Factors limiting and facilitating changes in caring for the intensive care unit patients' relatives.

AIM: To explore how the intensive care unit (ICU) context influenced receptivity to change in clinical practice, in order to improve the care offered to patients' relatives. BACKGROUND: Families of critically ill patients have unmet needs that are not being addressed. Lack of attention to these needs is related more to the ICU context than to a lack of scientific evidence. DESIGN: Participatory action research (PAR), a qualitative study conducted in a Spanish ICU. METHOD: Eleven participants agreed to represent their teams in all scheduled group discussions. Field diaries were kept by the principal investigator and discussion participants, and five in-depth interviews were conducted. Content analysis was performed. RESULTS: Four factors limited change: (1) Not acknowledging the legitimacy of scientific evidence regarding the families of critically ill patients. (2) Imbalanced power relationships between the members of multidisciplinary teams. (3) Lack of nurse participation in the information flows. (4) The organization of time and physical space in the unit. Three factors facilitated change: (1) A sense of individual and shared commitment. (2) Leadership in day-to-day matters. (3) A process based on reflection. CONCLUSIONS: PAR can lead to change in clinical practice, although the process is complex and requires substantial input of time and energy. Contextual factors limiting this change were structural whereas facilitating factors were circumstantial and depended upon individuals' characteristics. Professionals working at the bedside are capable of identifying, developing and introducing changes to the context in which they work. RELEVANCE TO CLINICAL PRACTICE: Knowing these factors and sharing the experience of a successful change process can help others design processes appropriate to their site.