ORIGINAL ARTICLE
Involving relatives in ICU patient care: critical care nursing challenges Bridget McConnell and Tracey Moroney
Aims and objectives. To identify the barriers critical care nurses experience to relative involvement in intensive care unit patient care. Background. Previous studies have discussed the experiences of relatives visiting an intensive care unit, the needs of relatives in the intensive care environment, critical care nurse and relative interaction, intensive care unit visiting policies and the benefits of including relatives in patient care. The barriers that critical care nurses experience to relative involvement in patient care have received minimal exploration. Design. Critical care nurses were recruited for a mixed methods study. An explanatory mixed method design was used, with two phases. Phase 1 was Quantitative and Phase 2 was Qualitative. Methods. Data collection occurred over five months in 2012–2013. Phase 1 used an online questionnaire (n = 70), and semi-structured interviews (n = 6) were conducted in Phase 2. Phase 1 participants were 70 critical care nurses working in Australian intensive care units and six critical care nurses were recruited from a single Sydney intensive care unit for Phase 2. Through sequential data collection, Phase 1 results formed the development of Phase 2 interview questions. Results. Participants reported various barriers to relative involvement in critically ill patient care. Factors related to the intensive care unit patient, the intensive care unit relative, the critical care nurse and the intensive care environment contributed to difficulties encompassing relative involvement. Conclusions. This study has identified that when considering relative involvement in patient care, critical care nurses take on a paternalistic role. The barriers experienced to relative involvement result in the individual critical care nurse deciding to include or exclude relatives from patient care. Relevance to clinical practice. Knowledge of the barriers to relative involvement in critically ill patient care may provide a basis for improving discussion on this topic and may assist intensive care units to implement strategies to reduce barriers.
What does this paper contribute to the wider global clinical community?
• Attitude of critical care nurses •
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towards relative involvement in patient care. Improved knowledge of the barriers experienced by critical care nurses to relative involvement in patient care. Some of the identified barriers may be transferred to other clinical nursing settings.
Key words: barriers, challenges, critical care nurse, ICU patient care, Intensive Care Unit, relative, relative involvement Accepted for publication: 26 November 2014
Authors: Bridget McConnell, RN, BN (Hons), RN, Nursing, Notre Dame University , Sydney, NSW; Tracey Moroney, RN, BN (Hons), PhD, Associate Professor and Dean, Nursing, Notre Dame University Australia, Sydney, NSW, Australia
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, doi: 10.1111/jocn.12755
Correspondence: Bridget McConnell, Nursing, Notre Dame University Australia, 160 Oxford Street, Darlinghurst, NSW 2010, Australia. Telephone: +61 (02) 8204 4275. E-mail: [email protected]
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B McConnell and T Moroney
Introduction and background The admission of a patient to an intensive care unit (ICU) impacts on the equilibrium of the entire family unit. Critical care nurses are important members of the ICU team and are responsible for the provision of holistic care to both patients and their relatives. It is widely acknowledged that relatives play an important role in the ICU patient’s recovery and thus, should be included in patient care activities. However, little is documented about the issues critical care nurses face when attempting to include relatives in patient care. Using a mixed methods design, a research study was conducted to explore the everyday barriers critical care nurses experience when involving relatives in ICU patient care, with the aim of increasing knowledge around these barriers. This is an international issue and study findings could be applied to ICUs at an international level. In recent years, there has been an increased focus on relative involvement in acute care settings, with research suggesting that relative inclusion in physical ICU patient care is of benefit to the patient, relative and critical care nurse. The major areas of discussion in nursing literature, related to relatives within the ICU setting, include the experiences of relatives visiting an ICU (Verhaeghe et al. 2005, McKiernan & McCarthy 2010, Cypress 2011, Eriksson et al. 2011), the needs of relatives in the ICU environment (Verhaeghe et al. 2005, El-Masri & Fox-Wasylyshyn 2007, Blanchard & Alavi 2008, Al-Mutair et al. 2013), critical care nurse and relative interaction (Stayt 2007, Ag ard & Maindal 2009, Mitchell & Chaboyer 2010) and ICU visiting policies (Farrell et al. 2005, Hunter et al. 2010, Ag ard & Lomborg 2011, SouryLavergne et al. 2011). In addition, the benefits of including relatives in patient care, which included improving the patients’ and relatives’ psychological well-being has been identified (Williams 2005, Blanchard & Alavi 2008, Mitchell et al. 2009, W ahlin et al. 2009, Hunter et al. 2010, Mitchell & Chaboyer 2010, Ag ard & Lomborg 2011, Cypress 2011, Al-Mutair et al. 2013). Although the importance of involving relatives in ICU patient care has been discussed, the barriers that critical care nurses face to involving relatives in care activities is a largely untouched area of nursing research. While potential difficulties have been suggested, it is essential to identify further challenges, as critical care nurses interact with relatives on a daily basis. It is documented that the technical ICU environment often makes it difficult for some critical care nurses to remain focused on the personal and individualised nature of nursing (Wilkin 2003, Wilkin & Slevin 2004). Given that technology can interfere with the caring component of nursing, critical
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care nurses may not recognise the benefits of including relatives in ICU patient care. Critical care nurses have reported the lack of time and energy to instruct relatives how to perform specific care activities, indicating time constraints are a barrier to relative involvement (Wilkin & Slevin 2004). Furthermore, patients within the ICU environment are connected to an array of multiple invasive lines and monitors, often making it difficult to involve relatives in care. Some critical care nurses fear that relative involvement in care may result in distraction, which could ultimately lead to adverse events such as accidental invasive line removal (Farrell et al. 2005, Nelson & Plost 2009, Garrouste-Orgeas et al. 2010). Critical care nurses report that the inclusion of relatives in patient care could result in over-involvement with relatives, causing conflict between the nurse’s professional and personal role (Stayt 2007). However, participants in the study by Stayt (2007) did not identify reasons as to why they were concerned with relative involvement in care and how within a professional ICU environment this could result in the development of a personal relationship with the relative. Similarly, when the desire of a relative to become involved in care differs from the wishes of the patient, the critical care nurse is challenged when attempting to respect the patient’s rights and fulfil the relative’s needs. Critical care nurse participants of research conducted by Engstr€ om et al. (2011) stated that relatives will be requested to leave the patient’s room if the patient’s integrity is threatened. To ensure that relatives experience the benefits of care involvement, for example reducing feelings of inadequacy and helplessness, it was necessary to identify further challenges that critical care nurses could face to this practice. This is an important issue as relatives will always be present within the ICU setting and patient care activities are a part of daily ICU nursing.
