Jane S. Leske

Overview of family needs after critical illness: from assessment to intervention.

Results of numerous independent studies suggest that families of a critically ill hospitalized member have similar needs that they can readily identify as very important. Empirical analysis of results compiled from many studies across patient populations, settings, geographic locations, and over time indicates that families have primary needs for assurance, proximity, and information. These primary family needs provide a research-based framework to guide critical care nurses in implementing and evaluating family-centered nursing interventions.

Experiences of Families When Present During Resuscitation in the Emergency Department After Trauma

Several organizations have published national guidelines on providing the option of family presence during resuscitation (FPDR). Although FPDR is being offered in clinical practice, there is limited description of family experiences after FPDR. The aim of this study was to describe family experiences of the FPDR option after trauma from motor vehicle crashes and gunshot wounds. A descriptive, qualitative design based on content analysis was used to describe family experiences of the FPDR option. Family members (N = 28) were recruited from a major level 1 adult trauma center in the Midwest. Participants in this study were 1 family member per patient who were 18 years or older, visited the patient in the surgical intensive care unit, spoke and understood English, and had only one critically injured patient in the family. Family interview data on experiences during FPDR after trauma were used to identify themes. Two main categories were found. Families view the role of health care professionals (HCPs) to “fix” the patient, whereas they as family members have an important role to protect and support the patient. Subcategories related to the role of the HCP include the following: multiple people treating the patient, completion of many tasks with “assessment of the damages,” and professionalism/teamwork. Important subcategories related to the family member role include the following: providing information to the HCP, ensuring that the medical team is doing its job, and remaining close to provide physical and emotional comfort to the patient. Health care professionals are viewed positively by the family, and the role of the family is viewed as important. Families wanted to be present and would recommend the choice to other family members. The findings of this study support that the FPDR option is an intervention that helps family members build trust in HCPs, fulfills informational needs, allows family members to gain close proximity to the patient, and support their family member emotionally.

Comparison of family stresses, strengths, and outcomes after trauma and surgery.

This study aimed to compare family stresses, strengths, and outcomes after motor vehicle crashes, gunshot wounds, and coronary artery bypass graft surgery. A multivariate descriptive design based on the resiliency model of family stress was used. A convenience sample of 127 family members participated within 2 days of admission to the intensive care unit. Family stresses were measured using the Family Inventory of Life Events and the Acute Physiology, Age, and Chronic Health Evaluation Scale (APACHE III). Family strengths were measured by the Family Hardiness Index and the Family Crisis Oriented Personal Evaluation Scale. Family outcomes were measured by the Family Member Well-Being Index and the Family Adaptation Scale. Family members ranged in age from 18 to 80 years (Mean, 42 years). Most of the participants in the study were women (64%) with previous intensive care unit experience (83%). The patients ranged in age from 19 to 78 years (Mean, 44 years). Multivariate analysis of variance was used to control for group differences in family member age, education, and income along with patient age and race. The results indicated that family members of patients who have experienced motor vehicle crashes, gunshot wounds, or coronary artery bypass graft surgery reported no significant differences in family strengths of hardiness and family outcomes of well-being and adaptation. However, families of patients with gunshot wounds reported significantly more stress (F = 7.94; P< 0.01) and less use of coping strategies (F = 4.33; P< 0.01) than families of patients who have experienced motor vehicle crashes or coronary artery bypass graft surgery. Interventions that address family stress and develop or mobilize coping are needed for selected families after admission of a family member to the intensive care unit.

Treatment for family members in crisis after critical injury.

A sudden critical injury produces a great amount of stress within a family. Families faced with this experience require treatment to modify the stress of the situation, receive and comprehend information, maintain patterns of adequate family functioning, use effective coping skills, and provide positive support to the patient. Specific questions discussed include: Who are family members? Why treat family members who are in crisis? What areas should be included in family assessment? What treatments are effective for families? What family outcomes can be expected? A clinical case study is used to describe assessment areas and initial treatments for family in crisis after one of their members is critically injured.

The Influence of “Quiet Time” for Patients in Critical Care

The primary aim was to examine the influence of “quiet time” in critical care. A dual-unit, nonrandomized, uncontrolled trial of a quiet time (QT) protocol was completed. A sample of adult patients from the Neurosciences Intensive Care Unit (NICU) and Cardiovascular Intensive Care Unit (CVICU) participated. Environmental stressors were reduced and patient rest promoted prior to QT. One hundred twenty-nine patients participated in 205 QTs. A one-way, repeated measure analysis of covariance (ANCOVA) was calculated comparing Richards-Campbell Sleep Questionnaire scores, pain and anxiety over three consecutive QTs. No significant statistical effect was found. However, patients rated sleep higher and anxiety levels decreased over consecutive QTs. Ninety-three percent of patients reported QT mattered to them. The combined efforts of nursing, medicine, and ancillary staff are necessary to foster periods of uninterrupted rest, thereby optimizing patient care. Further research is needed to determine if successive QTs positively influence patient outcomes.

