make most analytical sense.
These processes are not linear but iterative as focused
coding produces new insights and prompts the researcher
to return to earlier data or follow up leads by returning
to the eld to collect further data (Charmaz, 2006). Our
themes were revised and rened as analysis progressed and
as new insights emerged from checking the themes against
the codes and the overall data (Liamputtong, 2013). NVivo

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P. Wong et al.

version 8 software was used to store and manage the data.


While computer-assisted qualitative data analysis software
was useful for organising the large volumes of data, the
authors still had to interpret the data using analytical thinking processes to analyse and formulate the themes and
categories (Liamputtong, 2013).
Table 2 offers an outline of how each theme was developed during the analysis, with verbatim examples that
represent each theme. In presenting verbatim examples
from the participants, we used a ctitious name to preserve
their anonymity.

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

clock and therefore, were a more accessible source of


information. However, families also felt more at ease
communicating with nurses as they were more friendly,
approachable and claried information using simplied language families could understand, as Michaels experience
illustrates:
Yeah it might have been a bit technical for me . . . just
the ner points I think was what I needed . . . a bit of
clarication . . . and I got that off the nurse.
The nurses kept the families informed by channelling
important information from the physicians to the families.
They were able to facilitate this communication because
they were most accessible, approachable and used language
families could understand.
The information families wanted about their family members treatment or progress was often framed by a context of
time. Some could only cope by focusing on the current situation. Others wanted detailed information about the future
plan well before discharge was discussed. Terry expressed
his frustration when he was unable to be informed about
future services for his wife in the following statement:
One of the things I found frustrating is Ive asked about
the occupational therapy and rehab . . . where shes going
to go.
Further analysis revealed several explanations for experiences such as Terrys. According to the families, staff
sometimes believed the families did not need to be concerned with specic issues at that point in time; other
families suggested staff were only concerned about the
day-to-day care in ICU and perceived that staff were not
concerned about what happened down the track:
You know the ones youre dealing with are just totally
absorbed in the current . . . in the moment care sort of
thing . . . its not their issue about what happens down
the track I guess after ICU. (Kay)
In the process of obtaining information, families used
a variety of strategies including asking staff questions, as
well as less direct methods, such as eavesdropping on the
ward round, picking up cues and piecing together bits of
information.
Obtaining information was important to families. They
obtained information from healthcare professionals either
directly or indirectly and most often it was the ICU nurses
who were the communication channels between other
healthcare professionals and families. Families varied in
their need for information about the future. For some families, information about what to expect in the future was
important, however for others, the current situation was all
they could cope with.

The Language of communication


Families, who received bad news, appreciated the way
healthcare professionals communicated the information
openly and honestly. They used the term sugar-coating
to describe how they did not want staff to disguise bad
news and make it sound better than it actually was in order
to avoid upsetting them. Families felt that by receiving

Families experiences of their interactions with staff in an Australian ICU


Table 2

57

Outline of thematic analysis.

Theme

Category

Codes

Example quotes

Nurses as
communication
channels

Accessible
Personable
Clarifying

Strategies for
becoming
informed

Asking questions
Being resourceful
Putting the pieces
together

The nursing staff would pretty much keep us up to date


with everything . . . The doctors would come in and see
[patient] . . . if they had missed us we knew that we
could speak to the nursing staff and . . . they were
pretty good as far as telling us what the doctors had
said. (Linda)
The way theyve tried to explain things to me about
whats happening to her, the way theyve explained
things to me that the doctors have told them have been
. . . you know, things that theyve said in that way have
been good and theres not so many grey areas. (Terry)
If we ever had a question or something you just go up
and ask them, if they were on their rounds we would
certainly ask. (Linda)
I thought of gure Id like to be in hand over and nd
out what theyre saying in there compared to what
things Im trying to . . . cues Im trying to pick up from
whats happening (Kay)
Theyre very careful not to say more than what theyre
looking after . . . and when you ask . . . what about
after, hows she going to go? The answer . . . was Oh I
dont know about then, they move on . . . hes ready to
look after the next badly broken person (Eileen)
The most disappointing would be having to say the
follow up now, whats going to happen. As I said I dont
know, I have no idea what happens from here. (Cheryl)
Im concentrating on now. I just . . . think Id have a
nervous breakdown if I tried to look too far ahead.
(Sharon)