Aims The aim of this study was to uncover the barriers and enablers that critical care nurses experience to involving relatives in ICU patient care. This article will discuss the barriers that were identified by participants and the issues related to involving relatives in the care relationship.
Methods Design This study used a mixed methods design. Methodological triangulation was used to enhance reliability and validity, and assisted in gaining a deeper understanding of the topic © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing
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under investigation. An explanatory mixed method design was adopted and this involved sequential data collection. Initially, quantitative (Phase 1 – Online questionnaire) data were collected, followed by qualitative (Phase 2 – Interviews) data collection. This was to ensure that Phase 1 would inform the development of questions used in Phase 2.
Participants In the quantitative Phase 1 stage, 70 critical care nurses who worked in Australian ICUs, completed an online questionnaire. Purposive sampling, with a snowball sample approach, was used to recruit participants. Inclusion criteria listed that participants were to be critical care nurses working in an adult ICU at the time of data collection. The majority of participants were aged between 41–50 years (300%) and had worked in the intensive care setting for more than eight years (571%). In the qualitative Phase 2 stage, six critical care nurses were interviewed. Purposive sampling was used to recruit participants who were employed in a 14 bed tertiary adult ICU of a private Sydney hospital. Inclusion criterion was that each participant was to be an employed critical care nurse at the identified ICU at the time of data collection. Participant recruitment continued until data saturation was achieved.
Data collection In Phase 1, an online questionnaire was developed drawing on previously published questionnaires (Hammond 1995, El-Masri & Fox-Wasylyshyn 2007, Ag ard & Maindal 2009, Garrouste-Orgeas et al. 2010). The questionnaire was available over a three-month period in 2012 using the online tool ‘Survey Monkey’ (Survey Monkey 2014). The online questionnaire consisted of three demographic data questions, 10 Likert Frequency Scale questions (Never, Rarely, Some of the time, Most of the time, Always) to determine participants’ attitudes towards relative involvement in ICU patient care and a list of 15 patient care activities, in which participants would respond Yes, Maybe or No as to whether they would allow a relative to perform each of the given tasks. Content validity was determined prior to the data collection period by a panel of 10 critical care nurses. In Phase 2, interviews were conducted to provide a greater understanding into relative involvement in ICU patient care. Semi-structured interviews were held with participants in a private location over a two-month per© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing
Relative involvement in ICU patient care
iod in 2013. During each 30-minute interview, participants were asked to respond to a series of 13 interview questions, however as interviews were semi-structured, further exploration into each participant’s answers was possible.
Data analysis A systematic approach to data analysis was followed. Phase 1 quantitative data were analysed using basic statistical data analysis. Initially, the first 10 questionnaires completed were compared with the next 10 questionnaires to ensure that questions were interpreted in a similar manner by participants. This comparison was used to determine validity and reliability in recognising comparable results. Findings were organised by assigning percentages for each response and then were visually represented as a bar graph or table to assist in the recognition of data trends (Table 1). The highest percentage response was determined and then descriptive analysis was documented. A field diary was used as a means of audit. The analysis of Phase 1 results led to the development of interview questions asked in Phase 2. For example, Phase 1 results indicated that the majority of critical care nurses understand the needs of relatives most of the time. Therefore, a Phase 2 interview question related to this issue was ‘In a survey I conducted, I asked critical care nurses whether they believe they understand the needs of relatives visiting a patient in ICU. The main response to this question was most of the time. Do you agree with this that you understand relatives’ needs most of the time? What do you believe to be the main needs of relatives when visiting a patient in ICU?’ Thematic analysis, including transcribing, reading the transcript in a line by line manner, coding and theme development, was used for Phase 2 data analysis.
Ethical considerations Ethical approval for this study was obtained from The University of Notre Dame Australia’s Human Research Ethics Committee and the Institutional Human Research Ethics Committee at the study location. Online questionnaire participants were provided a study information sheet and questionnaire completion implied consent. Interview participants were provided with an information sheet and gave written consent. Consent included the provision for interviews to be audio-taped. Interview participants created an alias to maintain confidentiality. Therefore, the names presented within this article are not the true identity of
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B McConnell and T Moroney Table 1 Phase 1: Nurse’s attitude towards relative involvement (Part A). Response (%)
Question
Never
Rarely
Some of the time
Most of the time
Always
When a family member is entering the intensive care unit I prepare them for what they will see I believe I understand the needs of relatives in the intensive care environment I believe it is the responsibility of a critical care nurse to provide care to the patient’s relatives Allowing relatives to assist in simple nursing tasks is of benefit to relatives and patients I like the part of my job where I can involve relatives in providing patient care I involve family members in patient care
1 14 0 00 0 00 2 29 0 00 4 57 1 14 1 14 6 87 1 14
1 14 0 00 0 00 5 71 7 100 13 186 14 200 18 257 17 246 2 29
8 114 11 157 17 243 37 529 31 443 38 543 25 357 44 629 22 319 16 229
26 371 43 614 25 357 19 271 23 329 12 171 18 257 6 86 12 174 30 429
34 486 16 229 28 400 7 100 9 129 3 43 12 171 1 14 12 174 21 300
When patients ask for relatives to be present during physical care I support their wishes I feel that relatives interrupt my work When performing a procedure, such as a dressing change, I feel uncomfortable if family members are present* When performing a procedure I ask relatives to leave the room
Results are presented as the frequency and percentage for each response. *Question skipped by one participant.
study participants. Participants were able to withdraw from this research, however none chose to withdraw.
