Emotional responses of family members during a critical care hospitalization.

BACKGROUND: The needs and satisfaction levels of family members of critically ill patients have received much attention in the literature. The feelings of family members, however, have not been thoroughly investigated. To develop appropriate nursing interventions to assist family members in coping with a critical care hospitalization, accurate information about their emotional response to the situation is needed. OBJECTIVE: To examine emotional responses of family members and their descriptions of supportive behaviors of others during a critical care hospitalization. METHODS: An exploratory design was used to study 52 subjects with critically ill family members in the pediatric, neonatal, medical, surgical and cardiovascular intensive care units in a large tertiary care hospital. The subjects kept daily logs of their feelings and the supportive behaviors of others. Thematic analysis was used to identify major themes. RESULTS: Analysis revealed a broad range of powerful emotions throughout the intensive care unit stay. Negative and positive emotions such as despair and joy were sometimes identified by subjects within a 24-hour period. Although fear, worry, anger and exhaustion were dominant themes during the first 24 hours and when the family received bad news about the patient, there was no pattern of emotional response evident as the stay progressed. Some differences between subjects drawn from the medical and neonatal intensive care units were evident. CONCLUSIONS: The findings suggest that family members of critically ill patients experience deep emotional turmoil throughout the intensive care unit stay. Specific nursing interventions to promote adaptive coping are needed throughout the experience.

Effects of child visitation in adult critical care units: a pilot study.

OBJECTIVE: To examine the behavioral and emotional responses of the child and of the nonhospitalized adult family member (NHAFM) to facilitated child visitation in the critical care setting. DESIGN: Quasi-experimental, posttreatment design. SETTING: An adult surgical intensive care unit at a large Midwestern teaching hospital. PARTICIPANTS: Twenty families participated in the study, 10 families in a restricted and 10 families in a facilitated visitation group. Each family unit had a child, an NHAFM, and a critically ill family member. In the control group the NHAFMs visited the patient in the customary routine, but children were restricted from visiting. After a 2-week waiting period a facilitated child visitation intervention was implemented for the experimental group. OUTCOME MEASURES: The child completed measures on anxiety as measured by the Manifest Anxiety Scale and behavioral and emotional changes as measured by the Perceived Change Scale. The NHAFM completed measures on anxiety as measured by the State-Trait Anxiety Inventory and mood as measured by the Mood Adjective Check List. Family functioning, as measured by the Feetham Family Functioning Survey, and life event changes, as measured by the Life Event Scale, were examined as extraneous variables. INTERVENTION: The Child Visitation Intervention encompassed systematic facilitation and supervision of children visiting a critically ill adult family member in a surgical intensive care unit and provision of emotional support before, during, and after visitation (the intervention protocol may be obtained from the investigators on request). RESULTS: Children in the facilitated visitation group had a greater reduction (t = 4.0, df = 18, p = 0.0004) in negative behavioral and emotional changes as measured by the Child-Perceived Change Scale when compared with children in the restricted visitation group. CONCLUSION: Facilitated child visitation may help children deal with the critical illness of an adult family member and deserves further study.

Behavioral responses of family members during critical illness.

This articles describes the behavioral responses of adult family members to critical illness and how these responses change over the course of the hospitalization. A convenience sample of 52 family members of patients in intensive units completed the Iowa ICU Family Scale, a self-report tool measuring sleep, eating, activity, family role, and support behaviors. Scales were completed by family members each day during the first week and then weekly throughout the patient's ICU stay. Family members reported sleeping less with a poorer quality of sleep, less nutritional intake, an increased use of cigarettes, alcohol, and over-the-counter and prescription medications, and spending more time talking, visiting the patient, and waiting. Stress was highest at the time of the ICU admission, began to plateau at Day 6, and then dropped considerably by Day 28. These findings suggest that crisis intervention is important during the early phase of caring for critically ill patients and their family members.

Guideline for i.v. infiltrations in pediatric patients.

A large Midwestern tertiary care center used a multidisciplinary approach to develop an intravenous infiltration/extravasation guideline for pediatric patients, ages 0-18 years old, using the Iowa Model for research utilization. This infiltration clinical practice guideline included a site appearance staging tool, decision algorithm, research-based antidotes, and standard of care. The goal of the guideline was to prevent or minimize adverse occurrences for pediatric patients at risk for intravenous infiltrations. Quality assessment and improvement tracking suggested that there was an increased consistency in use of practice guideline interventions for and reporting of the infiltration event, a reduction in adverse patient outcomes and potential cost savings.

Group functioning of a collaborative family research team.

Collaborative research teams are an attractive means of conducting nursing research in the clinical setting because of the many opportunities that collaboration can supply. These opportunities include a chance to: (1) network with other nurses who have similar interests, (2) share knowledge and expertise for designing clinical studies that directly affect daily practice, (3) develop instruments, (4) write grant proposals, (5) collect and analyze data, and (6) prepare manuscripts for publication. The effectiveness of research teams, however, is strongly influenced by group functioning. This article describes the functioning of a collaborative family interventions research team of nursing faculty members and CNSs at a large Midwestern university setting. The formation of the group and membership characteristics are described, along with strategies used to identify the research focus and individual and group goals. Aspects related to the influence of the group on members and the internal operations of the group are also addressed. Future strategies to be explored will focus on the size of the group and joint authorship issues. The authors also set forth a number of recommendations for development of collaborative research groups.

