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ORIGINAL RESEARCH
Correspondence to P. Black:
e-mail: p.black@ulster.ac.uk
Pauline Black BSc (Hons) PhD PGCE
Lecturer in Nursing
School of Nursing, University of Ulster,
Coleraine, Northern Ireland
Jennifer R.P. Boore BSc PhD FRCN
Emeritus Professor of Nursing
School of Nursing, University of Ulster,
Coleraine, Northern Ireland
Kader Parahoo BA (Hons) PhD RMN
Director
School of Nursing, Institute of Nursing
Research, University of Ulster, Coleraine,
Northern Ireland
Abstract
Aim. This paper is a report of a Neuman systems model-guided study of the effects
of nurse-facilitated family participation in psychological care on the extent of
patient delirium and psychological recovery following critical illness.
Background. Psychological disturbances resulting from critical illness have been
well documented in international literature. Few studies have tested interventions
designed to alleviate such disturbances.
Methods. A comparative time series design was used. A total of 170 critically ill
patients and families participated in the study 83 in the control group and 87 in
the intervention group. Data were collected during critical illness and subsequent
recovery using the Therapeutic Intervention Scoring System-28, Intensive Care
Delirium Screening Checklist and the Sickness Impact Profile. The study was carried
out in Northern Ireland, data collection taking place from January 2004 to
December 2005.
Results/findings. Nurse-facilitated family participation in psychological care did
not significantly reduce the incidence of delirium among patients in critical care, but
patients receiving intervention demonstrated better psychological recovery and
wellbeing than the control group at 4, 8 and 12 weeks after admission to critical
care.
Conclusion. Nurse-facilitated family participation in the psychological care may
strengthen the lines of defence and resistance against the stressors experienced by the
patient during critical illness and improve psychological recovery.
Keywords: critical care nursing, family involvement, intensive care unit delirium,
Neuman Systems Model, psychological care
Introduction
The physical effects of critical illness are obvious to patients,
families and nurses, but the psychological impact can be
overlooked. Exploration of the psychological effects of
2011 The Authors
Journal of Advanced Nursing 2011 Blackwell Publishing Ltd
P. Black et al.
Background
The experiences of intensive care (ICU) patients have been
explored in qualitative studies carried out in the United
States, Scandinavia, Australia and Europe (Granberg et al.
1999, Maddox et al., 2001, Roberts et al. 2007, Hofhuis
et al. 2008, Storli et al. 2008). The incidence of psychological
disturbance has been found to vary from 30% to 100%
(Daffurn et al. 1994, Granberg et al. 1998, Wojniki-Johansson 2001, Van de Leur et al. 2004). Some patients reported
no recall of their stay in ICU (1040%), whereas in
longitudinal studies, memories emerged as time passed.
Those patients who did remember could do so in vivid detail
often describing dreams and unreal experiences (Granberg
et al. 1999, Russell 1999, Lof et al. 2006). This pattern of
psychological disturbance has been referred to as ICU
syndrome (Granberg et al. 1999), ICU psychosis and an
acute confusional state (Pun & Ely 2004). It is suggested that
these symptoms are not exclusive to ICU and use of the term
delirium to describe them is recommended by Devlin et al.
(2007) and Arend and Christensen (2009).
Even at the lowest incidence rate, it is clear from the
literature that psychological disturbances resulting in delirium leave a lasting impact on a significant proportion of ICU
patients across cultural and international boundaries. Longterm effects of psychological disturbances have included
fatigue and pain (Robson 2003), sleep disturbance (Granberg-Axell et al. 2001), tachycardia (LaPlante & Cole 2001),
hypertension (Dubois et al. 2001), increased oxygen consumption (Yagan et al. 2000), disturbing dreams and memories (Russell 1999), unpredictable mood swings (Wunderlich
et al. 1999) and an ongoing search for meaning (Storli et al.
