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JAN

JOURNAL OF ADVANCED NURSING

ORIGINAL RESEARCH

The effect of nurse-facilitated family participation in the psychological


care of the critically ill patient
Pauline Black, Jennifer R.P. Boore & Kader Parahoo
Accepted for publication 27 July 2010

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

B L A C K P . , B O O R E J . R . P . & P A R A H O O K . ( 2 0 1 1 ) The effect of nurse-facilitated


family participation in the psychological care of the critically ill patient. Journal of
Advanced Nursing 67(5), 10911101. doi: 10.1111/j.1365-2648.2010.05558.x

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

critical illness has been the focus for international nursing


research and the experiences of patients from the United
States, Scandinavia, Asia and Europe demonstrate many
similarities (Bergbom & Askwall 2000, Granberg-Axell et al.
2001, Engstrom & Soderberg 2004, Alsaad & Ahmad 2005,
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P. Black et al.

Hofhuis et al. 2008). Some patients become agitated and


confused; others successfully disguise their distress and are
wary of confiding in family members or nurses. Experiencing
and observing these disturbances can distress and alarm
patients and families, and can impact negatively on recovery
outcomes (Gardner & Sibthorpe 2002, Chaboyer & Grace
2003).
The nursing response has been to explore the needs of
critically ill patients to identify interventions that might be
integrated into psychological care (Hupcey 2000, Price
2004). These include improving nurse communication with
patients (Scott 2004) and recognizing the needs of families to
be involved in patient care (Hupcey 1999). Whittemore and
Grey (2002) suggest that nurses have a responsibility to
provide quality interventions, which produce positive patient
outcomes. This requires the testing of interventions developed
for such patients and families (Rattray & Hull 2007).

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.
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2008). Sensory disturbances were discovered by Blondell


et al. (2004) and Wesley-Ely et al. (2004) to increase length
of ICU and ward stay. To date, there has been no research on
the effect of psychological intervention on length of ICU or
ward stay.
The concepts of Neumans system model provide the
framework for the design of this study. Individuals interact
with and adjust to their environment while being protected
by lines of defence and resistance (Freese 2002). This
dynamic state ensures that equilibrium is maintained when
confronted with a stressor. Normal physiological lines of
defence are violated during critical illness by stressors such as
sedation, ventilation and the patients attempts to make sense
of what is heard and seen in an unfamiliar environment. This
process has been described as sensoristrain by Black et al.
(1997), and produces behaviours and emotions such as
anxiety, fear and loss of control and self concept, typified in
Neumans system model as reactions to stressors and in the
literature as delirium.
Neumans model offers a tripartite framework for nursing
interventions. If commenced as soon as possible on admission
to ICU, nurse-facilitated family participation in psychological
care could represent a primary prevention designed to assist
patients to interpret their environment accurately. This has
the potential to strengthen their lines of defence against
violation by psychological stressors, thus minimizing reactions such as confusion, hallucinations and distress described
in the literature. If used remedially to reduce reactions once
these are observed in the patients behaviour, nurse-facilitated family participation in psychological care could also
reflect secondary prevention. For the purposes of this study,
the intervention has been designed to be implemented as soon
as possible after admission and is thus conceptualized as a
primary prevention. This is because the sedation and analgesia usually administered to patients in the early stages of
admission to ICU could potentially mask accurate assessment
of reactions and could delay implementation of any intervention designed as a secondary prevention. Outcome measures used in this study include signs of delirium (indicating
reactions to stressors) and psychological recovery patterns
over time, including physical recovery, length of stay in ICU
and in hospital (all signs associated with the strength of the
lines of resistance and defence).