Rigour A rigorous approach was applied during data collection. For example, the researcher has provided a clear description of the study process, assuring credibility and making transferability of study findings to other ICUs possible. Furthermore, conformability was affirmed as similar results were obtained in both Phase 1 and Phase 2. Asking questions in Phase 1 and then confirming the responses in Phase 2 is a notion of truthfulness and indicates that findings were clearly linked to collected data.
Results It was evident that participants faced several barriers when attempting to involve a relative in patient care activities. Factors related to the ICU patient, the ICU relative, the critical care nurse and the intensive care environment caused challenges for relative involvement. The results presented in this section reflect only the barriers uncovered in the combined phases of this study. The enablers to relative involvement in care are not discussed in this article.
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The ICU patient Invasive technology and the physical condition of the ICU patient often made it challenging for participants to involve relatives in patient care. Participants frequently asked relatives to leave during patient care activities if the patient was unstable and complicated with multiple invasive lines. Similarly, participants were concerned that an untrained relative may accidently disconnect or dislodge an invasive line, amplifying the risk to the patient. This was illustrated by Fred, who suggested ‘complicated patient. . .better to have them [relatives] leave and probably safer’. This made it difficult for participants to actively promote relative participation. Patient privacy was also identified as a barrier to relative involvement. Some patient care activities, particularly bed baths, were perceived to expose the vulnerable patient, reducing their dignity and for this reason, participants found it challenging to involve relatives. Linked to patient privacy, the relative–patient relationship was assessed by the critical care nurse to determine whether relative involvement was appropriate. Penelope stated she would involve relatives ‘If it’s not something where their [patient] going to be exposed’. The ICU length of stay often caused challenges for critical care nurses involving relatives in patient care. Partici© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing
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pants found it more challenging to involve short-term ICU relatives as opposed to long-term relatives. Participants stated that they were less likely to develop a rapport with a short-term patient’s relative, which made it difficult to involve them in patient care. Megan described this as, ‘you don’t know them [relative] as well [as long term relatives], you don’t have as much of a rapport’.
The ICU relative Participants found that relatives visiting an ICU patient were often fragile and vulnerable. It was feared that involvement in care activities may increase stress levels as relatives gained insight into the patient’s poor health condition. Fred reiterated this, ‘get them [relatives] to leave and then just come back in, then you’re [critical care nurse] saving them [relative], protecting them [relative] from having that experience’. It was reported that the involvement of a fragile relative created difficulties as opposed to exclusion. When conducting a relative assessment, participants stated that they would assess the relative’s ‘personality, their behaviour, their mannerisms’ (Brooke) to decide whether to include or exclude the relative. All participants agreed that they found it difficult to include the ‘loud and obnoxious’ (Greg) relative in patient care. Fred highlighted this belief stating, ‘Some relatives are so intensive, loud and boisterous and it’s not doing the patient any good’.
The critical care nurse Each participant had a personal attitude towards relative involvement in patient care. For example, some participants took on the persona of the patient, stating that if they would not like their relative to be involved, it was difficult to allow the patient’s relative to participate. Charlie excluded relatives from assisting with patient bed baths; ‘I just wouldn’t like someone staring at my bum’. Similarly, some participants feared that requesting relative involvement could suggest that the participant themselves did not want to fulfil their role. This belief made it challenging for these participants to include relatives as they did not want to be viewed as transferring their responsibilities to the relative. This suggestion was expressed by Fred, ‘I don’t usually sort of push- can you [relative] help?. . .I don’t want to come across as not wanting to do my job’. All participants agreed that the length of ICU experience impacted on whether a critical care nurse felt comfortable including a relative in care activities. Participants with extensive critical care nursing experience stated they felt © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing
Relative involvement in ICU patient care
confident performing tasks with relative assistance, compared with those who had less intensive care nursing experience, who stated this practice was challenging. Megan expressed her thoughts stating ‘being continually watched. . .off-putting for nurses, I’m a junior. . .not sort of used to it. . .senior nurses might be different’. Furthermore, participants explained that if they had a negative past experience, they found it challenging and were less likely to involve relatives in patient care. Participants felt uncomfortable performing procedures in front of relatives some of the time and as a result of this, asked relatives to leave the patient’s room most of the time. Although participants stated they performed care activities at a competent level, they felt challenged when performing care in front of relatives. Participants believed that relatives were judging their performance, which created feelings of insecurity: ‘it’s like they are judging you. . .such an uncomfortable feeling’ – Charlie.
The intensive care environment The ICU environment itself was recognised as a barrier for some participants. The physical layout of the ICU, including compact sized rooms made it difficult to include relatives in the patient’s care: ‘don’t need another body in the room. . .getting in the road’ – Greg. More than half the participants felt that relatives interrupted their work within this busy, fast paced environment at least some of the time. Participants expressed the difficulty of explaining the process of a care activity to a relative prior to their involvement due to a lack of time. This resulted in participants performing the care activities quickly themselves, often leading to relative exclusion. Related to the ICU environment, participants feared that relatives may injure themselves when assisting in care activities. Participants were afraid of the legal consequences if this occurred. The legal issues surrounding relative involvement often confused and deterred participants from including relatives in ICU patient care. Fred explained ‘I always like to do the lifting with a wardsman myself; just from a litigation point of view’.
Discussion The results of this study have identified the various barriers that critical care nurses experience when allowing relative involvement in patient care. Findings suggest that some critical care nurses take on a paternalistic role with regard to ICU patient care. Critical care nurses view patient care as part of their professional role and responsibility.
