Critical Care Nurse. 2009;29: 46-52 doi:10.4037/ccn2009890
Copyright © 2009 by the American Association of Critical-Care Nurses.
Clinical Article
CE Article
Registered Nurses as Family Care Specialists in the Intensive Care Unit
Delores Privette Nelson, RN, BSN
Gerald Plost, MD
Delores Privette Nelson has worked in acute care for more than 30 years. She was a registered nurse data analyst for the adult intensive care units at St John Medical Center in Tulsa when this article was written.
Gerald Plost is the medical director of adult critical care services at St John Medical Center, Tulsa, Oklahoma.
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.
eLetters
Now that you’ve read the article, create or contribute to an online discussion about this topic using eLetters. Just visit www.ccnonline.org and click "Respond to This Article" in either the full-text or PDF view of the article.
dotmore
To learn more about families in critical care, read "The Vortex: Families’ Experiences With Death in the Intensive Care Unit" by Karin T. Kirchhoff et al in the American Journal of Critical Care, 2002;11:200-209. Available at www.ajcconline.org.
Financial Disclosures
None reported.
This article has been designated for CE credit. A closed-book, multiple-choice examination follows this article, which tests your knowledge of the following objectives:- Understand the role of the family care specialist (FCS) in the intensive care unit (ICU)
- Describe the duties of the FCS in the ICU
- Recognize the benefits of a FCS in the ICU
Corresponding author: Delores P. Nelson, RN, BSN, P. O. Box 140370, Broken Arrow, OK 74014 (e-mail: deloresprivettenelson{at}gmail.com).
Escalating needs of the families of critical care patients can overwhelm intensive care unit (ICU) staffing resources, contribute to occupational stress1,2 and turnover for nurses at the bedside, and markedly affect patients’ response to illness.3,4 As overburdened staff nurses try to meet the needs of both patients and patients’ families, a disparity may develop between desired and achievable nursing goals.1 For example, the distraction of trying to meet a family’s needs may slow critical patient care.
In 2000, requests by patients’ families for information not only about the patients but also for the families’ personal needs (eg, lodging) overwhelmed staff nurses in the adult ICUs at St John Medical Center, a tertiary hospital in Tulsa, Oklahoma. At the same time, telephone calls with requests for information on patients beset the managers of the ICUs. The pervasive mood of the adult critical care unit was chaotic and stressed, signifying a need for change. A need for improvement was further supported by the results of a family satisfaction survey, which indicated a number of areas in which the satisfaction of patients’ families was less than optimal. In response to this need, staff in the ICUs developed a new family-centered care program with 2 full-time positions for critical care nurses as family care specialists (FCSs). This change not only improved family care but also moved the culture5 of the ICUs from hectic to healing. Getting from the problem to the solution was, however, far from simple. In this article, we describe 5 basic steps the hospital took to develop a new family-centered program and explore the efficacy of the associated FCS positions.
 |
Development of the Program
|
|---|
Step 1: Identifying the Need
The results of a family satisfaction survey provided the first alert to a need for improvement in the adult ICUs. This initial indicator was also the first step in the development of a new program. The need for change was further supported by complaints of staff nurses in the adult ICUs of an increased workload burden. At least part of this heavier burden on staff was attributable to greater demands placed on them by family members of ICU patients.
Step 2: Information Gathering
The second step was information gathering related to strategies that would best serve the families of the adult ICU patients. Literature searches and perusal of medical journals by the interdisciplinary ICU management team, which consisted of the adult ICU medical director, nurse managers, a registered nurse (RN) data analyst, and other clinical staff as needed, were guided by the following question: What are best practices for meeting the needs of patients and the patients’ families and for satisfying global safety needs as well as the hospital’s needs? Information on hospital liaison positions in existence at that time was reviewed in addition to available data on family-centered care.
The top 10 needs from the Critical Care Family Needs Inventory (CCFNI)6 seemed to best address the diverse needs of the adult ICUs in the hospital. Items on a revised CCFNI are evaluated by using an ordinal scaling method that indicates which items are most important to patients’ families (Table 1
). The 45-item needs statement in the original CCFNI was later divided into 5 domains of need7: support, comfort, information, proximity, and assurance.
Step 3: Acquisition of Funding
The third step was acquisition of funding through administrative approval. This approval was facilitated through presentations by the adult ICU medical director, who discussed the results of the family satisfaction survey, staff complaints, evidence gathered on family-centered care, and a proposed initiative for family-centered care.2,7 The initiative appealed to the hospital administrators because of their commitment to excellence, and 2 new full-time positions were approved for FCS nurses, 1 position for the 20-bed medical ICU (MICU)/intensive cardiac care unit (ICCU) and 1 position for the 15-bed surgical ICU (SICU).
