research article

Reception by Brazilian Nurses to Relatives of Adult Patients hospitalized in Intensive Care Units

Danilo Lima Ceccon, Christian Marx Carelli Taets, Gunnar Glauco de Cunto Carelli Taets*

Integrated Health Research Group, School of Nursing, Federal University of Rio de Janeiro Campus Macaé, Brazil

*Corresponding author: Gunnar Glauco de Cunto Carelli Taets, School of Nursing, Federal University of Rio de Janeiro Campus Macaé, Rio de Janeiro, Brazil. 1133 Boiuna Road 57, Rio de Janeiro, 22723-021, Brazil. Tel: +5521980375799; Email:

Received Date: 18 July, 2018; Accepted Date: 26 July, 2018; Published Date: 01 August, 2018

Citation: Ceccon DL, Taets CMC, Taets GGDCC (2018) Reception by Brazilian Nurses to Relatives of Adult Patients hospitalized in Intensive Care Units. Int J Nurs Res Health Care: IJNHR-129. DOI: 10.29011/ IJNHR-129. 100029

1.       Abstract

This is an integrative review with a qualitative approach that aimed to describe the reception by Brazilian nurses to relatives of adult patients admitted to Intensive Care Units (ICUs). We searched the databases of the Virtual Health Library, and a content analysis was done for the data treatment. Results: Two main analytical categories were established: Identifying the needs and feelings of family members; and the second: Providing guidance and information to family members of the latter, two subcategories emerged: Providing information and guidance to family members on the routine and the functioning of the sector and its machinery; and providing information and guidance to family members about the patient. Conclusion: the reception developed by Brazilian nurses to the relatives of adult patients hospitalized in ICUs is based on the identification of their needs and feelings in health education regarding clear and objective information and guidelines on the routine functioning of the unit and its technological complexity and also about the patient himself, especially regarding the clinical picture of the patient using a simple language easily understood by relatives.

2.       Keywords: Family; Intensive Care Units; Nursing; Reception

1.       Introduction

The family is one of the oldest institutions in the world and has undergone changes in its composition over the years. Despite all the changes that have taken place in society, the family is still the mother unit in which individuals grow and develop [1]. The Family-Centered Model of Care can provide support for strengthening the family, stimulating its potential and promoting its empowerment [2]. However, we find through the literature that between theory and practice of making families the object of care there is a long way to go. According to a study developed by nurses at a Neonatal Intensive Care Unit (NICU) in 2004 in the city of Curitiba, Paraná, Brazil, with families of newborns hospitalized, relatives report that they do not receive care, care only to newborns [3]. The nurse must also direct his or her care to the family, since it is considered a professional that in its essence takes care [1]. For the professional to make the family an axis of his care is necessary to understand it, and this is done through much effort and dedication. Understanding the family is not a simple process, because each one is unique [3]. It is necessary that the nurse knows the reactions, feelings, meanings, customs and ​​of each of the families of people who are in their care, such families suffer socio-cultural influences, and it is up to the professional to respect them, even if most of the time do not understand them.

The families of people who are hospitalized in health facilities are often sensitive and fragile, especially when their affections are being treated in ICUs, since many understand the high complexity care units as a place that precedes the patients' death. The prospect of death increases tension, insecurity and vulnerability [4]. The nurse as care manager in the health team needs to be able to recognize the situations that threaten the autonomy of the family and act in a way to guarantee a relationship of subjects in which the ethical criteria of autonomy, beneficence and justice are guaranteed. This requires that the family care model move forward in order to include the family as the participant agent of care, making it stronger and able to take care of one's own problems and decision-making [4]. Recognizing the importance of taking the family as an integrative part of nursing care is to assume professional sensitivity. For the family it is disturbing to encounter a discrepancy between their own emotional turmoil and the insensitivity of professionals [2].

Nursing, especially nurses, needs to develop skills so that they can assess the intensity of the problem that family members are facing and how this problem interferes with their daily lives. Only then can you plan and implement efficient and resolute actions, acting in an integral way, interacting with families, supporting teaching and meeting the needs of each one. Finally, family-centered care is seen as an approach that ensures the participation of all in the planning of actions, offering an innovative way of care, giving the family the opportunity to define its problems. The family member whose affection is hospitalized in an ICU can present himself emotionally shaken with fear of what can happen, and most of the time he seeks the professionals, especially the nursing ones, for being with the patient most of the time, the support needed to confront this moment. This study aimed to describe the reception of Brazilian nurses to relatives of adult patients admitted to Intensive Care Units (ICUs). The discussion of care is part of the routine of nursing, this is the profession that definitely has people in their care most of the time, however, most often the action of caring is thought and planned only for the patient. The patient's family presents need and needs to be placed more frequently within the health setting as an object of care, so the practitioner is expected to understand that he has no responsibility only to the person being cared for, with the family of this individual.