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Personal values appear to be fundamental in the decisionmaking process of whether to involve relatives in the care of a patient. For example, Charlie stated she refused relative involvement in care, as she would want her relatives excluded if she was a patient. The influence of a critical care nurse’s personal attitude, towards including or excluding relatives from care, has not received previous exploration. Given the variation in individual beliefs, it is essential for critical care nurses to understand the impact that their values have on the involvement of relatives. Similarly, participants found it difficult to involve a relative if they were not considered to be the ‘right’ relative. Loud and aggressive relatives were frequently excluded from being involved in ICU patient care, because these types of relatives create stress for the critical care nurse. Participants also acknowledged that these relatives were likely to cause stress for the patient. This has previously been described by W ahlin et al. (2009), Cypress (2011), Engstr€ om et al. (2011) and Al-Mutair et al. (2013). As some care activities may expose the vulnerable patient, the patient’s right to privacy caused challenges. This view is supported by critical care nurses in the study by Engstr€ om et al. (2011) who asked relatives to leave the patient’s room if their privacy would be threatened, for example, during personal hygiene. Although participants felt it was challenging to involve relatives to preserve patient privacy, it is significant to note that not all care activities are intrusive. Therefore, as part of daily nursing practice, critical care nurses could involve relatives in care activities that do not impact on patient privacy. Anecdotes from some participants provided evidence that participants often failed to recognise that the relative and patient may interact at a deep level. The participant who declares to protect the patient’s privacy intrudes on the patient’s personal space on a daily basis. In comparison, a relative may have already entered the patient’s personal space. This was suggested by one participant who recalled a patient’s wife stating ‘I’ve been married to the guy [patient] for 30 years, I’ve seen his backside’. The suggestion that a patient would feel more comfortable having a relative involved in their care is supported by Engstr€ om and Soderberg (2007). Gaining patient consent may reduce the issue of patient privacy. It is essential for critical care nurses to consider the closeness of the patient and relative as part of their nursing practice, rather than taking on a paternalistic role. Some participants stated that they were less likely to involve a short-term patient’s relative in care activities compared with a long-term ICU patient’s relative. One possible reason as to why participants chose to limit short-term ICU
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relative involvement included the belief that the admission would not significantly impact on their life, thus their participation in patient care was unlikely to be of benefit: ‘I agree with involving relatives. . . not so much with an overnight stay. . .there’s often no real need’- Fred. Whether a stay is for two days or two months, emotions vary. Critical care nurses should not judge a relative’s worthiness of care involvement based on the patient’s length of stay, instead all relatives should be provided with the opportunity to participate. No other studies identifying length of stay as a barrier to relative involvement have been found. Furthermore, some participants explained that hospital policies made it difficult to include relatives in ICU patient care. However, the hospital policies that were referred to were nonexistent. Similarly, Stayt (2007) found that critical care nurses did not refer to institutional guidelines when discussing relative involvement in ICU patient care. This suggests that critical care nurses make their own decisions regarding relative involvement. As critical care nurses have varying opinions concerning relative participation, this means that their practice will vary. As a result of this, a relative’s level of involvement may differ each day, dependent upon the individual critical care nurse providing care to the patient. Fluctuating involvement, a lack of guidelines and structure may cause confusion for relatives. Consistency is essential for ICU nursing practice.
Limitations As with many research studies, there are potential limitations to this research. A questionnaire was developed and so, it is recommended that further studies use this tool to test reliability. It is acknowledged that Phase 2 was undertaken within a single institution and has a small sample size. There is also the possibility of ‘elite bias’ as participants were volunteers who wanted their views to be understood. Similarly, there is potential bias related to the researcher’s knowledge of ICU. However, this prior knowledge and experience allowed greater insight into relative involvement in ICU patient care. The findings of this study should not be generalised, however the results can be transferred to other ICUs.
Recommendations for future research Further research is required into the area of investigation. Future studies could investigate why critical care nurses experience the discussed barriers. Following this research, directed strategies should be developed to reduce barriers. Additional insight into this topic, through research, is likely © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing
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Relative involvement in ICU patient care
to improve the intensive care experience for relatives and assist critical care nurses to involve relatives in patient care. It is recognised that relative involvement in ICU patient care is a limited topic of discussion within the intensive care environment, with study results indicating that not all participants understand the benefits of relative involvement. As part of the process of employment in ICU, critical care nurses should be educated on the topic of relative involvement in patient care. Regular in-service programmes may assist critical care nurses to enhance their knowledge base by recognising patient care issues as well as encouraging them to consciously think about relative involvement. The development of a relative caregiver specialist may reduce the barriers of involvement. Employing a critical care nurse who understands the needs of relatives and educates them as to how they could be involved in the patient’s care would be useful. Although critical care nurses working with relatives in ICU patient care is ideal, it is often difficult for them to simultaneously perform complex care tasks on the patient while supporting and involving relatives. The emergence of this role in the ICU setting may reduce pressure for critical care nurses. ICU policies and guidelines require ongoing review. The development of policies which promote relative involvement in ICU patient care is essential. Critical care nurses, within individual ICUs, could agree upon care activities to include in policy guidelines.
Conclusion By identifying additional barriers not previously discussed, this study contributes to the growing knowledge base of relative involvement in ICU patient care. This research highlights the fact that relative involvement in patient care is feasible within the intensive care setting, despite these barriers. Critical care nurses, at a national and international level should reflect on and embrace these findings, attempting to implement solutions within their own ICUs to limit
barriers. In doing so, this is likely to improve relative satisfaction in the often frightening intensive care environment and assist critical care nurses in the daily practice of relative involvement in ICU patient care.
Relevance to clinical practice This study has identified and discussed a range of barriers critical care nurses experience to relative involvement in ICU patient care. The participation of relatives in the care of critically ill patients is a complex task with many difficulties arising from the process. Knowledge of these barriers may provide the platform for improving discussion on relative involvement in care and could assist ICUs to focus on reducing barriers. These results may assist in further research into why critical care nurses experience the discussed barriers and direct the development of strategies to reduce barriers. Recommendations include that ICU policies and guidelines are reviewed and polices which promote relative involvement in ICU patient care are developed. Relative participation may result in benefits for the patient, relative and critical care nurse, thus, this information is relevant to clinical nursing practice.
Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content and (3) final approval of the version to be published.
Conflict of interest No conflict of interest has been declared by the authors.
