Creating a collaborative environment to care for complex patients and families

It starts with access! A grounded theory of family members working to get through critical illness

The critical illness of an adult constitutes a crisis for the patient's family. They relinquish primary responsibility for the physical well-being of the patient to health providers, but remain involved, working to get through the situation. What constitutes this "work"? Results of two grounded theory studies revealed that family members were engaged first in the pivotal work of gaining access because of their overarching need to be present with and for their critically ill relative. Other work included patient-related work, nurse/physician-related work, and self-related work. These findings extend our understanding of their experiences beyond current knowledge and paternalistic perceptions of burden, stress and coping, and need recognition and fulfillment. Critical care nurses are exhorted to support family members in their work by removing barriers to patient, staff, and information access and to partnering opportunities.

The bodily presence of significant others: Intensive care patients' experiences in a situation of critical illness

This study is about intensive care patients and the bodily presence of significant others. The aim of the study is to inquire and understand the patients experience of the body in relation to their significant others during critical illness. Open, unstructured, in-depth interviews with six former intensive care patients provide the data for the study. The phenomenological-hermeneutical analysis points to a theme among ICU patients' experience of conflict between proximity and distance during the bodily presence of their relations. Patients experience different and conflicting forms of responses to the presence of their significant others. Patients experience significant positive confirmation but also negation through this presence. In the ICU situation, the reactions of significant others appear difficult to deal with, yet the physical presence is significant for establishing a sense of affinity. Patients seek to take some responsibility for themselves as well as for their relatives, and are met with a whole spectrum of reactions. Intensive care patients experience the need to be actively, physically present, which often creates sharp opposition between their personal needs and the needs of their significant others for active participation.

Multicultural family members' experiences with nurses and the intensive care context: a hermeneutic study

BACKGROUND

The aim of this study was to illuminate the experiences of multicultural family members in intensive care units in hospitals, when a loved one was critically ill. An increasing migration from non-Western countries to Norway and potential double-stress for multicultural families experiencing critical illness are pre-understandings.

METHODS

The study utilised a Gadamerian hermeneutic design. Data were collected through in-depth-interviews (n=5) and interpreted, inspired by Lindseth and Norberg's phenomenological hermeneutical method.

FINDINGS

Multicultural family members' experiences of their encounters with nurses were understood as: 'Struggling to preserve the families' cultural belonging within the health care system', based on four themes: (a) filtering information to reduce concern; (b) understanding and being understood; (c) protecting cultural traditions and (d) interaction between roles, rules and expectations.

CONCLUSION

Family members with a non-Western ethnic background experienced several challenges within the complex ICU environment. Multicultural family members had distinct strategies to deal with the hospitalisation of a critically ill loved one. Interaction difficulties and cultural traditions were not influenced by the environment alone, however the challenges seemed to deal with universal human interaction independent of the context. Nurses need to be sensitive to the families' cultural customs in order to meet their expectations in a respectful way.

The experience of secondary traumatic stress upon care providers working within a children's hospital

This study examined the impact of routine occupational exposure to traumatic aspects of child illness, injury, and medical treatment upon care providers working within a children's hospital. Three hundred fourteen providers completed a demographic data sheet and four questionnaires. Results suggested overall that the level of Compassion Fatigue in this sample was similar to a trauma worker comparison group. In addition, 39% of the sample was at moderately to extremely high risk for Compassion Fatigue, and 21% was at moderate to high risk for Burnout. Burnout and Compassion Fatigue were related to type of profession and length of employment. Various dimensions of empathy were related to both Burnout and Compassion Fatigue. Regression analyses indicated that years in direct care and greater blurring of caregiver boundaries were predictive of greater Burnout and Compassion Fatigue. There is a need to further refine the assessment of occupational exposure to potential traumatic aspects of care within pediatric hospital settings and link assessment to prevention and intervention efforts.