Step 4: Deciding Who Would Fill the Role
The fourth step was deciding which discipline should fill the new role of FCS. Historically, staff at the hospital viewed patients’ families as the province of chaplains, social workers, and other nonclinical staff; clinical staff provided care at the bedside for patients. However, the interdisciplinary ICU management team wanted critical care RNs to fill the FCS position8 because clinical knowledge and skills would equip the nurses to
- Communicate with a patient’s family about all aspects of the patient’s clinical problems, disease processes, treatments, and the ICU environment
- Act as liaison between patients’ families and other departments in the hospital and community
- Have proximity to and a special rapport with patients and the patients’ families
Although the ICU management team sought an evidence-based approach for this program, no previous documentation was found regarding RNs in this role. Placing an RN in this role was a proactive step made to meet the needs of patients’ families described in published reports.
Step 5: Developing a Foundation and Function
After funding was obtained, the ICU management team selected Molter’s research and the CCFNI6 as a foundation for the new family-centered care program. The team developed a family support protocol for the ICU (Table 2) that incorporated the top family needs from the CCFNI. This protocol remains an unchanged cornerstone for our current family-centered care program more than 5 years later.
Even though this protocol has not changed, methods used by the FCS nurses to meet the diverse family needs of the ICUs have expanded to include a multiplicity of family-focused interventions (Table 3) Over time, application of the protocol evolved to meet the needs of the populations of the individual units. The more advanced age and multiple disease processes of the typical MICU and ICCU patients necessitated a greater focus on end-of-life issues for those units. The FCS in the MICU/ICCU, who received training from the End-of-Life Nursing Education Consortium,9 became increasingly involved in situations of patients’ families during the time leading up to and even beyond the patients’ death. The SICU patients tended to be younger than those in the MICU/ICCU and had problems related to trauma and life-altering injuries. Therefore, the SICU FCS may be called upon to provide crisis intervention for patients’ families affected by trauma ranging from motor vehicle injuries to assault-related wounds. In addition, trauma patients in the SICU may need referral to drug treatment or other counseling services, a situation that further affects the patients’ families. In all instances, the FCS provides a vital link to adjunct services, such as social work, clergy, and self-care resources.
|
Expansion of the FCS Role
|
|---|
The ability to remain responsive to the needs of patients’ families and to ICU staff has been a pivotal ingredient in the long-term success of this family-centered care program. Functions of the expanded FCS role currently include planning, developing, and presenting educational programs for unit staff and patients’ families, including, but not limited to, programs about safety in the ICU for patients’ families, presentations on end-of-life issues for staff, and orientation to family care for new hospital residents. The FCS position is also a "hands on" role, so the FCS nurses occasionally supplement ICU staffing or staffing of the hospital’s rapid response team. Retaining an active role in the unit milieu helps maintain nursing skills and promotes a collaborative relationship with the staff nurses. The current FCS nurses provide leadership and education for individual ICU staff in the development of family care skills to help the staff after hours and on weekends when an FCS is not available.
|
Benefits of Having an FCS
|
|---|
Benefits to Staff Nurses
Although our ICU staff nurses did not initially anticipate any benefits from having an FCS other than the obvious advantages to patients’ families, the nurses were pleasantly surprised to find their workload lightened. Currently, each FCS is an appreciated staff member and enjoys the staff nurses’ enthusiastic support. Input was solicited from the hospital’s bedside ICU nurses about the efficacy of the FCS position. In a survey, MICU, ICCU, and SICU nurses were asked, "On a scale of 0 to 10, how likely would you be to recommend an FCS program to colleagues at another health care system?" The survey form also provided space for the respondents to indicate why they would or would not make a recommendation.
Of the 75 surveys handed out to nurses on both day and night shifts, 42 (56%) were completed. The combined responses from all units were overwhelmingly supportive, with no negative comments (Figure 1). The only comment with a possibly negative note concerned having an FCS routinely take patients on short-staffed days. This comment was offset by the overwhelming consensus that the FCS nurses consistently helped ease the work load (Table 4). The most frequent favorable remarks stated that although a patient might have a different staff nurse from day to day, the unit’s FCS provided a familiar face for the patient’s family. This continuity of care throughout a patient’s stay in the ICU was valued by the staff nurses. The staff nurses also valued the support provided by the FCS nurses for staff as well as for patients’ families. Having an RN as the FCS was seen as essential by the staff nurses.