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Involving relatives in ICU patient care: critical care nursing challenges Bridget McConnell and Tracey Moroney
Aims and objectives. To identify the barriers critical care nurses experience to relative involvement in intensive care unit patient care. Background. Previous studies have discussed the experiences of relatives visiting an intensive care unit, the needs of relatives in the intensive care environment, critical care nurse and relative interaction, intensive care unit visiting policies and the benefits of including relatives in patient care. The barriers that critical care nurses experience to relative involvement in patient care have received minimal exploration. Design. Critical care nurses were recruited for a mixed methods study. An explanatory mixed method design was used, with two phases. Phase 1 was Quantitative and Phase 2 was Qualitative. Methods. Data collection occurred over five months in 2012–2013. Phase 1 used an online questionnaire (n = 70), and semi-structured interviews (n = 6) were conducted in Phase 2. Phase 1 participants were 70 critical care nurses working in Australian intensive care units and six critical care nurses were recruited from a single Sydney intensive care unit for Phase 2. Through sequential data collection, Phase 1 results formed the development of Phase 2 interview questions. Results. Participants reported various barriers to relative involvement in critically ill patient care. Factors related to the intensive care unit patient, the intensive care unit relative, the critical care nurse and the intensive care environment contributed to difficulties encompassing relative involvement. Conclusions. This study has identified that when considering relative involvement in patient care, critical care nurses take on a paternalistic role. The barriers experienced to relative involvement result in the individual critical care nurse deciding to include or exclude relatives from patient care. Relevance to clinical practice. Knowledge of the barriers to relative involvement in critically ill patient care may provide a basis for improving discussion on this topic and may assist intensive care units to implement strategies to reduce barriers.
What does this paper contribute to the wider global clinical community?
• Attitude of critical care nurses •
•
towards relative involvement in patient care. Improved knowledge of the barriers experienced by critical care nurses to relative involvement in patient care. Some of the identified barriers may be transferred to other clinical nursing settings.
Key words: barriers, challenges, critical care nurse, ICU patient care, Intensive Care Unit, relative, relative involvement Accepted for publication: 26 November 2014
Authors: Bridget McConnell, RN, BN (Hons), RN, Nursing, Notre Dame University , Sydney, NSW; Tracey Moroney, RN, BN (Hons), PhD, Associate Professor and Dean, Nursing, Notre Dame University Australia, Sydney, NSW, Australia
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, doi: 10.1111/jocn.12755
Correspondence: Bridget McConnell, Nursing, Notre Dame University Australia, 160 Oxford Street, Darlinghurst, NSW 2010, Australia. Telephone: +61 (02) 8204 4275. E-mail: [email protected]
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B McConnell and T Moroney
Introduction and background The admission of a patient to an intensive care unit (ICU) impacts on the equilibrium of the entire family unit. Critical care nurses are important members of the ICU team and are responsible for the provision of holistic care to both patients and their relatives. It is widely acknowledged that relatives play an important role in the ICU patient’s recovery and thus, should be included in patient care activities. However, little is documented about the issues critical care nurses face when attempting to include relatives in patient care. Using a mixed methods design, a research study was conducted to explore the everyday barriers critical care nurses experience when involving relatives in ICU patient care, with the aim of increasing knowledge around these barriers. This is an international issue and study findings could be applied to ICUs at an international level. In recent years, there has been an increased focus on relative involvement in acute care settings, with research suggesting that relative inclusion in physical ICU patient care is of benefit to the patient, relative and critical care nurse. The major areas of discussion in nursing literature, related to relatives within the ICU setting, include the experiences of relatives visiting an ICU (Verhaeghe et al. 2005, McKiernan & McCarthy 2010, Cypress 2011, Eriksson et al. 2011), the needs of relatives in the ICU environment (Verhaeghe et al. 2005, El-Masri & Fox-Wasylyshyn 2007, Blanchard & Alavi 2008, Al-Mutair et al. 2013), critical care nurse and relative interaction (Stayt 2007, Ag ard & Maindal 2009, Mitchell & Chaboyer 2010) and ICU visiting policies (Farrell et al. 2005, Hunter et al. 2010, Ag ard & Lomborg 2011, SouryLavergne et al. 2011). In addition, the benefits of including relatives in patient care, which included improving the patients’ and relatives’ psychological well-being has been identified (Williams 2005, Blanchard & Alavi 2008, Mitchell et al. 2009, W ahlin et al. 2009, Hunter et al. 2010, Mitchell & Chaboyer 2010, Ag ard & Lomborg 2011, Cypress 2011, Al-Mutair et al. 2013). Although the importance of involving relatives in ICU patient care has been discussed, the barriers that critical care nurses face to involving relatives in care activities is a largely untouched area of nursing research. While potential difficulties have been suggested, it is essential to identify further challenges, as critical care nurses interact with relatives on a daily basis. It is documented that the technical ICU environment often makes it difficult for some critical care nurses to remain focused on the personal and individualised nature of nursing (Wilkin 2003, Wilkin & Slevin 2004). Given that technology can interfere with the caring component of nursing, critical
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care nurses may not recognise the benefits of including relatives in ICU patient care. Critical care nurses have reported the lack of time and energy to instruct relatives how to perform specific care activities, indicating time constraints are a barrier to relative involvement (Wilkin & Slevin 2004). Furthermore, patients within the ICU environment are connected to an array of multiple invasive lines and monitors, often making it difficult to involve relatives in care. Some critical care nurses fear that relative involvement in care may result in distraction, which could ultimately lead to adverse events such as accidental invasive line removal (Farrell et al. 2005, Nelson & Plost 2009, Garrouste-Orgeas et al. 2010). Critical care nurses report that the inclusion of relatives in patient care could result in over-involvement with relatives, causing conflict between the nurse’s professional and personal role (Stayt 2007). However, participants in the study by Stayt (2007) did not identify reasons as to why they were concerned with relative involvement in care and how within a professional ICU environment this could result in the development of a personal relationship with the relative. Similarly, when the desire of a relative to become involved in care differs from the wishes of the patient, the critical care nurse is challenged when attempting to respect the patient’s rights and fulfil the relative’s needs. Critical care nurse participants of research conducted by Engstr€ om et al. (2011) stated that relatives will be requested to leave the patient’s room if the patient’s integrity is threatened. To ensure that relatives experience the benefits of care involvement, for example reducing feelings of inadequacy and helplessness, it was necessary to identify further challenges that critical care nurses could face to this practice. This is an important issue as relatives will always be present within the ICU setting and patient care activities are a part of daily ICU nursing.