1092
The intervention
Each patient is part of a family unit whose ties are under
strain during critical illness. The therapeutic power of the
family has potential to influence positively the experience of
an ICU admission if it is harnessed and used sensitively
2011 The Authors
Journal of Advanced Nursing 2011 Blackwell Publishing Ltd
The study
Design/methodology
The aim of this Neuman systems model-guided study was to
examine the effects of nurse-facilitated family participation in
psychological care on the extent of patient delirium and
psychological recovery following critical illness. A comparative time series design was chosen. This allowed the
2011 The Authors
Journal of Advanced Nursing 2011 Blackwell Publishing Ltd
Sample/participants
A convenience sample of patients admitted to a seven-bedded
general ICU in an inner city public hospital was chosen.
Potential subjects were male or female, aged 18 years or over,
with a family member who was willing to provide consent to
participate. Patients with family members who were physically unable to participate in the intervention due to being
unable to visit were excluded. Patients with no living family
would have been at risk of exclusion; however, no patients in
this category were admitted during the study. Those patients
with a terminal diagnosis were excluded. The recruitment
protocol is illustrated in Figure 2. A total of 171 patients and
1093
P. Black et al.
New patient
admitted to ICU
Yes
Commence data
collection based
on first 24 hours
of admission
No
Data collection
Patient not included
Researcher discusses
study with family,
ascertains decision
regarding consent
Is consent
provided?
No
Yes
Data collection
continued for 12 weeks
pending patient
consent and survival
The new scoring system was then clinically validated and the
total scores using the TISS-76 and the TISS-28 were then
correlated (r = 093).
Indicators of delirium
The Intensive Care Delirium Screening Checklist (ICDSC)
developed by Bergeron et al. (2001) and Dubois et al. (2001)
was used to identify symptoms of delirium. It consists of a
checklist of eight features of delirium altered level of
consciousness, inattention, disorientation, hallucinations,
inappropriate speech or mood and sleep disturbance. Manifestation of an item scores one point; a score of 4 or more
points indicates delirium. Evaluation of the tool was reported
by Bergeron et al. (2001) who estimated levels of sensitivity
and specificity using the ROC curve. With a cut-off score of 4
points, sensitivity was 99%, but specificity was low at 64%.
Item reliability was calculated using Cronbachs alpha
homogeneity coefficients and resulted in alpha values
between 071 and 079. This test, while useful for Likert style
items, is not an appropriate measure for the ICDSC, which is
a checklist of items. However, it was the only tool available
that allowed the measurement of a range of relevant
behavioural symptoms.
Psychological recovery
The Sickness Impact Profile (SIP) is a behaviourally based
health status measure designed by Bergner et al. (1981) that
consists of 136 items grouped into twelve categories representing physical, psychosocial and emotional activities. This
tool recognizes a link between physical recovery and the
effect on psychological and emotional wellbeing. Items are
numerically weighted, the higher the score, the greater the
perceived impact of illness on lifestyle at the time of measurement. Although not designed for use with individuals
who have experienced critical illness, the SIP has been used in
critical care follow-up studies (Brooks et al. 1990, Tian &
Reis Miranda 1995, Gardner & Sibthorpe 2002, DiMattio &
Tulman 2003).
A complete summary of data collection procedures is
illustrated in Figure 3. Prior to data collection, inter-rater
reliability between the researcher and nursing staff on the
unit was measured using interclass correlation coefficients.
Results indicated a correlation of 0962 (ICDSC) and 0956
(TISS). This was considered to reflect a high level of interrater reliability.
Pilot study
A pilot study with five patients and families was carried out
for 7 days prior to data collection for both groups. No
changes were made as a result of the pilot study prior to the
2011 The Authors
Journal of Advanced Nursing 2011 Blackwell Publishing Ltd
Patient
admitted to
ICU
Day 1
Family consent
Intervention started
for intervention group
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Tools used on
Days 114:
Physiological data
TISS-28
ICDSC
Patient transferred to
ward
Patient consent
Day 14
Patient
discharged
to home
Week 4
Week 8
Tools used in
Weeks 4-12:
SIP
Week 12
P. Black et al.
Data analysis
Results/findings
Demographic characteristics
The age of participants in the control group ranged from 18
to 87 years. Sixty-one of the eighty-three patients were over
60 years old. In the intervention group, patients ages ranged
from 19 to 89 years. Sixty-four of the eighty-seven patients
were over 60 years old. The person identified as the next-ofkin was generally the spouse and, for widowed patients, the
next-of-kin was specified as a daughter or son.
