A Theoretical Lens Through Which to View the Facilitators and Disruptors of Nurse-Promoted Engagement With Families in the ICU.

The theory of nurse-promoted engagement with families in the intensive care unit (ICU) was developed to describe the dynamic and complex interplay between factors that support or impair nurses' efforts to promote family engagement. Theory construction involved theory derivation and theory synthesis. Concepts and relationships from ecological theory, the Resiliency Model of Family Stress, Adjustment and Adaptation, moral distress theory, and the healthy work environment framework informed the initial formation of the emerging theory. The synthesis of findings from the literature further expanded the scope of the relationships and propositions proposed in the theory. This middle-range theory can set direction for theory-informed focused nursing research that can advance the science of family nursing and guide ICU clinicians in overcoming challenges in family nursing practice. Recommendations are provided for applying this new theoretical lens to guide family nursing curriculum development, practice improvements, and policy changes to support nurses in promoting family engagement.

Relationships among Climate of Care, Nursing Family Care and Family Well-being in ICUs.

BACKGROUND: Frequent exposure to ethical conflict and a perceived lack of organizational support to address ethical conflict may negatively influence nursing family care in the intensive care unit. RESEARCH AIMS: The specific aims of this study were to determine: (1) if intensive care unit climate of care variables (ethical conflict, organizational resources for ethical conflict, and nurse burnout) were predictive of nursing family care and family wellbeing and (2) direct and indirect effects of the climate of care on the quality of nursing family care and family wellbeing. RESEARCH DESIGN: A cross-sectional, correlational design was used. PARTICIPANTS AND RESEARCH CONTEXT: Convenience sample of 111 nurses and 44 family members from five intensive care units at a Midwest hospital in the United States. INSTRUMENTS: The Ethical Conflict Questionnaire-Critical Care Version, Maslach Burnout Inventory-Human Services Survey and Hospital Ethical Climate Scale were used to measure climate of care. The Family-Centered Care-Adult Version and Nurse Provided Family Social Support Scale were family measures of the quality of nursing family care. The Family Wellbeing Index was used to measure family wellbeing. DATA ANALYSIS: Hierarchical regression and mediation analysis were used to answer the study aims. ETHICAL CONSIDERATIONS: The study was approved by the Institutional Review Board at the study site. FINDINGS: In separate regression models, organizational resources for ethical conflict (ß = .401, p = .006) and depersonalization (ß = -.511, p = .006), a component of burnout, were significant predictors of family-centered care. In simple mediation analysis the relationship between organizational resources for ethical conflict and family-centered care was mediated by depersonalization (ß = .341, 95% confidence interval (.015, .707)). DISCUSSION: Inadequate organizational resources and depersonalization may be related to family care delivery, and present obstacles to family-centered care in the intensive care unit. CONCLUSION: Further research to explicate the relationships among organizational resources, ethical conflict, burnout, and family-centered care is needed to guide the development of effective interventions that enhance the quality of nursing family care in the intensive care unit.

Moral distress in critical care nursing: The state of the science.

BACKGROUND: Moral distress is a complex phenomenon frequently experienced by critical care nurses. Ethical conflicts in this practice area are related to technological advancement, high intensity work environments, and end-of-life decisions. OBJECTIVES: An exploration of contemporary moral distress literature was undertaken to determine measurement, contributing factors, impact, and interventions. REVIEW METHODS: This state of the science review focused on moral distress research in critical care nursing from 2009 to 2015, and included 12 qualitative, 24 quantitative, and 6 mixed methods studies. RESULTS: Synthesis of the scientific literature revealed inconsistencies in measurement, conflicting findings of moral distress and nurse demographics, problems with the professional practice environment, difficulties with communication during end-of-life decisions, compromised nursing care as a consequence of moral distress, and few effective interventions. CONCLUSION: Providing compassionate care is a professional nursing value and an inability to meet this goal due to moral distress may have devastating effects on care quality. Further study of patient and family outcomes related to nurse moral distress is recommended.

Family Presence During Resuscitation After Trauma.