Aims The aim of this study was to uncover the barriers and enablers that critical care nurses experience to involving relatives in ICU patient care. This article will discuss the barriers that were identified by participants and the issues related to involving relatives in the care relationship.
Methods Design This study used a mixed methods design. Methodological triangulation was used to enhance reliability and validity, and assisted in gaining a deeper understanding of the topic © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing
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under investigation. An explanatory mixed method design was adopted and this involved sequential data collection. Initially, quantitative (Phase 1 – Online questionnaire) data were collected, followed by qualitative (Phase 2 – Interviews) data collection. This was to ensure that Phase 1 would inform the development of questions used in Phase 2.
Participants In the quantitative Phase 1 stage, 70 critical care nurses who worked in Australian ICUs, completed an online questionnaire. Purposive sampling, with a snowball sample approach, was used to recruit participants. Inclusion criteria listed that participants were to be critical care nurses working in an adult ICU at the time of data collection. The majority of participants were aged between 41–50 years (300%) and had worked in the intensive care setting for more than eight years (571%). In the qualitative Phase 2 stage, six critical care nurses were interviewed. Purposive sampling was used to recruit participants who were employed in a 14 bed tertiary adult ICU of a private Sydney hospital. Inclusion criterion was that each participant was to be an employed critical care nurse at the identified ICU at the time of data collection. Participant recruitment continued until data saturation was achieved.
Data collection In Phase 1, an online questionnaire was developed drawing on previously published questionnaires (Hammond 1995, El-Masri & Fox-Wasylyshyn 2007, Ag ard & Maindal 2009, Garrouste-Orgeas et al. 2010). The questionnaire was available over a three-month period in 2012 using the online tool ‘Survey Monkey’ (Survey Monkey 2014). The online questionnaire consisted of three demographic data questions, 10 Likert Frequency Scale questions (Never, Rarely, Some of the time, Most of the time, Always) to determine participants’ attitudes towards relative involvement in ICU patient care and a list of 15 patient care activities, in which participants would respond Yes, Maybe or No as to whether they would allow a relative to perform each of the given tasks. Content validity was determined prior to the data collection period by a panel of 10 critical care nurses. In Phase 2, interviews were conducted to provide a greater understanding into relative involvement in ICU patient care. Semi-structured interviews were held with participants in a private location over a two-month per© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing
Relative involvement in ICU patient care
iod in 2013. During each 30-minute interview, participants were asked to respond to a series of 13 interview questions, however as interviews were semi-structured, further exploration into each participant’s answers was possible.
Data analysis A systematic approach to data analysis was followed. Phase 1 quantitative data were analysed using basic statistical data analysis. Initially, the first 10 questionnaires completed were compared with the next 10 questionnaires to ensure that questions were interpreted in a similar manner by participants. This comparison was used to determine validity and reliability in recognising comparable results. Findings were organised by assigning percentages for each response and then were visually represented as a bar graph or table to assist in the recognition of data trends (Table 1). The highest percentage response was determined and then descriptive analysis was documented. A field diary was used as a means of audit. The analysis of Phase 1 results led to the development of interview questions asked in Phase 2. For example, Phase 1 results indicated that the majority of critical care nurses understand the needs of relatives most of the time. Therefore, a Phase 2 interview question related to this issue was ‘In a survey I conducted, I asked critical care nurses whether they believe they understand the needs of relatives visiting a patient in ICU. The main response to this question was most of the time. Do you agree with this that you understand relatives’ needs most of the time? What do you believe to be the main needs of relatives when visiting a patient in ICU?’ Thematic analysis, including transcribing, reading the transcript in a line by line manner, coding and theme development, was used for Phase 2 data analysis.
Ethical considerations Ethical approval for this study was obtained from The University of Notre Dame Australia’s Human Research Ethics Committee and the Institutional Human Research Ethics Committee at the study location. Online questionnaire participants were provided a study information sheet and questionnaire completion implied consent. Interview participants were provided with an information sheet and gave written consent. Consent included the provision for interviews to be audio-taped. Interview participants created an alias to maintain confidentiality. Therefore, the names presented within this article are not the true identity of
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B McConnell and T Moroney Table 1 Phase 1: Nurse’s attitude towards relative involvement (Part A). Response (%)
Question
Never
Rarely
Some of the time
Most of the time
Always
When a family member is entering the intensive care unit I prepare them for what they will see I believe I understand the needs of relatives in the intensive care environment I believe it is the responsibility of a critical care nurse to provide care to the patient’s relatives Allowing relatives to assist in simple nursing tasks is of benefit to relatives and patients I like the part of my job where I can involve relatives in providing patient care I involve family members in patient care
1 14 0 00 0 00 2 29 0 00 4 57 1 14 1 14 6 87 1 14
1 14 0 00 0 00 5 71 7 100 13 186 14 200 18 257 17 246 2 29
8 114 11 157 17 243 37 529 31 443 38 543 25 357 44 629 22 319 16 229
26 371 43 614 25 357 19 271 23 329 12 171 18 257 6 86 12 174 30 429
34 486 16 229 28 400 7 100 9 129 3 43 12 171 1 14 12 174 21 300
When patients ask for relatives to be present during physical care I support their wishes I feel that relatives interrupt my work When performing a procedure, such as a dressing change, I feel uncomfortable if family members are present* When performing a procedure I ask relatives to leave the room
Results are presented as the frequency and percentage for each response. *Question skipped by one participant.
study participants. Participants were able to withdraw from this research, however none chose to withdraw.