Reasons for admission to ICU for both groups included
general medical and surgical conditions. Although the numbers of emergency surgical admissions in both groups were
similar, there was a greater number of elective surgical
admissions in the intervention group (n = 31, 449%) than in
the control group (n = 19, 275%). This difference in the
elective surgery categories could have exerted an influence on
the results, and was explored in more detail. The data file was
split according to reason for admission and scores compared
between the groups for length of ICU stay, length of ward
1096
Physiological values
There were no significant differences in the physiological
variables between the control and intervention groups. Both
groups received similar categories of sedative medication.
The most frequently used sedative was Propofol 2% followed
by Midazolam and Lorazepam. Fentanyl was the analgesic
drug of choice, followed by Bupivicaine and Fentanyl
epidural analgesia. Atracurium was the drug of choice if
muscle relaxants were required. There were no significant
differences in the amount of intravenous analgesia and
sedation received by both groups.
TISS-28
There were no significant differences in the groups mean
scores for severity of illness at any timepoint. This is an
important finding as it indicates equivalence between the
groups, particularly on day 1 prior to the implementation of
the intervention with the intervention group.
ICDSC
Fifty-four patients (77%) in the control group and twentythree of patients (29%) in the intervention group scored 4 or
more at one of the timepoints, indicating the presence of
delirium. Of these, twenty-one (26%) of those in the control
group and three (4%) in the intervention group scored 4 or
more on three occasions during data collection. There were
no significant differences in mean scores between groups.
2011 The Authors
Journal of Advanced Nursing 2011 Blackwell Publishing Ltd
SIP
The total, physical and psychosocial mean scores were
calculated and compared. The total mean SIP scores for the
intervention group were significantly lower at all time points
at week 4, 2179 compared to 2943, at week 8, 1488
compared to 2402 and at week 12, 1103 compared to 1969.
This meant that the patients who received the intervention
considered the impact of critical illness on their functional
wellbeing to be less than the impact perceived by patients
who did not receive the intervention. The extent of the
difference at each time point was large (g2 = 025, 040 and
024 respectively). These effect sizes signify that the contribution of the intervention to explaining the difference in
outcome of critical illness was important.
This pattern of significance was repeated when the mean
scores for physical and psychosocial outcome categories were
compared. The mean physical category scores for the
intervention group were significantly lower at each time
point at week 4, 2264 compared to 2984, at week 8,
1512 compared to 2346 and at week 12, 1067 compared
to 1948. The effect size at each time point was large
(g2 = 011, 014 and 015 respectively). The mean psychosocial category scores for the intervention group were
significantly lower across the time points at week 4,
1486 compared to 2597, at week 8, 880 compared to
2053 and at week 12, 586 compared to 1583. The effect
sizes at each time point was found to be larger than those
calculated for the physical category (g2 = 037, 040 and
039 respectively).
Discussion
Factors influencing outcomes
Standard multiple regressions were used to clarify which
explanatory variables contributed most to these differences
between the groups. From the literature reviewed, it seemed
reasonable to assume that severity of physical illness (TISS)
and incidence of delirium (ICDSC) could be associated with
Limitations
Research procedures
The use of a non-randomized approach means that control
over extraneous variables is compromised. However, the
Table 1 Explanatory variables significantly associated with outcome as measured by mean total SIP score
Variable
SIP (week 4)
SIP (week 8)
R2
P value
0597
00005
b
P value
0674
00005
b
P value
0609
00005
b
P value
0409
0185
0337
0036
0284
0030
0075
00005
0005
00005
0519
00005
0584
0176
0463
0269
0435
0022
0155
0031
0020
00005
00005
00005
0673
0012
0547
0703
0430
0255
0456
0014
0144
0036
0054
00005
00005
00005
0801
0034
0528
0347
Study group
Length of ICU stay
Length of ward stay
TISS (day 1)
TISS (day 7)
ICDSC (day 1)
ICDSC (day 7)
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P. Black et al.
