Authors

1. Kynoch, Kate RN, BN, MN (Intensive Care)
2. Chang, Anne RN, Dip NEd, BEdSt(Hons), MEdSt, PhD, FRCNA
3. Coyer, Fiona RN, PhD
4. McArdle, Annie RN

Abstract

Review question/objective: The quantitative objective is to identify the effectiveness of interventions to meet the needs of families with a relative admitted to an adult ICU. The needs of families of ICU patients will be categorized according to the five areas of family needs identified from an earlier study.1 The five specific areas are:

- Assurance

- Proximity

- Information

- Support

- Comfort

Introduction: This is the protocol for a systematic review which will update a previous systematic review conducted in 2011.1

Background: The specialty of intensive care focuses on patients with a variety of life-threatening illnesses or events2, and as a result the ICU is often a very frightening environment for both the patient and family, resulting in feelings of stress, fear, uncertainty, depression and even post-traumatic stress disorder.3-5 Indeed, some family members will have long lasting effects which can impact on the critically ill patient's recovery3 Staff working within this technologically-oriented environment are trained to respond to the changing physiological needs of patients.6 However, it is increasingly recognized that nursing is most effective when directed towards the meeting of specifically identified human needs, rather than concentrating primarily on the patients' medical diagnoses.7 Therefore, understanding and effectively addressing the needs of family members is a necessary step to providing appropriate care.8

In a 1979 study, Molter developed the Critical Care Family Needs Inventory (CCFNI) which consisted of 45 needs that family members could rate on the 4-point Likert scales.9 The purpose underpinning the development of this tool was to ascertain the degree of importance attributed to specific needs by family members of critically ill patients.10 These needs identified by families of patients in the ICU have been broadly categorized into five distinct groups; assurance, proximity, information, support and comfort.11 Over the years the CCFNI has been used in many studies across a variety of countries.8,9,11-13

The current evidence appears to demonstrate that information about the patient's clinical condition is the greatest universal need, regardless of the relatives' educational background or culture.14-16 During the ICU admission period, communication appears to influence relatives' perceptions of whether their needs are met.17 Patients in intensive care are often too ill to participate in communication and decision making, therefore the patient's family can play an important role in discussions and decisions regarding their care.3 Several studies also highlight the emotional needs of family members with a relative in the ICU.12,16,17 Often the stress experienced by family members during this time can be greater than that of the patient. Hope, reassurance and being able to remain in the vicinity of the patient are crucial.18 For some family members, it is important to know that the patient is receiving the best possible care and is as comfortable as possible.19 Some families feel that the strict visiting hours in some units are very much an obstacle in allowing them to be with their relative.20 Studies have shown that families need to see their critically ill relative often and flexibility with visiting times is also important.4

To date the majority of research in this area has focused on identifying relatives' needs in the ICU, their satisfaction with the care and support they receive, how their needs are being met and interventions that may support them during this difficult time. A number of studies have identified factors relating to relatives of critically ill patients in the ICU that can affect their psychological well-being, including uncertainty about the patient's prognosis and technology.21,22 Additionally several literature reviews regarding the impact of critical illness on family members3, and on the needs and experiences of family have been published.16,23 These reviews provide a broad overview of what is currently known about the needs and experiences of family members of patients admitted to an ICU, but not an in-depth analysis and synthesis of the findings. For a holistic approach to care to be realized, it is essential that the critical care nurse is able to identify the specific needs of family members and demonstrate appropriate intervention techniques for those in need of support.24

A literature review conducted by Paul and Rattray examining the short- and long-term impact of critical illness on relatives, identified several gaps in the literature concerning families of critically ill patients. Although it is recognized that relatives have specific needs, it is not clear whether these needs are always met and whether further support is required, both during and after the intensive care admission. The studies summarized for this literature review mainly identified relatives' immediate needs using the CCFNI. There were few included studies that investigated interventions to address relatives' needs and the short- and long-term effects of critical illness on relatives.3

In 2007, the American College of Critical Care Medicine produced clinical practice guidelines for the support of family in the intensive care unit.15 Their recommendations included shared decision making, regular family conferences to improve communication, cultural and spiritual support, flexible visiting hours and family support from ICU staff.15 However, these published guidelines also identified several weaknesses during the development process including the lack of consultation with patients and families and a lack of high-level evidence for the support of family in the ICU.15 These limitations were again highlighted by McKinley and Elliott when they evaluated the guidelines for their applicability and implications for Australian intensive care units.6

A preliminary review of the literature identified a small number of experimental studies that evaluated the effectiveness of providing information to families including the distribution of pamphlets, structured meetings, tailored information and planned telephone calls. The results from these studies were shown to increase relatives' satisfaction, reduce anxiety and improve comprehension of information.8,25,26 The realization that ICU relatives may require more information than is sometimes provided, has led to the development of interventions to empower families such as family information leaflets27 and information websites for ICU patients and relatives.28 More recently, a study conducted by Shaw et al evaluated the effectiveness of a training program for ICU caregivers in communicating with the families of patients in the ICU. The results of the study showed that family satisfaction with their information needs increased significantly with the intervention, as well as staff confidence in communicating with the families.29

Since the original systematic review was published in 2011, a number of further studies have been conducted. Therefore an update of the review is required so that new findings are synthesized and included in the recommendations. This will ensure health care organizations, clinicians, researchers and policy makers are provided with the most up-to-date evidence to effectively meet the needs of families with a relative admitted to an adult intensive care unit.