Staff engagement during complex pediatric medical care: the role of patient, family, and treatment variables

OBJECTIVE

To examine the role of patient, family, and treatment variables on self-reported engagement for physicians and nurses working with pediatric complex care patients.

METHODS

Sixty-eight physicians and 85 registered nurses at a children's hospital reviewed eight case scenarios that varied by the patient and patient's family (each cooperative versus difficult) and the length of hospitalization (<30 days versus >30 days). Participants rated their engagement from highly engaged/responsive to distancing/disconnected behaviors.

RESULTS

Nurses were more likely than physicians to engage in situations with a difficult patient/cooperative family but less likely to engage in situations with a cooperative patient/difficult family.Nurses were more likely to consult a colleague regarding the care of a difficult patient/difficult family,while physicians were more likely to refer a difficult patient/difficult family to a psychosocial professional.

CONCLUSIONS

Differences were found for engagement with "difficult" patients/families, with physicians more likely to distance themselves or refer to a psychosocial professional, while nurses were more likely to consult with a colleague.

PRACTICE IMPLICATIONS

Communication between health care team members is essential for optimal family-centered health care. Thus, interventions are needed that focus on communication and support for healthcare teams working with pediatric complex care patients and their families.

Being family: the family experience when an adult member is hospitalized with a critical illness

AIMS AND OBJECTIVES

The purpose of this qualitative study was to understand and interpret the 'family experience' with an adult member hospitalized with a critical illness.

BACKGROUND

Nursing practice in critical care settings has traditionally focused on individual patient needs with only tangential recognition of family needs. Investigation to describe the family experience to illuminate family nursing practice has been lacking. The majority of studies thus far related to critical illness and family are quantitative and reveal constraints to family care and problematic nurse-family interactions. The logical next step is a new kind of family research to enhance nursing of the family as a whole.

DESIGN

Family systems theory and existential phenomenology provided the frameworks guiding the study.

METHODS

Semi-structured 'family as a group' interviews were performed with 11 families. Data were analysed using Van Manen's hermeneutic method. Rigor was addressed with trustworthiness criteria.

RESULTS

The family experience was analysed within Van Manen's framework of lived space, lived relation, lived body and lived time. A constitutive pattern of being family was revealed.

CONCLUSIONS

Being family bonds families and makes them exceedingly strong during the critical illness experience. Being a family unit is what gives most families the ability to endure the emotional upheaval and suffering that come with the critical illness experience.

RELEVANCE TO CLINICAL PRACTICE

Nurses have profound power to help families bear this experience. Family caring is enhanced with the presence of nurses who recognize the importance of 'Being Family' for the family, acknowledge the significance of the nurse-family relationship and act on a commitment to be with and for the family.

Families: from difficult to exceptional--one team's journey

Families of patients need support when the hospital stay becomes more difficult than anticipated. Healthcare providers also need assistance when caring for them. A continuous improvement team, Caring for Exceptional Families, was initiated to develop a system with tools and interventions for a proactive multidisciplinary approach to identifying families at risk for negative behavior during the hospital experience. The process and outcomes of this team are described.

Development of the Perinatal Concerns Program: care of mothers after diagnosis of fatal infant anomalies

Care of the grieving mother in the labor and delivery setting is a complex phenomenon requiring collaboration of professionals and designing sensitive care based on theory and compassion. This article describes The Perinatal Concerns Program, which was developed to make available a complete range of care for women whose pregnancies are complicated by fetal abnormalities. Development of this program required collaboration of several services, coordination of protocols, and establishment of clear lines of communication. It was born after a particularly difficult case in labor and delivery that alerted a staff nurse to the fact that coordination of care for this patient could have resulted in enhanced ability of all the staff to meet this woman's physical and emotional needs. The development of this program demonstrates that a motivated staff nurse with effective leadership skills can make major changes in an institution which can make a difference in the care of grieving patients.