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
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JAN: ORIGINAL RESEARCH

(Hupcey 2000). Empirical evidence has demonstrated that


the need to be with the patient is important to families.
Research has shown that flexible visiting meets family needs,
reduces anxiety and increases satisfaction (Appleyard et al.
2000, Giuliano et al. 2000, Lee & Lau 2003).
Family members have established communication patterns
which could be used to reduce the psychological stress
experienced by their loved one. Research from Scandinavia
and the United States into the needs of families from a diverse
range of cultures supports the inclusion of the family when
caring for patients who are critically ill (De Jong & Beatty
2000, Bournes & Mitchell 2002, Agard & Harder 2007,
Dreyer & Nortvedt 2007). Relatives were found to want to
be included as caregivers seeing this as an opportunity to
use their knowledge of the patient to support nurses. In
recognition of this, the intervention of nurse-facilitated
family participation in psychological care was designed to
use the unique communication skills of each family by
providing them with an opportunity to interact with critically
ill patients in a structured and meaningful way.
The intervention was designed to address stressors emanating from the unfamiliar environment of an intensive care unit
where sounds and activity could be perceived as threatening.
Hearing a familiar voice could provide security and orientation resulting in a reduction in perceived stress from audible
and visual stressors experienced by patients when both sedated
and conscious. Reports of patient recollections of critical care
experiences have revealed information that patients would
have appreciated hearing from family and friends. This was
seen as a way of maintaining contact with reality while
critically ill. This evidence was used to develop practical
guidelines, which were printed in a booklet given to families
who participated in the study. Suggestions were offered on
how to tailor the information to the patients unique interests
and lifestyle. The intervention consisted of family members
putting this advice into practice during visits to the patient.
The nurse at the bedside facilitated the intervention by
ensuring family access and comfort during visits to encourage
verbal and physical interaction between family and patient.
See Figure 1 for details of the intervention protocol.

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

Nurse-facilitated family participation in psychological care


Stage 1 Prior to study commencement
Development of a booklet containing information about delirium and a step by step
guide to providing psychological care to the patient through use of communication
skills based on the literature available (including the type of information the patient
might want to hear, how to talk to the patient, advice where to sit or stand at the
bedside and how to open and close the interaction, suggestions were made to read
out any cards or messages from friends or family and to talk about the topics they
knew held interest for the patient).
Stage 2 Day 1 (patient admitted to ICU)
Researcher or nurse to provide next of kin with a verbal and printed introduction to
the study and the booklet. Verbal and written information about the intervention and
how and when to use the strategies outlined in the booklet was provided.
Stage 3 Day 2 to transfer to ward
Nurse facilitation nurses actively to seek opportunities to promote family access
to patient by effective planning of routine care and dressings to avoid visiting time,
maximising the time available for families to be with the patient and ensuring that
comfortable seating was available at the bedside. When families were with the
patient, nurses were to verbally encourage them to interact by talking and holding
the patients hand. This verbal encouragement was to be given only once during
each visit.
Family participation families were responsible for implementing the advice in the
booklet, using the suggestions to individualise the content of their interactions to
the unique needs of the patient.

Figure 1 Details of the intervention protocol.


collection of pretest data on day 1 to determine whether
group characteristics were similar. The risk of inadvertent
cross contamination of the groups was reduced by recruiting
and collecting data first from the control group and then from
the intervention group prior to and following implementation
of the intervention. The incorporation of a time series
allowed measurement of the effect of time on the outcomes
of the intervention.
Data collection took place wherever patients were being
cared for at the time following an assessment of the patients
condition and ability to respond. Both groups received the
normal treatment provided to the critically ill patient in ICU,
and had family visits according to unit policy, but the families
of patients in the intervention group implemented the
intervention during visits.

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
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P. Black et al.

New patient
admitted to ICU

Does the patient


meet inclusion
criterion?

Yes

Commence data
collection based
on first 24 hours
of admission

No

Data collection
Patient not included

Provide family with study


details and invitation to
participate during their
first visit to the ICU

Researcher discusses
study with family,
ascertains decision
regarding consent

Is consent
provided?

No

Yes

Data collection stopped


and paperwork
destroyed

Data collection
continued for 12 weeks
pending patient
consent and survival

Figure 2 Flowchart illustrating the recruitment protocol for both


groups.

families were eligible from which 170 participated, 83


patients and families in the control group and 87 patients
and families in the intervention group. Thirty-two patients
died during data collection. Full data were collected from 138
patients and families, 69 patients and families in the control
group and 69 patients and families in the intervention group.
Sample size can be calculated using the results and effect
sizes achieved in studies with a similar focus and design. Bay
1094

et al. (1988) carried out a study to measure the effects of


family visits on patient mental status, but only descriptive
statistics were reported and no significant effect was measured. In the absence of an evidence-based effect size, tables
cited by Polit and Hungler (2002, p. 484) and power values
recommended by Barker Bausell and Li (2002) were used to
establish that a completed sample of 63 patients was required
for each of the two groups using P 005 as the level of
significance, an estimated intermediate effect size of 050 and
a power of 080.