2.       Method

This is an integrative review with a qualitative approach, where exhaustive searches were carried out in the databases of the Virtual Health Library (VHL), Scientific Electronic Library Online (SCIELO), Nursing Databases (BDENF), Latin American Literature (LILACS) and the Medical Literature Analysis and Retrieval System Online (MEDLINE), with Brazilian publications from 2005 to 2017, using the descriptors: Family, Reception, Units of Intensive Care, Nursing and the Boolean connector and that are included in the Descriptors in Health Sciences (DECS) of the VHL.

The criteria for inclusion of the articles were: complete article, available electronically and free of charge in the mentioned databases, with publication date between the years 2005 and 2017, in Portuguese, that had been developed in an intensive care unit directed to the adult population, and written by Brazilian nurses aiming to meet the objective of this study. The articles that did not comply with the inclusion criteria and which were repeated were excluded from this integrative review. In the initial search, 33 articles were found, however, after reading the abstracts, only 10 were included in this study, and after reading the articles, three articles that did not meet the objective of this research were excluded. Thus, seven articles were selected to be part of this review. To analyze the material, a content analysis was made with the emergence of the following categories: Identifying the needs and feelings of family members; and information and guidance to family members. From the latter, two subcategories emerged: information and guidance to family members about the patient, and information and guidance to family members about the routine and functioning of the sector as well as their machinery.

3.       Results and Discussion 

Regarding the analysis and discussion of the data, the seven articles that were part of this integrative review pointed out aspects of reception to the relatives of people hospitalized in ICU, such as: identification of the needs and feelings of family members, as well as the provision of information and guidance to them; in all the articles consulted, the authors ratified the importance of nurses being involved in fostering families by developing the aforementioned aspects, thus enabling a more humanized nursing care and valuing the family as part of care.

3.1.  Identifying the Needs and Feelings of Family Members

The relatives of people hospitalized in the ICU most of the time are fragile and afraid of the new reality, so it is up to the professional who is familiar with the environment to receive and give all the necessary support to these, making it necessary to understand the patients and families that are entering the intensive care setting. During this study, it was highlighted as an important tool for the ICU reception to identify the needs and feelings of the families, to ratify this fact we mention that the nursing team has the function of identifying the real needs of the relatives [5]. A study carried out by nurses at an adult ICU in the city of São Paulo, Brazil, between 2011 and 2012, pointed out the nursing visit at the time of admission as a key for establishing bonding and identifying the feelings and needs of families, stressing the importance of the nurse to receive the patient's family member, at this moment, it is important for the nurse to present himself and make himself available for what the family member deems necessary, in this way, the same will feel more willing to express their feelings [6]. In order to serve the family as people who express feelings such as sadness, impotence, despair and anguish, nursing professionals need to put themselves in their shoes [5].

In a study conducted by Brazilian nurses in an adult ICU in 2008 in a city in the South of the country, the conclusion is that dialogue is the main strategy for nurses to develop the family's perception of their needs and feelings. In the ICU, it is necessary to opportune the dialogue, with a view to building the reception in this critical situation, thus providing the sharing of needs and emotions [7]. Still, with the aim of stimulating dialogue between family members and professionals, two articles analyzed value the creation of moments where families can exchange experiences about how they are experiencing a loved one being cared for in an intensive care unit. One of them used as a tool to structure such a moment, the creation of a waiting room, and the other emphasizing the aspects of the work of a support group [5,8]. This makes family members feel more confident about the situation they are experiencing. Waiting rooms most often are shorter moments that precede the time of the visit usually happening every day, since the support groups are mostly longer lasting and happen once a week, each with its specific features are pointing to this moment of construction, respect, and listening to professionals and family members. The sense of solidarity present in many of the relationships between the families of critically ill clients in the waiting room should serve to guide working relationships and relationships with families who are in dire need of support. For family members, participation in a group of people living in similar situations can be an experience of therapeutic value, both through the support received from other participants and the opportunity to share their own experience and support others [8]. 