Obtaining
information

Temporality of
being informed

Language of
communication

Supportive
communication

Focused on the
present
Needing
information about
the future

Being open and


honest

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

They were honest . . . didnt sugar coat anything . . .


you know theyre not going to say hes got a scratch on
his leg when hes as bad as what he was so they . . .
prepared us for it. (Michael)
And the nurses. . . theyd been doing the dressings and
. . . said look, you know, Ill be honest it does look
gunky she said . . . (Jenny)
They just had a way about . . . talking and explaining
things in our terms too, not all in technical terms
because when youre in shock you dont want to hear
weve put him on these drugs and things like that.
(Jenny)
I think it was very much like a laymans terms really . . .
he communicated to me, and . . . I dont regard myself a
medico or an extremely intelligent person and yet
everything he was saying I could understand him clearly
(Terry)
They just reassured us that we could go home . . . just
being reassured that we can ring twenty-four seven . . .
and speak to someone if were concerned about
anything. (Jenny)
She conrmed that the interaction with the male nurse
who sat her down and explained things well, told her
that no questions were silly questions that this was . . .
reassuring for her. (Carol)

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

He said are you alright; I must have looked like a lost


soul. (Carol)
Spotting if we are having a bad day without even us
having to utter a word. (Jenny)

Poor
communication

Inconsistent
themes
Abrupt

Keeping a distance

Being fobbed off


Feeling excluded
Being in the way

What we were told at the bed was different to what


was actually happening. (Cheryl)
I was sort of told its going to be one-on-one and on a
number of occasions it wasnt one-on-one. (Terry)
I ask a lot of questions . . . there has been some where
they just give . . . a generic answer that they want . . .
not to fob you off, but just to say You know this is
why were doing it and not go into the detail maybe
that some of the other nurses do. (Michael)
[Physician] totally ignored me, totally ignored me and I,
um, apologised to him straight away and he just
ignored me, just continued talking on to the rest of
them. (Cheryl)
A couple of days later he [nurse] came . . . sort of
keeping a wide berth . . . didnt sort of . . . after being
sort of almost pally when we were initially there to
standofsh. (Kay)

information honestly and upfront, not only enabled them


to prepare for the future, but it established trusting relationships with them. This is illustrated by Sharon:
You could tell they were telling you the truth . . . they
werent sugar-coating it for you . . . they were telling you
everything, so you felt you could trust them, because
they werent keeping stuff from you.
Some healthcare professionals delivered bad news by
using well-chosen words and an appropriate tone in their
voice that considered the families fragile emotional condition, but others did this poorly. Linda described one
physician she labelled the bad news doctor because of the
way he delivered this type of information but contrasted this
with another physician who delivered bad news with a more
humanistic approach:
He said . . . shes in a bit of a hole, we need to get her out
of this . . . He didnt have a great deal to say to us, he
thought about everything he said very carefully . . . hes
just one of those people that I could go through life and
Ill never forget what he has to say and the way he says
it.
When receiving bad news, although families wanted staff
to be open and honest, it was still important for them to
deliver the information in a caring and compassionate manner that considered their vulnerable and emotional state.
The language of communication was also represented by
the way staff phrased the information provided. Simplifying
information, by rephrasing it in non-technical or lay terms,
so that families could understand the complex medical language used by healthcare professionals, was important for
facilitating communication with families. This was particularly helpful when families were in a state of shock early

in the admission and potentially unable to process much of


what they were told. It also helped families feel condent in
the care and treatment their family member was receiving,
as stated by Terry:
I think it was very much like . . . laymans terms . . . so I felt
condent with what he said . . . and it installed condence
in [wifes] care.
In order for families to fully understand the information
they are given, it needs to be provided in a language the
families comprehend and of which they can make sense.

