Dedicated Afternoon Rounds for ICU Patients' Families and Family Satisfaction With Care

A systematic scoping review of patient and caregiver self-report measures of satisfaction with clinicians' communication

OBJECTIVE

We conducted a systematic scoping review of self-report tools used to measure patient and/or caregiver satisfaction with clinician communication. Aims included identifying: 1) instruments that have been used to measure communication satisfaction, and 2) content of the communication items on measures.

METHODS

Two databases (PubMed and CINAHL) were searched for relevant studies. Eligibility included patient or caregiver self-report tools assessing satisfaction with clinicians' communication in a biomedical healthcare setting; and the stated purpose for using the measurement involved evaluating communication satisfaction and measures included more than one question about this. All data were charted in a form created by the authors.

RESULTS

Our search yielded a total of 4531 results screened as title and abstracts; 228 studies were screened in full text and 85 studies were included in the review. We found 53 different tools used to measure communication satisfaction among those 85 studies, including 29 previously used measures (e.g., FS-ICU-24, CAHPS), and 24 original measures developed by authors. Content of communication satisfaction items included satisfaction with content-specific communication, interpersonal communication skills of clinicians, communicating to set the right environment, and global communication satisfaction items.

CONCLUSION

There was high variability in the number of items and types of content on measures. Communication satisfaction should be better conceptualized to improve measurement, and more robust measures should be created to capture complex factors of communication satisfaction.

PRACTICE IMPLICATIONS

Creating a rigorous evaluation of satisfaction with clinician communication may help strengthen communication research and the assessment of communication interventions.

Validation of "the patient evaluation of emotional care during hospitalisation" questionnaire in intensive care unit patients

OBJECTIVE

To validate the "Patient Evaluation of Emotional Care During Hospitalization" (PEECH) questionnaire, which assesses hospitalised patients' emotional experiences, in patients admitted to the intensive care unit (ICU).

INTERVENTIONS

Prospective study. The PEECH consists of three sections and four sub-scales: "level of security", "level of knowing", "level of personal value", and "level of connection". The questionnaire was completed by 253 hospitalised patients. Expert judgement was used to analyse the content validity and factor analysis was performed to confirm construct validity. Cronbach's alpha was used to measure the internal consistency of the four sub-scales.

RESULTS

In the confirmatory factor analysis of the four sub-scales, the weights of all questions were found to be significant (>1). The internal consistency of the PEECH questionnaire was 0.86 (Cronbach's alpha) and the homogeneity index was high (>0.50).

CONCLUSION

The PEECH questionnaire is a valid and reliable tool to evaluate the perception of emotional care in ICU patients. The information gathered can help provide more comprehensive care for patients in the ICU and in other hospitalised patients.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

DATA SOURCES

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

METHODS

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

FINDINGS

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

CONCLUSION

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

Interventions to promote family member involvement in adult critical care settings: a systematic review

OBJECTIVE

To identify, appraise and synthesise evidence of interventions designed to promote family member involvement in adult critical care units; and to develop a working typology of interventions for use by health professionals and family members.

DESIGN

Mixed-method systematic review.

DATA SOURCES

Bibliographic databases were searched without date restriction up to June 2019: MEDLINE, EMBASE and CINAHL; the Cochrane Central Register of Controlled Trials, Joanna Briggs and Cochrane Libraries. Back issues of leading critical care and patient experience journals were manually searched, as were the reference lists of included studies. All evaluation studies of relevant intervention activities were included; all research designs and outcome measures were eligible. Due to heterogeneity in interventions, designs and outcome measures, the synthesis followed a narrative approach. Service users met with the research team termly.

RESULTS

Out of 4962 possible citations, a total of 20 studies were included. The overall evidence base was assessed as moderate to weak. Six categories of interventions were identified: environmental unit changes (n=2), web-based support (n=4), discussion-based support (n=6), multicomponent support (n=4), participation in rounds (n=3) and participation in physical care (n=1). Clinical and methodological heterogeneity across studies hindered meta-analysis, hence a narrative synthesis was pursued. Six main outcomes were identified, grouped under two categories: (i) involvement outcomes: communication (mean difference ranged from 6.39 to 8.83), decision-making (mean difference ranged from -0.8 to 5.85), satisfaction (mean difference ranged from 0.15 to 2.48); and (ii) health outcomes: family trauma (mean difference ranged from -7.12 to 0.9), family well-being (mean difference ranged from -0.7 to -4), patient outcomes (relative risk ranged from 1.27 to 4.91). The findings from the qualitative studies were thematically analysed to identify features of the interventions that participants perceived to influence effectiveness. Synthesised into five overarching categories (practicality, development, interaction, reflexivity and bridging), these can serve as principles to inform the future design and development of more refined family member involvement interventions.