On days 17 and on day 14, physiological data were collected


from patients in both groups. Severity of illness and delirium
scores were also calculated. These data were recorded at
20:00 hours and were based on the previous 24 hours of
monitoring. At 1, 2 and 3 months postadmission to ICU,
psychological recovery was measured.
Data collected on day 1 of admission to ICU served as a
comparative baseline measurement for both groups. While a
single pretest measurement is unusual, it was justified in this
study as it was designed to allow preintervention betweengroup equivalence to be established. Physiological data and
severity of illness scores were utilized as descriptors of the
two groups in the study.
Physiological data
Demographic details, reasons for and dates of admission to
ICU were recorded. Heart rate and blood pressure were
recorded from cardiac and invasive or non-invasive monitoring. Spontaneous respirations were recorded manually;
breaths delivered by mechanical ventilation were recorded
from ventilator monitoring screens. Body temperature was
measured tympanically. Routine blood test and arterial blood
gas analysis results were recorded if carried out. Details of the
type and amount of analgesia, sedation and muscle relaxants
administered to each patient were listed. If the patient was
not receiving an intravenous infusion, the drug, timing and
amount of the most recent bolus dose was recorded with the
total received during the previous 24 hours.
Severity of illness
Used as a means to classify critically ill patients (Pirret 2002),
the TISS-28 assumes that increasing severity of illness results
in the patient requiring more therapeutic interventions and
this is reflected in a higher score (maximum score is 60). The
tool was developed by Miranda et al. (1996) following
comprehensive review of the original TISS-76. Cross validation of TISS-76 and TISS-28 scores was carried out (r = 096).
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JAN: ORIGINAL RESEARCH

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
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Nurse-facilitated family participation in psychological care

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

Figure 3 Summary of data collection procedures.

control group. In the intervention group pilot, a comment


from two families that the information in the booklet would
have been useful at the start of admission prompted a change
to the research protocol allowing the study information and
booklet to be given to families on admission to the unit rather
than wait until the researcher was present. Data collection for
the main study commenced in January 2004 and was completed in December 2005.
Ethical considerations
Approval to conduct the study was granted by both the
university and hospital research ethical committees. Families
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P. Black et al.

were provided with an oral and written description of what


participation would involve and were invited to discuss any
perceived risks or benefits with the researcher prior to consenting. They were informed that they could withdraw their
participation at any time without affecting the care provided
to them or the patient. Confidentiality of collected data was
assured. Written informed consent was obtained from the
families following admission and then from the patient when
assessed as alert and orientated.

stay and TISS-28 scores on days 1 and 7, and SIP scores at 4,


8 and 12 weeks. The difference in length of ICU stay for
elective surgery patients in both groups was not significant.
Comparisons in length of ward stay and TISS-28 scores on
day 1 and 7 also showed no significant differences. This
indicates that despite the differences in numbers of emergency
and elective surgical admissions, all patients experienced
equal severity of illness on admission and at day 7, and
comparable length of ICU and ward stay.

Data analysis

Length of time spent in ICU and on the ward

The data were explored and analysed using SPSS version 12


(SPSS Inc., Chicago, IL, USA). Descriptive statistics were used
to illustrate the characteristics of patients in both groups.
Histograms and Q-Q plots were used to confirm normal
distribution. Independent sample t-tests were used to compare the mean values between groups. To avoid the risk of
finding a statistically significant result by chance through the
use of multiple t-tests, significant results (P 005) were
corrected using the Bonferroni adjustment (Stevens 1996)
which indicated the use of a higher threshold of significance
(P 0001) based on the use of 35 t-tests.
The strength of the association between variables was
measured using eta2. This was used to assess the effect of the
intervention on outcomes. Standard multiple regressions were
used to explore the association between the explanatory
variables and outcomes.