Rigour A rigorous approach was applied during data collection. For example, the researcher has provided a clear description of the study process, assuring credibility and making transferability of study findings to other ICUs possible. Furthermore, conformability was affirmed as similar results were obtained in both Phase 1 and Phase 2. Asking questions in Phase 1 and then confirming the responses in Phase 2 is a notion of truthfulness and indicates that findings were clearly linked to collected data.
Results It was evident that participants faced several barriers when attempting to involve a relative in patient care activities. Factors related to the ICU patient, the ICU relative, the critical care nurse and the intensive care environment caused challenges for relative involvement. The results presented in this section reflect only the barriers uncovered in the combined phases of this study. The enablers to relative involvement in care are not discussed in this article.
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The ICU patient Invasive technology and the physical condition of the ICU patient often made it challenging for participants to involve relatives in patient care. Participants frequently asked relatives to leave during patient care activities if the patient was unstable and complicated with multiple invasive lines. Similarly, participants were concerned that an untrained relative may accidently disconnect or dislodge an invasive line, amplifying the risk to the patient. This was illustrated by Fred, who suggested ‘complicated patient. . .better to have them [relatives] leave and probably safer’. This made it difficult for participants to actively promote relative participation. Patient privacy was also identified as a barrier to relative involvement. Some patient care activities, particularly bed baths, were perceived to expose the vulnerable patient, reducing their dignity and for this reason, participants found it challenging to involve relatives. Linked to patient privacy, the relative–patient relationship was assessed by the critical care nurse to determine whether relative involvement was appropriate. Penelope stated she would involve relatives ‘If it’s not something where their [patient] going to be exposed’. The ICU length of stay often caused challenges for critical care nurses involving relatives in patient care. Partici© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing
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pants found it more challenging to involve short-term ICU relatives as opposed to long-term relatives. Participants stated that they were less likely to develop a rapport with a short-term patient’s relative, which made it difficult to involve them in patient care. Megan described this as, ‘you don’t know them [relative] as well [as long term relatives], you don’t have as much of a rapport’.
The ICU relative Participants found that relatives visiting an ICU patient were often fragile and vulnerable. It was feared that involvement in care activities may increase stress levels as relatives gained insight into the patient’s poor health condition. Fred reiterated this, ‘get them [relatives] to leave and then just come back in, then you’re [critical care nurse] saving them [relative], protecting them [relative] from having that experience’. It was reported that the involvement of a fragile relative created difficulties as opposed to exclusion. When conducting a relative assessment, participants stated that they would assess the relative’s ‘personality, their behaviour, their mannerisms’ (Brooke) to decide whether to include or exclude the relative. All participants agreed that they found it difficult to include the ‘loud and obnoxious’ (Greg) relative in patient care. Fred highlighted this belief stating, ‘Some relatives are so intensive, loud and boisterous and it’s not doing the patient any good’.
The critical care nurse Each participant had a personal attitude towards relative involvement in patient care. For example, some participants took on the persona of the patient, stating that if they would not like their relative to be involved, it was difficult to allow the patient’s relative to participate. Charlie excluded relatives from assisting with patient bed baths; ‘I just wouldn’t like someone staring at my bum’. Similarly, some participants feared that requesting relative involvement could suggest that the participant themselves did not want to fulfil their role. This belief made it challenging for these participants to include relatives as they did not want to be viewed as transferring their responsibilities to the relative. This suggestion was expressed by Fred, ‘I don’t usually sort of push- can you [relative] help?. . .I don’t want to come across as not wanting to do my job’. All participants agreed that the length of ICU experience impacted on whether a critical care nurse felt comfortable including a relative in care activities. Participants with extensive critical care nursing experience stated they felt © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing
Relative involvement in ICU patient care
confident performing tasks with relative assistance, compared with those who had less intensive care nursing experience, who stated this practice was challenging. Megan expressed her thoughts stating ‘being continually watched. . .off-putting for nurses, I’m a junior. . .not sort of used to it. . .senior nurses might be different’. Furthermore, participants explained that if they had a negative past experience, they found it challenging and were less likely to involve relatives in patient care. Participants felt uncomfortable performing procedures in front of relatives some of the time and as a result of this, asked relatives to leave the patient’s room most of the time. Although participants stated they performed care activities at a competent level, they felt challenged when performing care in front of relatives. Participants believed that relatives were judging their performance, which created feelings of insecurity: ‘it’s like they are judging you. . .such an uncomfortable feeling’ – Charlie.
The intensive care environment The ICU environment itself was recognised as a barrier for some participants. The physical layout of the ICU, including compact sized rooms made it difficult to include relatives in the patient’s care: ‘don’t need another body in the room. . .getting in the road’ – Greg. More than half the participants felt that relatives interrupted their work within this busy, fast paced environment at least some of the time. Participants expressed the difficulty of explaining the process of a care activity to a relative prior to their involvement due to a lack of time. This resulted in participants performing the care activities quickly themselves, often leading to relative exclusion. Related to the ICU environment, participants feared that relatives may injure themselves when assisting in care activities. Participants were afraid of the legal consequences if this occurred. The legal issues surrounding relative involvement often confused and deterred participants from including relatives in ICU patient care. Fred explained ‘I always like to do the lifting with a wardsman myself; just from a litigation point of view’.
Discussion The results of this study have identified the various barriers that critical care nurses experience when allowing relative involvement in patient care. Findings suggest that some critical care nurses take on a paternalistic role with regard to ICU patient care. Critical care nurses view patient care as part of their professional role and responsibility.