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

Families experiences of their interactions with staff in an Australian ICU


up on that and said Well hes not going to die from this.
So that was reassuring.
When information received from different healthcare
professionals was a consistent theme, they felt reassured
even if the news was not always positive, as highlighted by
Terrys comment:
No ones really given me much of a deviation of what
the doctors have told me . . . but its been reassuring and
theres a consistent theme . . . and its helped me . . .
Families felt reassured, not only by constantly receiving
information about their family member, but also when the
information given was consistent between various staff.
Supportive communication is also represented by staff
that responded to families nonverbal cues that indicated
they were confused, anxious or worried while in ICU. The vigilance with which staff perceived their distress, by observing
their body language or facial expressions, prompted them to
clarify information, provide reassurance or further investigate why families may have been upset. In the following
statement, Jenny described the immediate response of the
ICU nurse to her concern, when she misinterpreted data on
the monitor:
At one stage I looked at it and it said 49 . . . and straight
away the nurse could see me looking . . . worried and she
said its not his temp . . . I said oh phew!
Linda described how the receptionist staff responded to
her nonverbal cues of distress and then followed up by asking
the ICU nurses to investigate further:
Im sitting there having a cry. And they [receptionists]
must have . . . rung [the] ICU nurse and said can you nd
out whats wrong with [Linda] because shes obviously not
herself today.
Families described the way staff were receptive to their
feelings of anxiety or distress, without them needing to say
anything. The ability of staff to subsequently respond to
their concerns was supportive for these families.

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

The ICU doctor . . . said look hes got a couple a bad


bugs in his system . . . were pretty sure that the leg is not
creating the bugs . . . and he walked out and wouldnt
have been a minute later the burns guys come in and said
ah look we think his legs creating all these bugs and . . .
we might have to amputate above the knee.
The manner in which staff spoke to families and the consistency of the information were important in terms of being
supported or unsupported. Speaking abruptly or rudely and
delivering inconsistent information, did not support families
during their time in ICU.
In summary, families interactions with physicians and
nurses in ICU revolved around communication. More specifically, families were constantly obtaining information from
the healthcare staff, and most often from the ICU nurses.
The context of time around which the information was
framed, was important for families. Direct and indirect
methods, such as eavesdropping were used by families to
obtain information they required. Of equal importance to
obtaining information from staff, was the language healthcare staff used to communicate that information. Families
appreciated staff that used lay terms and nontechnical language that was easier for them to comprehend.
It was also important that staff were honest and upfront
when communicating, especially bad news. Families experienced both supportive and unsupportive communication.
When staff communicated in ways that provided them with
reassurance or when they were astute to families nonverbal cues, the communication was considered supportive.
Poor communication, during which staff spoke rudely or
reprimanded families and inconsistent information, was considered unsupportive.

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

Families experiences of their interactions with staff in an Australian ICU


found families experienced confusion and further anxiety
as a result of receiving conicting messages from different
physicians and nurses. Staff rostering in ICU that promotes
continuity of care from both physicians and nurses would
help resolve this problem. In clinical practice guidelines,
based on a systematic review of the literature, Davidson
(2007) recommend that nurses and physicians allocated to
each patient should be as consistent as possible and the
number of healthcare professionals who provide information be minimised, in order to reduce the confusion and
frustration of families who interact with multiple healthcare professionals. Ongoing interdisciplinary communication
about the patients progress and planned treatment and
care is necessary to ensure consistent messages are being
delivered by all healthcare professionals (Davidson et al.,
2007).
Families in this study felt that staff were generally
alert to nonverbal cues and were then able to respond to
confusion or distress. In order for healthcare staff to support families who experience distress and anxiety while
they are visiting ICU, it is important that expressions
of concern, confusion or misunderstanding are identied
by staff so these can be addressed in a timely manner and before they escalate. grd and Harder (2007)
found that in the process of constantly seeking information, families form their own personal cues about the
patient and their environment. Sometimes these personal
cues are inaccurate representations of the actual situation but these misinterpretations may never come to
the nurses attention. Davidson (2009) suggests that families who have misconceptions about the ICU environment,
or patient related events, may benet from the nurses
questioning the family more to expose underlying concerns or misunderstandings, therefore avoiding unnecessary
anguish.

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.

We would like to acknowledge the families who contributed


to this research and to whom we are extremely grateful.

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