Exploring Adult Attachment Style and Conflict Resolution Strategies: A Directed Content Analysis to Improve Communications with Family Members of Patients in the Intensive Care Unit

Thesis (Ph.D.)--University of Washington, 2013Background: Multiple studies have suggested that communication with family members in the ICU is inadequate. Researchers have found that family members understand less than half of basic patient information; family members experience increased anxiety and depression when excluded from decision making; and family members often report conflicts with healthcare team (HCT). Most strategies to address this gap in communication have been general approaches that have offered a standard package of supports. Problem: This analysis used an exploratory design with an existing dataset to explore the use of individualized, targeted strategies for addressing communication needs of families of ICU patients and their HCTs. Methodology: The existing dataset of 79 field notes were recorded by trained facilitators as part of a multi-center, randomized trial of an intervention study designed to improve communication between the HCT and families of ICU patients. Data were analyzed using a directed content analysis approach. The initial coding scheme was derived from adult attachment theory and Moore's theory of conflict and conflict resolution. Results: Of the 79 field notes, the attachment style of the main family member was available for 62 and reflected the proportion reported in other research (i.e., secure = 48%; versus insecure types including self-reliant = 34%, cautious = 10%, or support-seeking = 8%). Eight communication strategies were identified to improve communication. Conflicts were identified commonly in the field notes (220 separate conflicts). The most common parties involved were families and the HCT (162 conflicts). Family members with cautious attachment experienced the most conflict. Discussion: These findings suggest that trained facilitators can use strategies based on attachment style to improve communication with family members. These facilitators tailored their interactions with self-reliant family members in an effort to encourage a typically reluctant population to ask questions and participate collaboratively in decision-making, while families with cautious attachment were assisted to build trust and participate collaboratively. Data from this analysis also suggest that family members with cautious attachment may be at risk for conflict with members of the HCT. Finally, HCT members may be more inclined to collaborate when family members have a secure attachment style

Subgroups of failure after surgery for pelvic organ prolapse and associations with quality of life outcomes: a longitudinal cluster analysis

BackgroundTreatment outcomes after pelvic organ prolapse surgery are often presented as dichotomous "success or failure" based on anatomic and symptom criteria. However, clinical experience suggests that some women with outcome "failures" are asymptomatic and perceive their surgery to be successful and that other women have anatomic resolution but continue to report symptoms. Characterizing failure types could be a useful step to clarify definitions of success, understand mechanisms of failure, and identify individuals who may benefit from specific therapies.ObjectiveThis study aimed to identify clusters of women with similar failure patterns over time and assess associations among clusters and the Pelvic Organ Prolapse Distress Inventory, Short-Form Six-Dimension health index, Patient Global Impression of Improvement, patient satisfaction item questionnaire, and quality-adjusted life-year.Study designOutcomes were evaluated for up to 5 years in a cohort of participants (N=709) with stage ≥2 pelvic organ prolapse who underwent surgical pelvic organ prolapse repair and had sufficient follow-up in 1 of 4 multicenter surgical trials conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Surgical success was defined as a composite measure requiring anatomic success (Pelvic Organ Prolapse Quantification system points Ba, Bp, and C of ≤0), subjective success (absence of bothersome vaginal bulge symptoms), and absence of retreatment for pelvic organ prolapse. Participants who experienced surgical failure and attended ≥4 visits from baseline to 60 months after surgery were longitudinally clustered, accounting for similar trajectories in Ba, Bp, and C and degree of vaginal bulge bother; moreover, missing data were imputed. Participants with surgical success were grouped into a separate cluster.ResultsSurgical failure was reported in 276 of 709 women (39%) included in the analysis. Failures clustered into the following 4 mutually exclusive subgroups: (1) asymptomatic intermittent anterior wall failures, (2) symptomatic intermittent anterior wall failures, (3) asymptomatic intermittent anterior and posterior wall failures, and (4) symptomatic all-compartment failures. Each cluster had different bulge symptoms, anatomy, and retreatment associations with quality of life outcomes. Asymptomatic intermittent anterior wall failures (n=150) were similar to surgical successes with Ba values that averaged around -1 cm but fluctuated between anatomic success (Ba≤0) and failure (Ba>0) over time. Symptomatic intermittent anterior wall failures (n=82) were anatomically similar to asymptomatic intermittent anterior failures, but women in this cluster persistently reported bothersome bulge symptoms and the lowest quality of life, Short-Form Six-Dimension health index scores, and perceived success. Women with asymptomatic intermittent anterior and posterior wall failures (n=28) had the most severe preoperative pelvic organ prolapse but the lowest symptomatic failure rate and retreatment rate. Participants with symptomatic all-compartment failures (n=16) had symptomatic and anatomic failure early after surgery and the highest retreatment of any cluster.ConclusionIn particular, the following 4 clusters of pelvic organ prolapse surgical failure were identified in participants up to 5 years after pelvic organ prolapse surgery: asymptomatic intermittent anterior wall failures, symptomatic intermittent anterior wall failures, asymptomatic intermittent anterior and posterior wall failures, and symptomatic all-compartment failures. These groups provide granularity about the nature of surgical failures after pelvic organ prolapse surgery. Future work is planned for predicting these distinct outcomes using patient characteristics that can be used for counseling women individually