Families’ experiences of their interactions with staff in an Australian intensive care unit (ICU): A qualitative study
Introduction
The importance of close family and friends to the Intensive care Unit (ICU) patient's 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 (Engström and Söderberg, 2007). Families may not only influence 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 influenced 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.
The needs of families in ICU have been the focus of family-related research in this context since the late 1970s. Much of the research centred on the importance of families’ needs, as identified in Molter's 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 notified of any changes in the patient's 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 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).
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, Engström and Söderberg, 2007, Williams, 2005). For example, ease of communication with staff and the use of everyday language help families to feel confident 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 conflicting 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 significant effect on the family and their involvement in ICU. Earlier research in this field 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 patient's care (Chesla, 1996, Chesla and Stannard, 1997, Hupcey, 1998). Similarly, Söderstrom 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 confident 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 influenced 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 (Söderstrom et al., 2006)
Most recently Mitchell and colleagues have been researching how Family-Centred Care (FCC) models can be 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 significant 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, Chaboyer et al., 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 significance 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 significant 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 (Ågård and Harder, 2007, Hughes et al., 2005, Jamerson et al., 1996, Lam and Beaulieu, 2004, Plakas et al., 2009, Plowfield, 1999, Walters, 1995); the experiences and perceptions of interacting with families in ICU, from the health professional's perspective (Cypress, 2010, Hughes et al., 2005, Hupcey, 1999, Söderstrom et al., 2003) and less frequently explored, the interactions between families and healthcare professionals from the families’ perspective (Söderstrom 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 specific 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. 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 findings limited to one major area within the broader study that highlight the families’ experiences of their interactions specifically with physicians and nurses in ICU.
Section snippets
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
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
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. Specifically, participants discussed who kept them informed, how information was delivered, the appropriateness of communication and what communication they found supportive and unsupportive.
Discussion
The findings from this study are supported by current and previous literature in this area. The following discussion will link the findings to the current literature and the implications for clinical practice.
The results of this study are similar to previous work in this area, specifically the important need families have for obtaining information. Molter's (1979) seminal work determined one of the most important needs of critically ill patients’ family members is information about the
Conclusion
When nurses are working in the busy and highly technological ICU environment, their priority is to maintain the critically ill patient's 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
Funding
The authors have no sources of funding to declare.
Conflict of interest
The authors have no conflict of interest to declare.
Acknowledgements
We would like to acknowledge the families who contributed to this research and to whom we are extremely grateful.
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