Living the situation stress-experiences among intensive care patients

The study is about the types of stress that patients in intensive care units experience. Ten reviewed articles selected from Cinahl and Pubmed between 1994 and 2003 constitute the data. The paper is a literature review, and the data is analysed from the phenomenological-hermeneutical point of view. Stress related to the body, room and relationships is discussed. Experiences of stress that are related to the body include bodily stress reactions, deprivation of control, emotions related to technical equipment, procedures and loss of meaning. Stress related to the room highlights the environment and the situation in which the patient finds him/herself. The ethical relations of professionals and separation of patients from their significant others constitute stress related to relationships.

The culture of a trauma team in relation to human factors

AIM

The aim of this ethnographic study was to explore the culture of a trauma team in relation to human factors.

BACKGROUND

Traumatic injury is the leading cause of death in the first four decades of life in the western world. Evidence suggests that the initial assessment and resuscitation of trauma victims is most successfully carried out by an organized trauma team. Most trauma teams use Advanced Trauma Life Support principles which focus on rapid assessment and management of the patient's injuries. Similarly, most trauma education focuses on Advanced Trauma Life Support principles, concentrating firmly on the patient's physical status. Nevertheless, contemporary literature about emergency teams suggests that human factors, such as communication and interprofessional relationships, can affect the team's performance regardless of how clinically skilled the team members are.

METHOD

Focused ethnography was used to explore the culture of a trauma team in one teaching hospital. Six periods of observation were undertaken followed by 11 semi-structured interviews with purposively chosen key personnel. Data from transcripts of the observation field notes and interviews were analysed using open coding, followed by formation of categories resulting in the emergence of six central categories.

RESULTS

Findings suggest that leadership, role competence, conflict, communication, the environment and the status of the patient all influence the culture of the trauma team. Interpretation of these categories suggests that trauma team education should include human factor considerations such as leadership skills, team management, interprofessional teamwork, conflict resolution and communication strategies.

RELEVANCE FOR CLINICAL PRACTICE

The findings suggest that support systems for role development of junior team leaders should be formalized. The proven airline industry techniques of Crew Resource Management, focusing on teamwork and effective communication, could be implemented into continuing professional development for trauma teams to engender collaboration and interprofessional practice.

Interdisciplinary Collaboration: The Heart and Soul of Health Care

In a health care system in which patient complexity, outcome indicators, and informed families are representative of current reality, an interdisciplinary approach to care is crucial to successful navigation of a patient's experience in the ICU. To guide practitioners toward favorable patient progression, a thorough understanding of interdisciplinary collaboration is necessary. This article focuses on definitions of, benefits of, and barriers to interdisciplinary collaboration and provides practical solutions for implementation.

Effects of nurse caring behaviours on family stress responses in critical care

Although nurses realise the importance of the family in holistic care of the patient, often they are reluctant to integrate family into the ICU environment. The family role in patient healing has been minimised. There is incongruence in nurses' assessments and families' perceptions of what constitutes caring behaviours. Traditionally ICUs have been primarily patient focused; changing to family-centred will require attitude changes and a multidisciplinary team approach to care. Studies have shown families to be stressed and at significant risk for maladaptation when acute illness or trauma strikes. Nurses potentially may alter family stress responses through caring behaviours, and a family-centred approach to care.

Using Mediation Techniques to Manage Conflict and Create Healthy Work Environments

Healthcare organizations must find ways for managing conflict and developing effective working relationships to create healthy work environments. The effects of unresolved conflict on clinical outcomes, staff retention, and the financial health of the organization lead to many unnecessary costs that divert resources from clinical care. The complexity of delivering critical care services makes conflict resolution difficult. Developing collaborative working relationships helps to manage conflict in complex environments. Working relationships are based on the ability to deal with differences. Dealing with differences requires skill development and techniques for balancing interests and communicating effectively. Techniques used by mediators are effective for resolving disputes and developing working relationships. With practice, these techniques are easily transferable to the clinical setting. Listening for understanding, reframing, elevating the definition of the problem, and forming clear agreements can foster working relationships, decrease the level of conflict, and create healthy work environments that benefit patients and professionals.