CONCLUSIONS

Future interventions should be developed with much closer family member input and designed by considering the key features we identified. We call for future interventions to be multilayered and allow for a greater or lesser level, and different kinds, of involvement for family members. Choice of intervention should be informed by a baseline diagnostic of family members' needs, readiness and preparedness for involvement.

PROSPERO REGISTRATION

CRD42018086325.

Predictors of Family Dissatisfaction with Support During Neurocritical Care Shared Decision-Making

BACKGROUND

There is a critical need to improve support for families making difficult shared decisions about patient care with clinicians in the neuroscience ICU (neuro-ICU). The aim of this study is to identify patient- and family-related factors associated with dissatisfaction with shared decision-making support among families of neuro-critically ill patients.

METHODS

We conducted a retrospective observational cohort study using survey data that had been collected from a consecutive sample of family members of patients in the neuro-ICU (one family member per patient) at two US academic centers. Satisfaction with shared decision-making support on ICU discharge had been measured among family members using one specific Likert scale item on the Family Satisfaction in the ICU 24 survey, a validated survey instrument for families of patients in the ICU. We dichotomized top-box responses for this particular item as an outcome variable and identified available patient- and family-related covariates associated with dissatisfaction (i.e., less than complete satisfaction) via univariate and multivariate analyses.

RESULTS

Among 355 surveys, 180 (49.5%) of the surveys indicated dissatisfaction with support during decision-making. In a multivariate model, no preexisting characteristics of families or patients ascertainable on ICU admission were predictive of dissatisfaction. However, among family factors determined during the ICU course, experiencing three or fewer formal family meetings (odds ratio 1.93 [confidence interval 1.13-3.31]; p = 0.01) was significantly predictive of dissatisfaction with decisional support in this cohort with an average patient length of stay of 8.6 days (SD 8.4). There was also a trend toward a family's decision to keep a patient as full code, without treatment limitations, being predictive of dissatisfaction (odds ratio 1.80 [confidence interval 0.93-3.51]; p = 0.08).

CONCLUSIONS

Family dissatisfaction with neuro-ICU shared decision-making support is not necessarily predicted by any preexisting family or patient variables but appears to correlate with participating in fewer formal family meetings during ICU admission. Future studies to improve family satisfaction with neurocritical care decision-making support should have broad inclusion criteria for participants and should consider promoting frequency of family meetings as a core strategy.

Analyzing clinical and system drivers of satisfaction in the intensive care unit as a component of high quality care

BACKGROUND

Quality improvement in the intensive care unit has transitioned from focusing on mortality to improving care and reducing morbidity.

OBJECTIVE

This study prospectively investigated clinical and system drivers of family satisfaction in a large quaternary hospital ICU.

METHODS

A validated tool was distributed to family members and a registry chart analysis was conducted. The aims were to assess associations with high or low family satisfaction to evaluate unit-level satisfaction. Candidate predictors were selected from univariate logistic regressions and finalized in a multivariate model by a stepwise selection approach.

RESULTS

Overall, 75% (n = 188) of respondents (n = 250) indicated high satisfaction. Respondents with higher satisfaction had a Plan of the Day posted (OR = 3.3, 95% CI: 1.63, 6.89, p = 0.001), and did not live with the patient (OR =0.5, 95% CI: 0.25, 0.96, p = 0.044).

CONCLUSION

This study indicates that communication and transparency of plans contributes to family satisfaction with ICU care.

Family ward rounds in intensive care: An integrative review of the literature

BACKGROUND

The involvement of family members in the ward rounds is a novel but under-researched family-centered care intervention in adult intensive care units, with limited evidence on the impact it has on patient and family-centered outcomes.

OBJECTIVES

This integrative review aimed to understand how family rounds are implemented in critical care and to appraise the evidence on outcomes for patients, family members, and healthcare professionals.

DESIGN

An integrative review methodological framework permitted the inclusion of all research designs.

DATA SOURCES

MEDLINE; CINAHL; PsycINFO; Cochrane Library; Web of Science Current Contents Connect; Web of Science-Core Collection; The Joanna Briggs Institute EBP Database; ProQuest Sociological Abstracts; and ProQuest Dissertation and Theses Global, Embase were systematically searched.

