Judith E. Hupcey

Establishing the Nurse-Family Relationship in the Intensive Care Unit

The nurse-family relationship in the intensive care unit (ICU) may replace the traditional nurse-patient relationship due to the patients compromised state. As a result, the nurse-family relationship becomes extremely important. Nurses and families may develop a relationship in which they work together to benefit the patient, or an inadequate relationship may develop. In this study, strategies used by nurses andfamilies to either develop or inhibit the development of the nurse-family relationship were identified. Using unstructured interviews with ICU nurses and family members of ICU patients, categories of strategies were identified and behaviors described. Nurses and families perceived that they each displayed only positive behaviors yet identified inhibiting behaviors of the other Once the behaviors were shown to nurses as secondary informants, they were able to identify with theirnegative behaviors. An understanding of these strategies will help nurses to reevaluate theirpractice and enhance their understanding of the behaviors offamily members.

Concept analysis: examining the state of the science.

As methods for analyzing concepts have proliferated in nursing, a critical methodological issue has arisen. Analytic techniques for examining conceptual meaning have incorporated varied strategies for advancing the concept under the rubric of concept analysis, concept development, and theory building. The authors argue that this evolution has created methodological confusion. Following a discussion of a conceptualization of concepts and concept-theory-truth linkages, methods of concept analysis are critiqued in terms of the purpose and the nature of the findings produced by analyses using both traditional and emergent methods. The authors argue that concept analysis is a process of strategic examination of the scientific literature that results in an integrated perspective of the state of the science, or what is known about the concept. In contrast, concept advancement refers to techniques that emphasize the synthesis of new or deeper knowledge that is relevant to the discipline. The authors conclude that disentangling concept analysis from techniques for concept advancement is critical to enhancing the utility of concept-based research in nursing.

Reframing person-centered nursing care for persons with dementia.

Alzheimer’s dementia manifests in a complex clinical presentation that has been addressed from both biomedical and phenomenological perspectives. Although each of these paradigmatic perspectives has contributed to advancement of the science, neither is adequate for theoretically framing a person-centered approach to nursing care. The need-driven dementia-compromised behavior (NDB) model is discussed as an exemplar of midrange nursing theory that promotes the integration of these paradigmatic views to promote a new level of excellence in person-centered dementia care. Clinical application of the NDB promotes a new level of praxis, or thoughtful action, in the care of persons with dementia.

Heart Failure and Palliative Care: Implications in Practice

The number of people with heart failure is continually rising. Despite continued medical advances that may prolong life, there is no cure. While typical heart failure trajectories include the risk of sudden death, heart failure is typically characterized by periods of stability interrupted by acute exacerbations. The unpredictable nature of this disease and the inability to predict its terminal phase has resulted in few services beyond medical management being offered. Yet, this population has documented unmet needs that extend beyond routine medical care. Palliative care has been proposed as a strategy to meet these needs, however, these services are rarely offered. Although palliative care should be implemented early in the disease process, in practice it is tied to end-of-life care. The purpose of this study was to uncover whether the conceptualization of palliative care for heart failure as end-of-life care may inhibit the provision of these services. The meaning of palliative care in heart failure was explored from three perspectives: scientific literature, health care providers, and spousal caregivers of patients with heart failure. There is confusion in the literature and by the health care community about the meaning of the term palliative care and what the provision of these services entails. Palliative care was equated to end-of-life care, and as a result, health care providers may be reluctant to discuss palliative care with heart failure patients early in the disease trajectory. Most family caregivers have not heard of the term and all would be receptive to an offer of palliative care at some point during the disease trajectory.

Review Article: A Model of Palliative Care for Heart Failure

The heart failure illness trajectory is both complex and unpredictable, which makes providing palliative care services to patients with heart failure a challenge. As a result, although services are needed, few tend to be offered beyond basic medical management. The traditional model of palliative care is typically based on palliative care being considered a system of care delivery most appropriate for patients with a predictable illness/death trajectory, such as terminal cancer. This type of model, which is based on the ability to predict the course of a terminal disease, does not fit the heart failure trajectory. In this article, we propose a new model of palliative care that conceptualizes palliative care as a philosophy of care that encompasses the unpredictable nature of heart failure.

Can a professional relationship be considered social support

T he concept of social support has been studied extensively during the past 25 years. However, theoretical definitions of social support remain so vague that anything associated with support or factors that may influence whether support is requested, given, or accepted (as well as other related processes, such as support networks) have been clustered under and labeled as social support. 1 As a result, almost anything tangentially related to support has been considered social support. The concept is complex, but it has been made even more complicated by researchers who have investigated distantly related relationships as aspects of and under the rubric of social support. Any potentially positive interaction, no matter who this interaction is with, has been considered social support (J.E.H., unpublished data, 1997). 2 Although the goal of providing any type of support implies an action that is intended to result in a positive outcome, the unique aspect of social support is that the action must be given by someone who has a personal relationship with the recipient.