The purpose of this study was to examine the effects of family presence during resuscitation (FPDR) in patients who survived trauma from motor vehicle crashes (MVC) and gunshot wounds (GSW). A convenience sample of family members participated within three days of admission to critical care. Family members of 140 trauma patients (MVC n = 110, 79%; GSW n = 30, 21%) participated. Family members ranged in age from 20-84 years (M = 46, SD = 15, Mdn = 47). The majority were female (n = 112, 80%) and related to the patient as spouse (n = 46, 33%). Participating in the FPDR option reduced anxiety (t = -2.43, p =.04), reduced stress (t = -2.86, p = .005), and fostered well-being (t = 3.46, p = .001). Results demonstrate the positive initial effects of FPDR on family members of patients surviving trauma injury.

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.

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.

Comparison of two pain assessment tools in nonverbal critical care patients.

It is recommended that patient's self-report of pain should be obtained as often as possible as the "gold standard." Unfortunately in critical care, many factors can alter verbal communication with patients, making pain assessment more difficult. Scientific advances in understanding pain mechanisms, multidimensional methods of pain assessment, and analgesic pharmacology have improved pain management strategies. However, pain assessment for nonverbal patients in critical care continues to present a challenge for clinicians and researchers. The purpose of this study was to compare the Pain Assessment in Advanced Dementia (PAINAD) and the Critical-Care Pain Observation Tool (CPOT) scores for assessment in nonverbal critical care patients. A descriptive, comparative, prospective design was used in this study. A convenience sample of 100 critical care, nonverbal, adult patients of varying medical diagnoses who required pain evaluation were assessed with the PAINAD and CPOT scales. Data were collected over a 6-month period in all critical care areas. Observations of pain assessments for nonverbal patients who required pain evaluation were recorded on the PAINAD and the CPOT successively. Internal consistency reliability for the PAINAD was 0.80 and for the CPOT 0.72. Limits of agreement indicated that there was no difference in PAINAD and CPOT scores for assessing pain in nonverbal patients in critical care. Further research in the area of pain assessment for nonverbal patients in critical care is needed.

Influence of moral distress on the professional practice environment during prognostic conflict in critical care.

Study purpose was to describe critical care nurses' levels of moral distress and the effects of that distress on their professional practice environment. A descriptive, correlational, prospective, survey design was used. The intensity of moral distress was inversely related to physician/nurse collegial relationships and the frequency of moral distress was inversely related to all aspects of the professional practice environment except foundations for quality of care. It is important to monitor the frequency of moral distress. Strategies to improve the nurse's sense of control over practice, teamwork, communication, and autonomy need to be developed and tested in future research.

Family presence during trauma resuscitation: ready for primetime?

BACKGROUND: The concept of family presence during trauma resuscitation (FPTR) remains controversial. Healthcare providers have expressed concern that resuscitation of severely injured trauma patients is inappropriate for family members as they may have psychologic distress, disrupt resuscitative efforts, or misinterpret provider actions, which can ultimately impact satisfaction with care. The minimal evidence that exists is descriptive or anecdotal. METHODS: Using a previously developed FPTR protocol, a prospective, comparative study assessing 50 adult family members, who were present (n = 25) or not present (n = 25) with their severely injured adult family member during resuscitation, was conducted. Family member anxiety was assessed using State-Trait Anxiety Inventory, satisfaction using a Revised-Critical Care Family Needs Inventory, and well-being using Family Member Well-being Index within 48 hours of intensive care unit admission. Mean total scores were compared for both groups with independent t tests. Significance was set at p < 0.05. RESULTS: Age and Injury Severity Score were statistically equivalent in all patients. Anxiety, satisfaction, and well-being were not statistically different in family members present compared with those not present during resuscitation. There were no untoward events during resuscitation efforts. Family members present felt they benefited the patient and gained a better understanding of the situation. Conversely, family members not present commented that they would have preferred to have been present during resuscitation. CONCLUSIONS: Family members present during trauma resuscitation suffered no ill psychologic effects and scored equivalent to those family members who were not present on anxiety, satisfaction, and well-being measures. Quality of care during trauma resuscitation was maintained. The fact that all the family members would repeat experience again supports the idea that FPTR was not too traumatic for those who chose to be present.

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.

Evaluating the Outcomes of an Organizational Initiative to Expand End-of-Life Resources in Intensive Care Units With Palliative Support Tools and Floating Hospice.