We then note that strategies such as the nursing visit at the moment of admission of the patient in the ICU, and the valuation of the dialogue using tools such as waiting rooms and support groups, will contribute to the nurses being able to understand the needs and feelings of the families, helping in the moment of their decision on how to structure the moment of reception so that it meets the expectations and desires of the people who are in their care and of their relatives. During the realization of this integrative review, they were pointed out as the main feelings and needs expressed by the families: anxiety; fear of the unknown; anguish; sadness; need for communication with the professional working in the ICU; information needs; and the need for flexibility when visiting. Some of the needs pointed out by relatives may be linked to hospital routines, such as flexibility in the time of the visit, so it will be up to the professional to take care that the protocols and routines are appropriate to the reality of the people he is caring for, favoring adequate and safe housing for families. A pointed need that deserves to be highlighted was that the nurse accompanies the family member on the first visit to their affection, such a moment may be disturbing for many, because total ignorance causes fear and negatively reflects on the act of welcoming.

The needs of family members are identified by situations or events of a physical and emotional nature, which can be experienced by having loved ones with a serious and unexpected illness hospitalized in the ICU. These needs can be exemplified by situations or events such as: knowing who can give information about the family member, feeling that there is hope for improvement, knowing what medical treatment is being given, and having general guidelines about the ICU at the first visit [6]. Identifying the needs and feelings of the relatives of ICU patients involves knowing the way these family members are facing hospitalization, seeking to understand their concepts and beliefs, thus building an individualized nursing care centered on the family. 

3.2.  Information and Guidance to Family Members 

Many are the questions of relatives who have their loved ones hospitalized in units of high complexity, especially those who have never experienced such a situation, the strangeness of the place comes before fear, and for many this experience can become more traumatic than it already seems to be. The questioning of family members pervades the clinical picture of their affection being cared for in the unit and its functioning in all its physical and emotional aspects. To answer these questions, it was noticed during data analysis that nurses have been making use of several tools. This category of analysis gave rise to two other subcategories: information and guidance to family members on the routine of the sector and on technology; and information and guidance to family members about the patient. 

3.3.  Information and Guidance to Family Members about the Industry Routine and about Technology

One of the nurses' strategies developed during this integrative review was the provision of clear and objective information to the family members about the routine of the intensive care unit and the technologies that comprise it. In order to develop this action, nurses create strategies. During the research, it was pointed out that it is necessary for the nurse to prepare the relative to enter the ICU especially when it is his first visit. One of the ways in which families can be used for such a time would be to familiarize them with the environment through some of the main strategies, such as: the use of information leaflets during waiting rooms, the encouragement of family members' support groups, in addition to the post-admission moments of the patient in the ICU where the families are oriented, and also the bedside, associating the strategies to obtain success in the passage of information. 

 Also, with a view to better information and guidance, one of the studies that compose this analysis highlights the use of information leaflets about the care process, the definition of some technical terms and interventions, as well as the physical and organizational structuring of the ICU, as factors that may aid in the communication process between the team and the family [6]. Many family members may find themselves stuck when they enter the environment where their loved one is receiving high complexity care, this tension may make them feel unwilling to question and often argue in the face of such a situation they cannot formulate and organize their doubts, the brochure strategy comes to collaborate on this issue, allowing families and professionals a more effective communication, where through the explanation given by the professionals about the information contained in the brochure, families can have a greater organizational capacity between their desires and their doubts, thus enabling nurses to better capture their needs, planning and directing their care.

Corroborating with the data obtained during this research, recognizing the use of information leaflets as a reception tool that nurses develop with relatives of patients hospitalized in an adult ICU, we cite that the adopted host strategy of distributing and presenting an explanatory leaflet about the ICU in the waiting room (with short information, with simple language, large letters, using colored figures) was evaluated as positive by family members, providing them with more security in this moment of separation, of uncertainties, of expectations, in which their emotional state can important changes [7]. One of the studies that aimed to implant the nursing visit in an adult ICU in the city of São Paulo, Brazil, showed in the results that at the time of the visit, especially during the first nursing visit, the professional had to clarify all doubts of the relatives and to question them about curiosities or situations that had not been clear to them [6]. Another study that presents the aspects of support group work with relatives of ICU patients shows that during group activities the professional needs to encourage people to talk about their questions so that they can respond to the doubts of one in the perspective of the need for information from other relatives [8]. When families are finally inside the ICU, doubts that once seemed clear resurface the bedside, in front of the monitors, ventilators, and other machines, when we find another rich moment for the nurse to act on the issues of families boosting its actions of reception at the bedside. 