Table 2 Explanatory variables significantly associated with outcome as measured by mean physical SIP score
Physical SIP (week 4)
Variable
Study group
Length of ward stay
b (%)
0254 (254)
0433 (433)
P value
0001
0001
036
b (%)
0293 (293)
0531 (531)
P value
b (%)
0001
0001
053
0300 (30)
0536 (536)
P value
r2
0001
0001
055
Table 3 Explanatory variables significantly associated with outcome as measured by mean psychosocial SIP score
Psychosocial SIP (week 4)
Variable
Study group
Length of ward stay
b (%)
0554 (554%)
0197 (197%)
P value
0001
0001
049
b (%)
0568 (568%)
0225 (225%)
P value
0001
0001
054
b (%)
0569 (569)
0222 (222)
P value
r2
0001
0001
048
P. Black et al.
Funding
The development of this research study was supported by a
nursing research studentship from the Research and Development office, Department of Health and Social Services.
Conflict of interest
No conflict of interest has been declared by the authors in
relation to the study itself. Note that Kader Parahoo is a JAN
editor but, in line with usual practice, this paper was subjected
to double blind peer review and was edited by another editor.
Author contributions
PB was responsible for the study conception and design,
performed the data collection, performed the data analysis,
was responsible for the drafting of the manuscript, and
provided administrative, technical or material support. PB,
JRB & AKP made critical revisions to the paper for important
intellectual content. JRB & AKP supervised the study.
References
Agard A.S. & Harder I. (2007) Relatives experiences in intensive
care finding a place in a world of uncertainty. Intensive and
Critical Care Nursing 23, 170177.
Alsaad J. & Ahmad M. (2005) Communication with critically ill
patients. Journal of Advanced Nursing 50(4), 356362.
Appleyard M.E., Gavaghan S.R., Gonzalez C., Ananian L., Tyrell R.
& Carroll D.L. (2000) Nurse-coached intervention for the families
of patients in critical care units. Critical Care Nurse 20(3), 4048.
Arend E. & Christensen M. (2009) Delirium in the intensive care
unit: a review. Nursing in Critical Care 14(3), 145154.
Barker Bausell R. & Li Y. (2002) Power Analysis for Experimental
Research: A Practical Guide for the Biological, Medical and Social
Sciences. Cambridge University Press, Cambridge.
Bay E., Kupferschmidt B., Opperwall B. & Speer J. (1988) Effect of
the family visit on the patients mental status. Focus on Critical
Care 15, 1016.
Bergbom I. & Askwall A. (2000) The nearest and dearest: a lifeline
for ICU patients. Intensive and Critical Care Nursing 16, 384395.
Bergeron N., Dubois M.J., Dumont M., Dial S. & Strobik Y. (2001)
Intensive Care Delirium Screening Checklist: evaluation of a new
screening tool. Intensive Care Medicine 27, 859864.
Bergner M., Bobbitt R.A., Kressel S., Pollard W.E., Gibson B.S. &
Morris J.R. (1981) The Sickness Impact Profile: development and
final revision of a health status measure. Medical Care 19, 787805.
Black P., McKenna H. & Deeny P. (1997) A concept analysis of the
sensoristrain experienced by intensive care patients. Intensive and
Critical Care Nursing 13, 209215.
Blondell R.D., Powell G.E., Dodds H.N., Looney S.W. & Lukan J.K.
(2004) Admission characteristics of trauma patients in whom
delirium develops. The American Journal of Surgery 187, 332337.
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