BACKGROUND: There is evidence that palliative care and floating (inpatient) hospice can improve end-of-life experiences for patients and their families in the intensive care unit (ICU). However, both palliative care and hospice remain underutilized in the ICU setting. OBJECTIVES: This study examined palliative consultations and floating hospice referrals for ICU patients during a phased launch of floating hospice, 2 palliative order sets, and general education to support implementation of palliative care guidelines. METHODS: This descriptive, retrospective study was conducted at a level I trauma and academic medical center. Electronic medical records of 400 ICU patients who died in the hospital were randomly selected. These electronic medical records were reviewed to determine if patients received a palliative consult and/or a floating hospice referral, as well as whether the new palliative support tools were used during the course of care. The numbers of floating hospice referrals and palliative consults were measured over time. RESULTS: Although not significant, palliative consults increased over time (P = .055). After the initial introduction of floating hospice, 27% of the patients received referrals; however, referrals did not significantly increase over time (P = .807). Of the 68 patients who received a floating hospice referral (24%), only 38 were discharged to floating hospice. There was a trend toward earlier palliative care consults, although this was not statistically significant (P = .285). CONCLUSION: This study provided the organization with vital information about their initiative to expand end-of-life resources. Utilization and timing of palliative consults and floating hospice referrals were lower and later than expected, highlighting the importance of developing purposeful strategies beyond education to address ICU cultural and structural barriers.

Continued professional competence and portfolios.

It is traditionally assumed that licensure of healthcare professionals means that they are minimally competent. Many nursing specialty organizations offer examinations and other processes for certification, suggesting that certification is associated with continued competency. Can standardized examination for certification and continuing education for recertification ensure continued competency? Continuing education and testing provide a limited picture of an individual's knowledge and/or skill acquisition in a limited area at one point in time. However, portfolios promote critical thinking, self-assessment, and individual accountability. A portfolio is a portable mechanism for evaluating competencies that may otherwise be difficult to assess. This article summarizes some of the literature addressing portfolios, including aspects of portfolio development process, the value of portfolios versus continuing education for competency assessment, evidence associated with portfolio usage, and suggestions for organizing nursing portfolios.

Quiet time for mechanically ventilated patients in the medical intensive care unit.

OBJECTIVE: Sleep disruption occurs frequently in critically ill patients. The primary aim of this study was to examine the effect of quiet time (QT) on patient sedation frequency, sedation and delirium scores; and to determine if consecutive QTs influenced physiologic measures (heart rate, mean arterial blood pressure and respiratory rate). METHOD: A prospective study of a quiet time protocol was conducted with 72 adult patients on mechanical ventilation. SETTING: A Medical Intensive Care Unit (MICU) in the Midwest region of the United States. RESULTS: Sedation was given less frequently after QT (p=0.045). Those who were agitated prior to QT were more likely to be at goal sedation after QT (p<0.001). Although not statistically significant, the majority of patients who were negative on the Confusion Assessment Method (CAM-ICU) prior to QT remained delirium free after QT. Repeated measures analysis of variance (ANOVA) for three consecutive QTs showed a significant difference for respiratory rate (p=0.035). CONCLUSION: QT may influence sedation administration and promote patient rest. Future studies are required to further understand the influence of QT on mechanically ventilated patients in the intensive care unit.

A Balancing Act: Experiences of Nurses and Physicians When Making End-of-Life Decisions in Intensive Care Units.

The purpose of this qualitative, descriptive study was to describe end-of-life decision-making experiences as understood by critical care nurses and physicians in intensive care units (ICUs). A purposive sample of seven nurses and four physicians from a large teaching hospital were interviewed. Grounded theory analysis revealed the core category of "end-of-life decision making as a balancing act." Three interacting subthemes were identified: emotional responsiveness, professional roles and responsibilities, and intentional communication and collaboration. Balancing factors included a team approach, shared goals, understanding the perspectives of those involved, and knowing your own beliefs. In contrast, feeling powerless, difficult family dynamics, and recognition of suffering caused an imbalance. When balance was achieved during end-of-life decision making, nurses and physicians described positive end-of-life experiences. The consequence of an imbalance during an end-of-life decision-making experience was moral distress. Practice recommendations include development of support interventions for nurses and physicians involved in end-of-life decision making and further research to test interventions aimed at improving communication and collaboration.

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 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.

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.