The Impact of Critical Injury as Described by a Spouse A Retrospective Case Study

This descriptive study explored the initial experience of critical injury from a spouses perspective. A case study was used to examine the Lazarus stress and coping paradigm. The subject was 43-year-old Caucasian woman, with three young children. Semistructured interviews were conducted i month following critical injury. Analysis of data confirmed the cognitive, behavioral, and emotional coping processes as suggested by Lazarus. From the spouses description, three distinct phases of the critical care experience also emerged. notification, arrival at the hospital. and waiting periods. Cognitive, behavioral. and emotional coping processes were clustered according to the spouses distinct phases of this experience. A 3 x 3 matrix provides a description of the coping processes during the initial critical care period and offers direction for nursing interventions.

Effects of family-witnessed resuscitation after trauma prior to hospitalization.

The purpose of this study was to the examine the effects of family-witnessed resuscitation (FWR) in patients experiencing trauma from motor vehicle crashes and gunshot wounds prior to hospitalization. Family members of 33 patients (motor vehicle crashes: n = 19, 57%; gunshot wounds: n = 14, 43%) participated in this study. Within 1 to 2 days after admission to critical care, families who witnessed resuscitation and those who did not witness resuscitation were asked to participate. Reliable and valid measures for family resources, coping, problem-solving communication, and well-being were used. Results indicated that scores for family resources, coping, problem-solving communication, and well-being were no different in families who witnessed resuscitation compared with those who did not witness resuscitation prior to hospitalization in this study. The effects of FWR during the prehospital time period are not detrimental to family members. Further research needs to be conducted to examine the effects of FWR.

The Importance of Self-Perceptions to Psychosocial Adjustment in Adolescents With Heart Disease

INTRODUCTION This study examined the importance of self-perceptions as determinants of psychosocial adjustment reported by adolescents with heart disease and compared adolescents with heart disease to healthy norms. METHODS Ninety-two adolescents with heart disease from a single Midwestern institution provided reports of self-perceptions (health, self-worth, competence, and importance), internalizing behavior problems (IPs; e.g., anxiety and depression) and externalizing behavior problems (EPs; e.g., attention problems and aggression), and health-related quality of life (HRQOL). Hierarchical linear regression was used to assess the impact of self-perceptions, as well as clinical factors (e.g., illness severity, time since last hospitalization, and medications) and demographic characteristics on outcomes. RESULTS Self-perceptions explained the most variance in behavioral and HRQOL outcomes (R(2)adj = 0.34 for IP, 0.24 for EP, and 0.33 for HRQOL, p < .001). Male gender and lower household income were associated with more behavior problems. Clinical variables were only related to HRQOL. Compared with healthy norms, IPs were significantly more common in male adolescents and HRQOL was lower (p < .001). DISCUSSION Adolescents with heart disease are at risk for internalizing behavior problems and reduced HRQOL; however, positive self-perceptions appear to be protective. Self-perceptions are critical and should be addressed by clinicians.

Challenges in Conducting Research After Family Presence During Resuscitation

Family presence during resuscitation (FPDR) is an option occurring in clinical practice. National clinical guidelines on providing the option of FPDR are available from the American Association of Critical-Care Nurses, American Heart Association, Emergency Nurses Association, and Society of Critical Care Medicine. The FPDR option currently remains controversial, underutilized, and not the usual practice with trauma patients. This article is based on the methodological and practical research challenges associated with an ongoing study to examine the effects of the FPDR option on family outcomes in patients experiencing critical injury after motor vehicle crashes and gunshot wounds. The primary aim of this study was to examine the effects of the FPDR option on family outcomes of anxiety, stress, well-being, and satisfaction and compare those outcomes in families who participate in FPDR to those families who do not participate in FPDR. Examples of real clinical challenges faced by the researchers are described throughout this article. Research challenges include design, sampling, inclusion/exclusion criteria, human subjects, and procedures. Recruitment of family members who participated in the FPDR option is a complex process, especially after admission to the critical care unit.

Using Clinical Innovations for Research-Based Practice

Making choices about patient-care interventions pervades critical care nursing practice. Research utilization activities provide the reasoning by which assessment parameters are established, preventative actions are identified, and interventions are evaluated in the clinical setting for positive effects on patient outcomes. For research results to be directly applicable, they must be transformed into clinical innovations specific to a patient population, clinical situation, or institutional setting. A brief summary of using research findings to design clinical innovations is provided. Examples of selected clinical innovations are included to illustrate the steps of the research utilization process. Clinical innovations are intended to improve or validate patient outcomes and are considered the key to quality patient care.