Interactions between family members and staff in intensive care units—An observation and interview study

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Abstract

Background: Research about interactions between family members and staff are sparse, although family members’ needs and experiences in intensive care units are well researched areas.

Aim: The aim was to describe and interpret interactions between family members and staff in intensive care units.

Methods: Interviews (n=24) with family members and repeated observations of interactions of family members and staff in intensive care units were performed and analysed together by means of content analysis.

Results: The initial interactions between staff and family members had a substantial effect on family members and influenced their further interactions with the staff. Two kinds of interactions were revealed; mutual understanding and mutual misunderstanding. Family members, who understood the explicit information and the implicit messages were open in communication with the staff, adjusted well to the system, were acknowledged by the staff and sometimes consoled. Family members, who had difficulties understanding information and implicit messages drew back from communication with staff, did not adjust to the system and were sometimes insulted by the staff.

Conclusions: Unambiguous information from the staff is important for developing interactions of mutual understanding. The results may be a starting point for intensive care unit staff to reflect on how all family members are initially met and further informed and treated. Further research of family members’ experiences of interactions with staff in a longitudinal perspective and the influence of critical illness on families are needed.

Introduction

This study focuses on interactions between staff and family members with a critically ill family member cared for in intensive care units (ICU). The way interactions between family members and staff in ICUs are mutually experienced influences further interactions. Nurses’ experiences of these interactions have been presented in an earlier study (Söderström et al., 2003), and the present study highlights the interactions focusing on family members. These interactions are of the utmost importance for supporting family members as the ICU context entails care situations where critically ill patients hover between life and death. ICUs are characterized by advanced technology, a high staff rate and a great intensity in interventions around the clock. Family members as well as patients can be overwhelmed with the stress of the alien environment and therefore have a wish to be close (Bijttebier et al., 2001), to encourage, help, protect (Burr, 1998) and follow what is happening with their critically ill family member (Jamerson, 1996). Furthermore, family members struggle with fears concerning the survival of the patient and strong feelings of despair and anxiety can arise (Burr, 1998; Hupcey, 1999). Often family members hide their feelings in front of the patient and other family members, leading to difficulties in communication (Hupcey, 1999; Titler et al., 1991) and to misunderstandings in interactions with the staff (Plowfield, 1999; Hupcey, 1999).

Nurses and physicians are to a great extent referred to family members for communication due to the critical state of the patients, but staff also have the responsibility to care for and create a confident and trustful context for family members. The unique ICU context requires that staff are aware of feelings and thoughts behind the façade of family members, in order to provide holistic care. Studies focusing on the interactions from the nurses’ perspective disclose various potential problems in the interactions with family members, for example, nurses having a medical and technical perspective and limited time to care for family members (Söderström et al., 2003) and nurses who restrict visiting policies for families (Fox and Jeffrey, 1997).

Studies have focused on family members’ needs at ICU, e.g. wanting the best possible care for the patient, maintaining hope and trying to obtain detailed information from staff (Molter, 1979). Both old and recent studies show how these needs were perceived as secondary to the patients’ needs and that family members could not claim time from staff (Burr, 1998; Leske, 1986; Norris and Grove, 1986). Other studies have focused on experiences of family members (Lam and Beaulieu, 2004; Titler et al., 1991), changed life patterns (Van Horn, 2000), and ways of coping (Twibell, 1998) in a situation when one family member is critically ill. Conflicting information from staff during the stay in ICU, causing confusion, sadness and anger is also described (Hupcey, 1999). Kleiber et al. (1994) found that nurses and physicians were supportive in their caring attitude and provided information and answered questions in a comprehensible and honest way, but did not offer any emotional support.

There are few studies explicitly focusing on interactions between family members and ICU staff and how these influence the family members. However, Hupcey (1998) interviewed family members (n=10) and ICU nurses (n=10) and found that family members wanted to develop a relationship with nurses, which would benefit the care of the patient, the possibility for families to receive information and be involved in decisions related to the patient. In a later study (Hupcey, 1999), the interactions between nurses and relatives in ICU were examined by interviewing nurses (n=10), relatives (n=11) and patients (n=30). The relatives described how the nurses comforted them and cared for them as well as for the patient. However, the relatives were upset about some stressful situations, e.g. when they were not sufficiently informed and when nurses suddenly changed the policies.

Families in a neurological ICU (n=12) experienced helplessness and frustration about being in an unfamiliar environment, depending on strangers for caring and trying to obtain information. Visiting times were often restricted, but when family members gained access to the patient they experienced a sense of control. Family members felt that nurses did not trust them to be able to promote the patients’ health (Plowfield, 1999). This is the only study we found based on observations of interactions.

Obviously, there is a lack of knowledge about family members’ interactions with staff in ICUs. An observation and interview study might render a more comprehensive picture of these interactions.

Section snippets

Aim

The aim was to describe and interpret interactions between family members and staff in intensive care units with the focus on family members.

Methods

A descriptive and interpretive design, including observations and interviews, was used to analyse interactions between family members and ICU staff. The choice of using observations was in accordance with Bogdewic (1999), who stated that if the aim is to study how activities and interactions give meaning to special behaviours or beliefs, this is an adequate method. Observations give the opportunity to grasp interactions which are lived but not conscious or articulated. The value of making

Result

The initial interactions between staff and family members had a substantial effect on family members and influenced their further interactions with the staff. The interactions consisted of the RN's explicit information to family members about rules and policies of the ICU, the condition of the patient, and how to behave in front of the patient, which was highly valued by all family members. However, when saying this, staff also transferred implicit messages. For example, the RNs said, “you have

Discussion

The main result of this study is described in two themes: Mutual understanding and Mutual misunderstanding. Whether the family members could understand the information and/or the implicit messages was decisive for their further interactions with the staff. In the first theme, the family members understood the explicit information and implicit messages. These family members felt accepted, well treated and sometimes even consoled by the staff, to which they had an open communication, even if some

Acknowledgements

We want to thank the family members for participating in the study. We are also grateful to Alan Crozier for revising the English. This study was supported by grants from Kalmar University and the Association Södra Sveriges Sjuksköterskehem (SSSH).

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