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B McConnell and T Moroney
Personal values appear to be fundamental in the decisionmaking process of whether to involve relatives in the care of a patient. For example, Charlie stated she refused relative involvement in care, as she would want her relatives excluded if she was a patient. The influence of a critical care nurse’s personal attitude, towards including or excluding relatives from care, has not received previous exploration. Given the variation in individual beliefs, it is essential for critical care nurses to understand the impact that their values have on the involvement of relatives. Similarly, participants found it difficult to involve a relative if they were not considered to be the ‘right’ relative. Loud and aggressive relatives were frequently excluded from being involved in ICU patient care, because these types of relatives create stress for the critical care nurse. Participants also acknowledged that these relatives were likely to cause stress for the patient. This has previously been described by W ahlin et al. (2009), Cypress (2011), Engstr€ om et al. (2011) and Al-Mutair et al. (2013). As some care activities may expose the vulnerable patient, the patient’s right to privacy caused challenges. This view is supported by critical care nurses in the study by Engstr€ om et al. (2011) who asked relatives to leave the patient’s room if their privacy would be threatened, for example, during personal hygiene. Although participants felt it was challenging to involve relatives to preserve patient privacy, it is significant to note that not all care activities are intrusive. Therefore, as part of daily nursing practice, critical care nurses could involve relatives in care activities that do not impact on patient privacy. Anecdotes from some participants provided evidence that participants often failed to recognise that the relative and patient may interact at a deep level. The participant who declares to protect the patient’s privacy intrudes on the patient’s personal space on a daily basis. In comparison, a relative may have already entered the patient’s personal space. This was suggested by one participant who recalled a patient’s wife stating ‘I’ve been married to the guy [patient] for 30 years, I’ve seen his backside’. The suggestion that a patient would feel more comfortable having a relative involved in their care is supported by Engstr€ om and Soderberg (2007). Gaining patient consent may reduce the issue of patient privacy. It is essential for critical care nurses to consider the closeness of the patient and relative as part of their nursing practice, rather than taking on a paternalistic role. Some participants stated that they were less likely to involve a short-term patient’s relative in care activities compared with a long-term ICU patient’s relative. One possible reason as to why participants chose to limit short-term ICU
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relative involvement included the belief that the admission would not significantly impact on their life, thus their participation in patient care was unlikely to be of benefit: ‘I agree with involving relatives. . . not so much with an overnight stay. . .there’s often no real need’- Fred. Whether a stay is for two days or two months, emotions vary. Critical care nurses should not judge a relative’s worthiness of care involvement based on the patient’s length of stay, instead all relatives should be provided with the opportunity to participate. No other studies identifying length of stay as a barrier to relative involvement have been found. Furthermore, some participants explained that hospital policies made it difficult to include relatives in ICU patient care. However, the hospital policies that were referred to were nonexistent. Similarly, Stayt (2007) found that critical care nurses did not refer to institutional guidelines when discussing relative involvement in ICU patient care. This suggests that critical care nurses make their own decisions regarding relative involvement. As critical care nurses have varying opinions concerning relative participation, this means that their practice will vary. As a result of this, a relative’s level of involvement may differ each day, dependent upon the individual critical care nurse providing care to the patient. Fluctuating involvement, a lack of guidelines and structure may cause confusion for relatives. Consistency is essential for ICU nursing practice.
Limitations As with many research studies, there are potential limitations to this research. A questionnaire was developed and so, it is recommended that further studies use this tool to test reliability. It is acknowledged that Phase 2 was undertaken within a single institution and has a small sample size. There is also the possibility of ‘elite bias’ as participants were volunteers who wanted their views to be understood. Similarly, there is potential bias related to the researcher’s knowledge of ICU. However, this prior knowledge and experience allowed greater insight into relative involvement in ICU patient care. The findings of this study should not be generalised, however the results can be transferred to other ICUs.
Recommendations for future research Further research is required into the area of investigation. Future studies could investigate why critical care nurses experience the discussed barriers. Following this research, directed strategies should be developed to reduce barriers. Additional insight into this topic, through research, is likely © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing
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Relative involvement in ICU patient care
to improve the intensive care experience for relatives and assist critical care nurses to involve relatives in patient care. It is recognised that relative involvement in ICU patient care is a limited topic of discussion within the intensive care environment, with study results indicating that not all participants understand the benefits of relative involvement. As part of the process of employment in ICU, critical care nurses should be educated on the topic of relative involvement in patient care. Regular in-service programmes may assist critical care nurses to enhance their knowledge base by recognising patient care issues as well as encouraging them to consciously think about relative involvement. The development of a relative caregiver specialist may reduce the barriers of involvement. Employing a critical care nurse who understands the needs of relatives and educates them as to how they could be involved in the patient’s care would be useful. Although critical care nurses working with relatives in ICU patient care is ideal, it is often difficult for them to simultaneously perform complex care tasks on the patient while supporting and involving relatives. The emergence of this role in the ICU setting may reduce pressure for critical care nurses. ICU policies and guidelines require ongoing review. The development of policies which promote relative involvement in ICU patient care is essential. Critical care nurses, within individual ICUs, could agree upon care activities to include in policy guidelines.
Conclusion By identifying additional barriers not previously discussed, this study contributes to the growing knowledge base of relative involvement in ICU patient care. This research highlights the fact that relative involvement in patient care is feasible within the intensive care setting, despite these barriers. Critical care nurses, at a national and international level should reflect on and embrace these findings, attempting to implement solutions within their own ICUs to limit
barriers. In doing so, this is likely to improve relative satisfaction in the often frightening intensive care environment and assist critical care nurses in the daily practice of relative involvement in ICU patient care.
Relevance to clinical practice This study has identified and discussed a range of barriers critical care nurses experience to relative involvement in ICU patient care. The participation of relatives in the care of critically ill patients is a complex task with many difficulties arising from the process. Knowledge of these barriers may provide the platform for improving discussion on relative involvement in care and could assist ICUs to focus on reducing barriers. These results may assist in further research into why critical care nurses experience the discussed barriers and direct the development of strategies to reduce barriers. Recommendations include that ICU policies and guidelines are reviewed and polices which promote relative involvement in ICU patient care are developed. Relative participation may result in benefits for the patient, relative and critical care nurse, thus, this information is relevant to clinical nursing practice.
Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content and (3) final approval of the version to be published.
Conflict of interest No conflict of interest has been declared by the authors.
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