Total scalp radiation using image-guided IMRT for progressive cutaneous T cell lymphoma.

Modern radiotherapy has advanced dramatically over the past decade and it is now possible to focus radiotherapy with extreme precision. This allows the radiation dose to be targeted to the area(s) of tumour while sparing adjacent normal tissues even in seemingly complicated and difficult parts of the body. The case report presented here will illustrate how it is possible to irradiate the entire scalp for extensive cutaneous T cell lymphoma while minimising radiotherapy to the underlying brain, orbits and other critical structures.

Poster - Thurs Eve-30: Investigation of a patient immobilization system for breast tomotherapy.

Using tomotherapy to deliver adjuvant radiation therapy for breast cancer treatment requires more precise immobilization than can be achieved using gravity alone. We evaluated the use of a thermoplastic shell to immobilize the patient's torso during breast cancer treatment. To measure intrafraction breathing motion, 4DCT scans were performed for eight post-lumpectomy or post-mastectomy breast cancer patients with the thermoplastic shell in place. The 4DCT scans were then analyzed to determine the magnitude of motion of the breast surface, chest wall, and heart over the breathing cycle. Maximum surface motion was typically less than 2mm, with a maximum of 4mm. Maximum displacement of the chest wall was less than 3mm with a maximum of 5mm in a single patient. Comparison with the setup errors recorded prior to repositioning the patients suggests that, with the thermoplastic shell in place, patient setup error will be a more significant source of uncertainty in patient position than breathing motion.

Implementing a clinical practice guideline to improve pediatric intravenous infiltration outcomes.

The focus on quality, efficiency, and cost containment has spurred development of clinical practice guidelines to facilitate the use of research-based knowledge and expert opinion to promote desired outcomes. At the University of Iowa Hospitals and Clinics, pediatric nursing took a leadership role in developing multidisciplinary guidelines for the prevention and treatment of intravenous infiltrations in pediatric patients, following the Iowa Model. The 3-year collaborative effort has resulted in a synopsis of the literature; a quick reference sheet based on the latter; infiltration staging guidelines; an infiltration decision algorithm; a table of recommended antidotes; and a standard of care. Outcome data showed improvement in ongoing intravenous site assessment, extent of infiltration and estimated infiltration volume assessment, physician notification of infiltrations, documentation of severity, and compliance with use of the guidelines and use of antidotes. The guideline recently has been revised, and outcomes will continue to be tracked.

Minimizing epidermal stripping in the very low birth weight infant: integrating research and practice to affect infant outcome.

As smaller infants are cared for in our NICUs, maintaining skin integrity and preventing epidermal stripping have become key aspects of neonatal nursing care. This article describes a research utilization project in which research-based knowledge, expert information, and scientific practice guided a practice change in one NICU. The implementation process, based on the Iowa model, included the following steps: identification of triggers; review, critique, and evaluation of the literature; determination of the soundness of the research base; identification of alternate strategies; making the practice change; and evaluation of the outcomes. Initial monitoring suggests that the recommended interventions can be successful with very low birth weight infants.

Determining research priorities in pediatric nursing: a Delphi study.

A two-round Delphi study was performed in Pediatric Nursing at a large midwestern teaching hospital. The purpose of the study was to identify research priorities for the Pediatric Research committee for future projects. The initial survey was sent to all pediatric nursing staff. Sixty-two staff (19%) responded to the first round. Forty-five separate research topics/themes of interest were identified. The second round survey was sent to the 62 staff who responded to Round 1. Forty-eight staff (76%) responded. Participants were given a list of the 45 topics identified in Round 1, and asked to identify their top five priorities. Results were analyzed by unit and by Division. The identified priorities for the Division are described here.

Information needs of the siblings of critically ill children.

This study explored parental and sibling perceptions and feelings about sibling information needs during a pediatric admission to an intensive care unit (ICU). Using a qualitative research design, parents (n = 14) and school-age siblings (n = 12) of children who were patients in ICU were interviewed using open-ended questions. Themes of information that the parents report having given to the siblings were similar to the themes that siblings report having heard. However, parents reported that the siblings had numerous questions about the reasons for hospitalization and expectations for the future of the family. The findings indicate that parents may neither be aware of the effects of the ICU experience on the siblings nor have the knowledge and skill to assist them. Parents may need counseling to increase their awareness of the siblings' need for information and teaching to increase skill in providing the information.

Perceived changes in adult family members' roles and responsibilities during critical illness.

An exploratory design was used to study the effects of critical care hospitalization on family roles and responsibilities of adult family members and how these effects changed over time. A convenience sample of 52 subjects from pediatric, neonatal, surgical, medical, and cardiovascular intensive care units was used. Data were collected using an open-ended question contained in the Iowa ICU Family Scale (IIFS). Using qualitative techniques, seven themes were identified: (a) Pulling together, (b) Fragmentation of families, (c) Increased dependence, (d) Increased independence, (e) Increased responsibilities, (f) Change in routine, and (g) Change in feelings. These findings indicate that nurses need to implement family-centered interventions such as role supplementation programs or identification of support systems to decrease role strain and role overload in families during a crisis.