View larger version (41K):
[in this window]
[in a new window]
|
Figure 1 Results of survey to assess nurses’ satisfaction with the family care specialists. Satisfaction was rated on a scale of 1 (least likely to recommend the program to another facility) to 10 (most likely to recommend the program to another facility).
|
|
Benefits to the Hospital
Among the benefits to the hospital was receiving the 2006 Family-Centered Care Award10 of the Society of Critical Care Medicine. This award recognizes innovations that improve care provided to critically ill and injured patients and their families (or designates). Applicants for the award are evaluated for their link to direct patient care, for raising the standard of family-centered care, for the ability to demonstrate innovation, and for the ability to be a model for emulation. Applicants must provide evidence of comprehensive services and interdisciplinary efforts to improve care for patients’ families in the ICU. Applicants must also foster support for families of critically ill patients that are meaningful to the families and must include patients’ families in the provision of care to critically ill patients, including end-of-life care.
Benefits to Patients
In addition to a higher level of satisfaction with care among family members of ICU patients (Figure 2), the complex end-of-life issues identified by the FCS nurses inspired creation of a separate palliative care consultation service (PCCS), which benefits adult patients throughout the hospital. Initiated by an FCS, the PCCS branched into an entirely separate program in 2004. This rapid-response consulting service offers adult patients access to a multidisciplinary team of palliative care specialists and is available to all adult hospital inpatients regardless of the patients’ location. The team is led by a physician specializing in palliative care and includes a full-time RN, a part-time RN, a social worker, and a chaplain, all extensively trained in palliative care. The PCCS provides services in conjunction with the attending physicians’ curative efforts and, unlike hospice care, is not limited to patients who are terminally ill. With the focus on relieving physical, psychosocial, and spiritual suffering, the goal of the PCCS is to help patients maintain the best possible quality of life.
|
Conclusion
|
|---|
Escalation of ICU family needs will most likely continue as the population ages. An estimated 80% of the population of the United States will experience an ICU during their lifetime, as a patient, a member of a patient’s family, or a friend of a patient.11 The stressors produced by the ICU experience can severely challenge not only patients and their families but also health care providers. The RNs in the role of FCS met a critical need at St John Medical Center, and our results suggest a method of coping with the escalation of family needs in other ICUs. This innovative RN position exemplifies our belief that nursing care should be a force for medical excellence and compassionate care for patients’ families as well as for patients.
|
PRIME POINTS
|
|---|
- Emergent needs of families of critically ill patients can overwhelm hospital staff and distract from care of the patients.
- To meet the needs of patients’ families, staff developed a family-centered care program in which critical care nurses act as family care specialists.
- Family care specialists provide a familiar face for patients’ families and ease the workload of health care staff.
- Identification of end-of-life issues by family care specialists inspired creation of a palliative care consultation service.
|
References
|
|---|
- Stayt LC. Nurses’ experiences of caring for families with relatives in intensive care units. J Adv Nurs. 2007;57(6):623–630.[CrossRef][Medline]
- Leske JS. Family stresses, strengths and outcomes after critical injury. Crit Care Nurs Clin North Am. 2000;12:237–244.[Medline]
- Miracle VA. Strategies to meet the needs of families of critically ill patients. Dimens Crit Care Nurs. 2006;25(3):121–125.[CrossRef][Medline]
- Medina J. A natural synergy in creating a patient-focused care environment: the Critical Care Family Assistance Program and critical care nursing. Chest. 2005; 128(3 suppl):99S–102S.[Free Full Text]
- Damboise C, Cardin S. Family-centered critical care: how one unit implemented a plan. Am J Nurs. 2003;103(6):56AA–56EE.
- Molter NC. Needs of relatives of critically ill patients: a descriptive study. Heart Lung. 1979;8(2):332–339.[Medline]
- Leske JS. Overview of family needs after critical illness: from assessment to intervention. AACN Clin Issues Crit Care Nurs. 1991;2(2):220–229.[Medline]
- Coulter MA. The needs of family members of patients in intensive care units. Intensive Care Nurs. 1989;5(2):4–10.[CrossRef][Medline]
- International Efforts to Implement and Disseminate ELNEC. End-Of-Life Nursing Education Consortium Web site. https://www.aacn.nche.edu/ELNEC/Global.htm. Updated May 2008. Accessed March 3, 2009.
- Family-centered care award. Society of Critical Care Medicine Web site. http://www.sccm.org/Membership/Awards/Pages/PreviousRecipients.aspx. Accessed March 3, 2009.
- Dowling J, Wang B. Impact on family satisfaction, the Critical Care Family Assistance Program. Chest. 2005;128(3 suppl): 76S–80S.[Free Full Text]
Top
Development of the Program
Expansion of the FCS...