Targeted Crisis Resource Management Training Improves Performance Among Randomized Nursing and Medical Students

Introduction: In this study designed with adequate statistical power to detect relevant training effects, investigators evaluated Crisis Resource Management (CRM) training during a simulated patient crisis. This study is guided by the Team Effectiveness Conceptual Model by Kozlowski and Ilgen. Methods: An experimental pretest/posttest design was used. Four-member, interdisciplinary teams, each composed of nursing and medical students, were randomly assigned to experimental or control conditions: Basic Life Support plus CRM training or Basic Life Support only, respectively. Team process (task management, teamworking, situation awareness, and interprofessional attitude) and team effectiveness (team error rate and response times) were the outcomes of interest. Results: Experimental teams demonstrated significant improvement in team process measures compared with control teams. CRM training predicted 13% of the variance in task management (P = 0.05), 15% of the variance in teamworking (P = 0.04), and 18% of the variance in situation awareness (P = 0.03). CRM training and task management predicted 22% of the variance (P = 0.04) in team error rate; CRM training and teamworking predicted 35% of the variance (P = 0.01), while CRM training and situation awareness predicted 20% of the variance (P = 0.04) in response time to chest compressions. Both experimental and control teams demonstrated significant improvement in team effectiveness measures. Conclusions: CRM team training and team practice in an environment of high-fidelity simulation and facilitated debriefing have significant effects on team process and team effectiveness. The conceptual framework is potentially adaptable to additional settings and populations for team-related research and education.

Dyadic Heart Failure Care Types: Qualitative Evidence for a Novel Typology

Background:Compared with other chronic illness populations, relatively little is known about heart failure (HF) patient and caregiver spousal/partner dyads and what effect dyadic interactions have on self-care. Objective:The aim of this study was to present a new typology of patient and caregiver dyadic interdependence in HF care, presenting exemplar cases of each type: patient oriented, caregiver oriented, collaboratively oriented, complementarily oriented. Methods:Stake’s instrumental case study methodology was used. Interviews were unstructured, consisting of open-ended questions exploring dyad’s experiences with HF, audiorecorded, and transcribed. Cases were selected because they exhibited the necessary characteristics and also highlighted a unique, little understood variation in self-care practice. Each case represents a dyad’s discussion of caring for HF in their normal environment. Results:From 19 dyads, 5 exemplar case studies illustrate the 4 dyadic types. A fifth, incongruent case, defined as a case where the patient and caregiver indicated incongruent dyadic types, was included to highlight that not all dyads agree on their type. A major theme of Sharing Life infused all of the dyad’s narratives. This typology advances the science of dyadic interdependence in HF self-care, explains possible impact on outcomes, and is an early theoretical conceptualization of these complex and dynamic phenomena. Conclusion:The cases illustrate how long-term dyads attempt to share the patient’s HF care according to established patterns developed over the trajectory of their relationship. In keeping with the interdependence theory, these couples react to the patient’s declining ability to contribute to his/her own care by maintaining their habitual pattern until forced to shift. This original pattern may or may not have involved the dyad working together. As the patient’s dependence on the caregiver increases, the caregiver must decide whether to react out of self-interest or the patient’s interest. Continued study of the typology is needed in nonspousal/partner dyads.

Caring for a spouse with end-stage heart failure through implantation of a left ventricular assist device as destination therapy

OBJECTIVES This qualitative study describes the experiences of spousal caregivers of a patient with end-stage heart failure (HF) from pre-LVAD to post-LVAD-DT implantation. BACKGROUND LVAD-DTs are implanted as permanent devices for end-stage HF patients with the goal of improving the length and quality of life. LVADs create new demands for both patients and caregivers. METHODS In-depth, semi-structured interviews of 10 spousal caregivers were thematically analyzed. RESULTS Throughout the process of caregiving, pre-implant through post-implant, all caregivers discussed their ability to adapt within the role as a caregiver. Adaptation as a caregiver occurred through three distinct time frames following the progression of the patients HF and subsequent LVAD implantation: caring for a spouse with HF, decision for LVAD implantation made, and caring for a spouse with the LVAD-DT. CONCLUSIONS Caregivers were able to adapt and develop effective strategies to incorporate the demands of caring for a spouse with an LVAD-DT, but the role remained challenging. The findings underscore the need for continued research that may be translated into effective interventions to support patient and caregivers as they live through this end-of-life trajectory.

Integrating concepts for the development of qualitatively-derived theory.

The development of qualitatively-derived theory (QDT) remains a challenge for researchers wishing to retain the complexity of reality. The techniques of concept integration provide a means to link concepts according to their shared attributes and logically according to their mutual interactions, reactions, and responses. While retaining all of the advantages of qualitative induction, integrating concepts in this manner places QDT theory at the upper end of mid-range theory, or disclosive theory, to produce a theory of higher abstraction and broader scope.