Of the study carried out by nurses from São Paulo, Brazil, which aimed to implant the nursing visit in the intensive care setting, among the family members, 4.4% expressed a desire to obtain information about equipment and monitors [6]. During the study, it was also pointed out the need of the family members to be better oriented on the routines of the sector, such as: meal times and types of exams that are performed. We find that in an attempt to inform and guide the routines and equipment of the intensive care sector, the nurse constructs strategies that allow greater involvement and participation of the family at the moment of exposing their doubts, using resources such as information leaflets, support groups and rooms waiting, nursing visits, post admission guidelines, and still on the bedside of the person being cared for showing the functioning of the materials that make up that environment, this fact, prepares the family member to experience the hospitalization of their loved one, possession of the desired information and guidance, people feel more empowered and welcomed, participatory members of the care plan being established, the family is at the center rather than the margins. 

3.4.  Information and Guidance to Family Members about the Patient 

In the face of the hospitalization process, most of the relatives are concerned about the actual state of health of their loved one, it is common to question the clinical picture, evolution, exams, procedures performed, physiological patterns, feeding issues and also the patient's prognosis. In their totality, the scientific productions that composed this integrative review pointed out that the desire of the relatives is always to receive information about the patient, that is, in addition to the other information that ended up varying from one family member to the other, the need to know how it is mainly clinically their affection is a common factor among all families. One of the analyzed articles shows that of the total of the families that participated in the study, 74.4% wanted to know about the clinical state of the patient [6]. During the course of this work, we find in the literature two main ways of informing about the patient in which the nurse is involved. Such techniques, are part of the host developed by the same and directed the families of the people in their care. The information and guidance in these cases are passed by bedside, and by telephone. There are other ways of informing, but in these the nurse is not directly involved.

The family member needs a professional's attention to get information on how his or her loved one spent the day [7]. In view of the observation of the authors of this study in the practice of intensive care, we found that most of the time, the nurse practitioner refuses this type of activity because he claims that it is not his job to provide information about the patient's clinical condition. articles, we show that nurses are increasingly involved in this follow up, adding the provision of information about the patient to their relatives as a possibility of receiving these in the ICU. Approaching the familiar at the bedside to inform and guide was an effective technique of reception, in this way, families end up finding in the professional support and support to face the moment of hospitalization of their affection, feeling this way welcomed. Passing information at the edge of the bed is an opportunity to strengthen the bond [7]. One of the great questions of the families regarding the therapies instituted in the ICU is in relation to the nutrition of the patient, who most of the time is receiving feeding through other ways than oral. At this moment, having a bedside nurse informing and guiding about this and other issues like normal sleep and physiological patterns conveys comfort and safety to these family members, who are starting to feel more and more welcomed. Being present, relating, and creating a bond between family / nursing are ways of establishing the host relationships [5]. 

Two of the seven articles analyzed have brought about the common practice of service, the familiar receiving information through telephone calls [7,9]. This information is passed through patient information bulletins issued by the medical professional. There is a daily established time with the family where the telephone contact is made and are informed of things like: how the patient spent the night; if there was improvement or worsening of the condition; what exams are scheduled for him throughout the day; and in case of discharge from the ICU to the infirmary before the visitation time, the family member is already aware of the patient's destination sector so that he does not waste time during visits. Another relevant fact is that in cases of worsening of the patient's clinical condition, the family member is advised immediately to be referred to the ICU, if necessary, in order for an extra visit to be released. This fact occurs through a manifest of interest still at the nursing visit at the time of admission. 

Still about communicating with the family member by telephone, it is mentioned that when he / she contacts the family member by telephone, the nurse always tries to find out who the relative is, what the last information the patient had about the patient, and as it is, is a simple and fast activity, but full of meaning. This strategy broadens the relationship of trust and ensures professionals the perception of including the family in the care process in ICU [9]. Informing and guiding by telephone can be a simple but effective reception technique through which the family member has the security and confidence that he can leave his loved one in the institution under the care of the team that in case of any intercurrence he will be immediately warned, thus avoiding being surprised in an unpleasant way at the time of the visit [10-12]. Informing and guiding the patient is a welcoming strategy developed to give security to the families, so the nurse needs to take ownership of this follow-up. 

4.       Conclusion 

The host developed by Brazilian nurses to relatives of adult patients hospitalized in ICUs is based on the identification of their needs and feelings in health education regarding clear and objective information and guidelines on the unit's routine functioning and its technological complexity and also on the patient himself, especially regarding the clinical picture of the patient using a simple language easily understood by relatives. We understand that the issue of receiving intensive care sometimes involves institutional issues, but it is up to nurses to work on the issue of developing host projects so that nursing care can be assured, focusing not only on the patient but also on the family, besides an individualized and humanized care

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International Journal of Nursing and Health Care Research