REVIEW METHODS

We reviewed studies that referred to or used as an intervention the involvement of family members in daily critical care team rounds. We included primary research in adult intensive care units regardless of patients' length of stay. We excluded patients receiving end-of-life care. We considered any outcome related to the critically ill patient and/or their family member, outcomes related to the healthcare professionals, and outcomes related to clinical and/or nursing treatment. The Mixed Methods Appraisal Tool was used to appraise the quality of the studies. The review was registered in the Prospero database.

RESULTS

From the 541 articles initially retrieved, 15 studies met the inclusion criteria and were included in the review. Studies originated from the United States of America and Canada since 2003, and a variety of designs were used. Four before and after studies and a non-randomized experimental study explored the impact of structured family rounds on family and staff satisfaction, showing limited improvement in satisfaction. Six cross-sectional survey studies explored family members' and clinicians' perceptions and demonstrated a positive attitude towards family-centered rounds, but some concerns were raised from the nursing staff. Three qualitative studies and a mixed-methods study identified structural and cultural factors influencing healthcare professionals' and families' acceptance of family rounds. Most studies were of poor to moderate quality, with limited confidence in the outcomes reported.

CONCLUSIONS

Most studies reported improved family satisfaction as the main outcome. Future research should focus on longitudinal patient and family-centered outcomes, including mental health outcomes, and on qualitative data to understand the processes, barriers, and facilitators to implement family-centered rounds in intensive care units.

Concerns of surrogate decision makers for patients with acute brain injury: A US population survey

OBJECTIVE

To determine whether groups of surrogates for patients with severe acute brain injury (SABI) with poor prognosis can be identified based on their prioritization of goals-of-care (GOC) decisional concerns, an online survey of 1,588 adults recruited via a probability-based panel representative of the US population was conducted.

METHODS

Participants acted as a surrogate for a GOC decision for a hypothetical patient with SABI and were randomized to 1 of 2 prognostic scenarios: the patient likely being left with a range of severe functional disability (SD) or remaining in a vegetative state (VS). Participants prioritized a list of 12 decisional concerns via best-worst scaling. Latent class analysis (LCA) was used to discover decisional groups.

RESULTS

The completion rate was 44.6%; data weighting was conducted to mitigate nonresponse bias. For 792 SD respondents, LCA revealed 4 groups. All groups shared concerns regarding respecting patient wishes and minimizing suffering. The 4 groups were otherwise distinguished by unique concerns that their members highlighted: an older adult remaining severely disabled (34.4%), family consensus (26.4%), doubt regarding prognostic accuracy (20.7%), and cost of long-term care (18.6%). For the 796 VS respondents, LCA revealed 5 groups. Four of the 5 groups had similar concern profiles to the 4 SD groups. The largest (29.0%) expressed the most prognostic doubt. An additional group (15.8%) prioritized religious concerns.

CONCLUSIONS

Although surrogate decision makers for patients with SABI are concerned with respecting patient wishes and minimizing suffering, certain groups highly prioritize other specific decisional factors. These data can help inform future interventions for supporting decision makers.

Communication with patients' families in the intensive care unit: A point prevalence study

PURPOSE

We aimed to describe point of care communication encounters with patients' families in centers with open visitation practices.

MATERIALS AND METHODS

Cross-sectional one-day point prevalence study in 14 Canadian adult intensive care units (ICUs) located in 7 academic and 7 community hospitals with open family visitation policies.

RESULTS

ICU bedside nurses working on a randomly selected weekday completed a survey reporting all observed communication between providers and patients' families. Family point of care communication encounters were measured for 146 of 159 patients (92%) admitted to the study ICUs. Most patients had family (98%) with the majority observed visiting on the study date (73%). Of patients with family (n = 143), direct in-person communication occurred 71% of the time, either via participation in rounds (23%), family meetings (24%), and/or informal updates (71%). 43% (n = 62) of families had direct communication with a physician or nurse practitioner. Nurses provided the largest portion of informal bedside updates (83%, n = 85) and supplemented family communication with phone calls (22%, n = 31). There was no communication contact for 13% (n = 19) of families.

CONCLUSIONS

ICUs adopt multiple ways of communicating with family members of critically ill patients. Significant interactions occur outside of traditional family meetings, in a less formal and more frequent fashion. Our study supports development of tools to support best practices within contemporary communication paradigms to support provider, patients and family needs.