The Development of Family-Focused Intensive Care Nursing Through Action Research

Abstract

Introduction: The purpose of this study was to facilitate an improved understanding by intensive care nurses about their care of family members of critically ill patients. The study aimed to challenge intensive care nurses to reconceptulaise family nursing within the context of the intensive care unit (ICU). Background to the study: Critical illness is not an event that occurs in isolation for the patient and staff. It affects the patient's family in a unique way. A plethora of literature exists identifying the needs of family members in the ICU. However, there are considerably fewer studies which have examined interventions to meet family members' needs and no identified research that discreetly examined the concept of family-focused nursing in the intensive care environment. Design of the study: This study utilised a collaborative action research methodology. It was developed in four phases through the cyclical, dynamic steps of action research. Setting: This study was undertaken in the general intensive care facility of a metropolitan tertiary referral hospital. Phase One: Phase One of the study was the establishment of a collaborative action research group (CARG) with interested registered nurses working in a general intensive care unit. The CARG explored the first two research questions of this study: 1) What are intensive care nurses' perceptions of family-focused nursing? and 2) Is familyfocused nursing appropriate in the intensive care environment? Data were collected through audio taping meetings, flip chart notes and the researcher's reflective diary. Data analysis was undertaken utilising open coding. For the first research question, open coding of the data revealed two categories relating to perceptions of family focused intensive care nursing: partnership in care and maintaining a balance. For the second research question, CARG members agreed unanimously that family focused nursing was appropriate in the intensive care environment. The CARG determined future direction of the action research phases, commencing with a family needs analysis in Phase Two. Phase Two: Phase Two of the study was the utilization of a descriptive survey to determine family member needs in the ICU to determine focuses for interventions during Phase Three. Both family members and staff in the ICU were surveyed utilising the Critical Care Family Needs Index (CCFNI) (Molter & Leske, 1983). Data were analysed by the CCFNI subcategories of assurance, proximity, information, comfort and support, comparing means, rank ordering of means and t-test for statistically significant differences in means between the family members and staff participants. Results indicated that statistically significant differences in means scores between family members and staff participants were in the CCFNI categories of assurance, proximity, information and support. On the basis of these results, a platform for Phase Three of this study arose. The areas for intervention for Phase Three were identified by the CARG as: the provision of staff education seminars to raise staff awareness of family needs and the development of a structured family assessment tool to identify family needs in the ICU. Phase Three: Phase Three of the study addressed research question three: &quotHow can intensive care nurses provide care that is focused toward the family of the critically ill patient?" Phase Three examined practice interventions in two areas. Phase Three Part A was the implementation of nursing staff education seminars. Forty-two nursing staff participated in the family needs education seminars. Data were collected by detailed researcher field notes and completion of a descriptive survey, the CCFNI, post seminar attendance. Thirty-five participants completed the CCFNI. This CCFNI data from nursing participants in the education seminars was compared to family members CCFNI data from Phase Two. Open coding of data from the education seminars revealed codes of family needs, visiting, family presence, encouragement, simple things and boundaries under the theme of &quotestablishing the context" and attitudes, confidence, empathy and culture under the theme of &quotbuilding a partnership". CCFNI results highlighted statistically significant differences in means scores between family members and staff participants were in the subcategories of proximity and support. Results demonstrated that through understanding family members needs that intensive care nurses can provide care that is focused toward the family of the critically ill patient. This is a building process to be achieved over time. Phase Three Part B was the content validity development of a family assessment tool for the Computer Information System (CIS) in the ICU. A family assessment tool (See Figure 6.1) was developed through the literature and in consultation with the CARG. A series of focus groups were organised. All nursing staff in the general ICU were invited to participate. Twenty-nine registered nurses (43.9%, n=66) participated in the family assessment tool focus groups. The five domains of the family assessment tool, family roles, family spokesperson, family perception and coping, family issues and family health needs, were each discussed to determine readability, clarity and applicability. The focus groups agreed on content validity of the family assessment tool. (See Figure 6.2). Phase Four: Finally, Phase Four of the study has addressed research question four: &quotIs action research an appropriate methodology to transform intensive care nursing practice?" Somekh's (1995) framework was utilised to guide this critical evaluation. It is suggested that action research is an appropriate methodology to transform intensive care nursing practice as it enables the development of professional, it is sensitive to the specific nature of intensive care nursing, it acknowledges of attributes of the researcher in the process. It is also an appropriate methodological choice as it provides opportunity for a critical evaluation and a platform for the ongoing nature of the action research journey. Conclusions: Overall the findings achieved the objectives of the study in that organisational, cultural and clinical practice changes were identified to facilitate family-focused intensive care nursing. Collaboration occurred with intensive care nurses to effect change. The action research process involved in the change process was articulated throughout the four phases of the study. An improved understanding by intensive care nurses about their family nursing practice was demonstrated in Phase Three and the efficacy of action research methodology for clinical practice change was demonstrated in Phase Four