In the control group, the length of ICU stay ranged from 3 to


96 days (mean 1531 days) and in the intervention group, the
length of ICU stay ranged from 2 to 47 days (mean
1015 days). Although the intervention group had a shorter
ICU stay, the difference was not significant. There were no
significant differences in the groups length of stay in hospital
following critical illness.

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.
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Nurse-facilitated family participation in psychological care

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).

outcome measures. Length of stay in ICU and ward may also


have been associated with outcomes prolonged admissions
indicating a complicated recovery. Receiving psychological
care from family during visits may also have had an impact
on outcome (study group). Explanatory variables entered as
possible predictors were length of ICU stay, length of ward
stay, TISS-28 scores on days 1 and 7, ICDSC scores on days 1
and 7 and study group. The mean total SIP scores at 4, 8 and
12 weeks were considered as outcomes.
Of the variables entered as potential predictors, length of
ICU stay, length of ward stay, mean TISS-28 scores on day 7
and receipt of the intervention (study group) made a
significant contribution to the equation (P 005). Length
of stay on ward and receipt of the intervention (study group)
were the most consistent predictors of mean SIP scores at
each time-point (Table 1).
To explore this further, the tests were repeated using the
mean physical and psychosocial categories of the SIP
scores as separate outcomes and study group and length of
ward stay as the explanatory variables. It became clear that
the length of stay on the ward following critical illness made
the strongest contribution to mean physical category scores
(Table 2), and that receipt of the intervention (study group)
made the strongest contribution to psychological recovery as
measured by the mean psychosocial category scores
(Table 3). This indicates that patients who received the
intervention demonstrated more positive psychological outcomes than patients in the control group.

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)

SIP (week 12)

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)

Physical SIP (week 8)


2

P value

0001
0001

036

b (%)
0293 (293)
0531 (531)

Physical SIP (week 12)


2

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%)

Psychosocial SIP (week 8)


2

P value

0001
0001

049

b (%)
0568 (568%)
0225 (225%)

degree of similarity between groups was established by


comparisons of demographic characteristics and day 1
physiological data and TISS and ICDSC scores, which indicated no significant differences. It was also difficult to control
for coping strategies developed by patients and families as a
result of previous life experiences. The generalizability of the
findings to other settings may be limited as the study took
place in a seven-bedded general medical-surgical ICU.
Intervention procedures
The details of the intervention protocol were supplied to all
participants in printed format. This presupposed literacy and
although verbal explanations of the intervention procedures
were given by both the nurse and researcher, this may not
have been retained by families preoccupied with the stress of
the situation and may have resulted in inconsistency. The
researcher also had no control over how individual families
implemented the intervention they may have adapted the
advice or introduced new intervention behaviours.
The researcher had no control over the quality of nurse
facilitation of the families as they participated in psychological care, although all nursing staff on duty during
intervention group data collection received education on
facilitation. The quality of facilitation was dependent on
individual nurses professional commitment to involving the
families. Care for unstable patients took priority over
intervention procedures and as a result, families of less
critically ill and dependent patients may have received more
facilitation.

Incidence of delirium in ICU


Although the results showed that fewer patients in the
intervention group scored 4 or more on the ICDSC, signif1098

Psychosocial SIP (week 12)


2

P value

0001
0001

054

b (%)
0569 (569)
0222 (222)

P value

r2

0001
0001

048

icant differences were not demonstrated. This means that


there was no evidence to suggest that family participation in
psychological care reduced the incidence of delirium in
patients during their stay in ICU.

Psychological recovery following critical illness


Comparison of the mean total SIP scores provided evidence
that patient assessment of physical and psychosocial functioning up to 12 weeks after admission to ICU was influenced
by the length of stay, both in ICU and on the ward following
ICU and by receiving the intervention. The total SIP score
measures both physical and psychological aspects of recovery
and as psychological recovery was the specific area hypothesized to be influenced by the intervention, it was important
to consider each area of recovery separately. Nurse-facilitated
family participation in psychological care was associated
with more positive patient appraisal of psychosocial recovery. This finding supports the hypothesis that the intervention
would result in improved psychological recovery following
critical illness.
These results imply that the intervention, provided during
the patients stay in ICU, remained effective for up to
12 weeks. Investing in the intervention during the acute
phase of the illness provides significant long-term benefits for
patients. As family members were involved during the ICU
stay, it is possible that they continued to use the communication skills practised there during the remainder of the
hospitalization and after discharge. This may have enhanced
the intervention effect. The support provided by the families
may help patients to come to terms with their illness and
adjust to their recovery lifestyle. Johansson et al. (2002)
identified the provision of such security and support as an
important aspect of family caring that should be encouraged
 2011 The Authors
Journal of Advanced Nursing  2011 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH

What is already known about this topic


Critical illness can cause profound physical and
psychological stress for patients and families.
The effects of this stress on patients, as observed in their
behaviour, are best described as delirium.
Family members need to be involved in understanding
and participating in the care of the patient.

What this paper adds


Psychological stress, evidenced by delirium, can be
experienced by patients regardless of the degree of
severity of illness.
Receiving psychological care from family members does
not reduce the assessed incidence of delirium while in
ICU.
Patients who received psychological care from family
members demonstrated improved psychological
outcomes at 412 weeks postcritical illness.

Implications for practice and/or policy


Nurses in intensive care need to be enabled to appreciate
and facilitate the involvement of families in providing
psychological care.
Policies of care need to be developed to allow a focus on
the involvement of families in care.
Further research is needed to explore the effectiveness of
other forms of family involvement in care.

in nursing practice. Implementation of this intervention may


facilitate that process.
The use of the Neuman Systems Model was demonstrated
to be of value in explaining the relationship between
stressors causing reactions symptomatic of delirium and
the use of the intervention as primary prevention. Nursefacilitated family participation in psychological care was
implemented prior to patients demonstrating reactions
symptomatic of delirium and the results demonstrate effectiveness in maintaining the strength of lines of defence and
resistance ensuring stability up to 12 weeks after onset of
critical illness.

Implications for practice, education and further research


Consideration should be given to the routine use of a
screening tool such as the ICDSC in ICUs to allow the timely
identification of patients who are experiencing delirium. In
 2011 The Authors
Journal of Advanced Nursing  2011 Blackwell Publishing Ltd

Nurse-facilitated family participation in psychological care

association with this, the practice of nurse-facilitated family


participation in psychological care should be encouraged
during critical illness. This will be dependent on the development of family friendly visiting policies that facilitate
patient and family interaction. For practice to develop, the
role of family members as they visit and participate in care
needs to be clarified and accepted within ICU philosophies
and policies.
The skills required to assess and identify patients experiencing delirium and the knowledge required to implement
appropriate nursing interventions need to be addressed
during preregistration education and during postregistration
critical care programmes. Education on the valuable therapeutic contribution families may make to the recovery of
patients should also be given wider recognition at all stages of
nurse education.
The process of testing the effectiveness of the intervention has raised questions for further research to address,
including the need for a randomized study to assess the
effectiveness of the intervention under more controlled
circumstances. Alternative forms for presentation of intervention information could be explored. Verbal and printed
material proved effective in this study, but investigation
into the use of audiovisual formats such as CD-ROM or
DVD could potentially increase effectiveness by communicating in a more relevant way to families, and could
overcome any literacy obstacles. There could have been
implications for patients whose family could or would not
participate as these patients may be more at risk of
psychological stress resulting in delirium. Consideration
must also be given to the different strategies required to
implement the intervention with patients who have no
family to be involved in their care. Alternative interventions could be explored. Family involvement in physical
care and discharge planning, to facilitate coping on
discharge, are both potential areas where interventions
could be developed. Qualitative studies could examine
family perceptions of being involved in care and the effect
of involvement on the coping strategies used by families
and patients. Further research is also required to expand
understanding of how nurses can support family involvement in ICU care.
Critical care nurses must not be solely concerned about the
provision of optimal physical care to the patient. Each patient
needs holistic care that is integrated into the family unit
where appropriate (Roberts et al. 2007). In recognition of the
fact that the ICU experience can be extremely stressful for
patients and their families, nurse-facilitated family participation in psychological care can be shown to improve patients
perceptions of psychological recovery.
1099

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.

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