Instructor Guide Chapter 10: Family-Focused Care in Acute Settings Sandra K. Eggenberger & Marcia Stevens

Family-Focused Nursing Care: Think Family and Transform Nursing Practice Chapter Objectives: Instructor Guide Chapter 10: Family-Focused Care in Acute Settings Sandra K. Eggenberger & Marcia Stevens 1. Examine individual and family needs during acute care episodes. 2. Discuss evidence that supports use of family strengths and family presence during acute and crisis care situations. 3. Describe nursing actions that support individual and family needs during transitions in acute care settings. 4. Examine stress, uncertainty, and family member concerns that often occur during an acute illness experiences. 5. Describe environmental factors that support and challenge family focused nursing practice in acute care settings. Chapter Concepts Acute Care Acute Care Environments Bedside Rounding Discharge Empowerment Family Advisory Council Family Communication Family Decision-Making Family Interactions Family Meetings Family Processes Policies and Visitation Satisfaction Supports Suffering Uncertainty

Family-Focused Nursing Care: Think Family and Transform Nursing Practice 2 Chapter Introduction Students are often eager to learn about acute care settings during their formal nursing education. Many choose practice areas linked with urgent needs -- where care delivery is critical. Much of traditional nursing education has been focused on meeting acute care needs of individual family members with an illness or disease, but far less consideration has been centered on family needs that are likely associated with the acute experience. The immediacy of physiological concerns validates reasons to quickly focus on immediate individual needs at critical times. However, caring family members often accompany individuals to acute care settings. As families experience distress in these settings they are often ignored and excluded (Nelms & Eggenberger, 2010; Vandall-Walker & Clark, 2011).. It is vital that nursing students learn that acute or crisis events are not just medical concerns, they are personal and family issues.. Nurses and other health professionals often view acute care settings as their domains and territory. They often forget that others are uncomfortable in these environments. Chapter ten of the textbook describes acute care experiences and examines family needs across various care settings. Nurses that think family use communication and supportive actions during illness trajectories to address individual needs and those of the family unit. Various needs and concerns occurring in acute care settings are examined and nursing actions to support family strengths during illness trajectories are discussed. Barriers to family care in acute settings are explored in the chapter and ways to overcome them are described. Care challenges, ways to influence care outcomes, clinician concerns, family needs, and system influences in acute care settings are presented. Family-Focused Nursing Care 2015

Family-Focused Nursing Care: Think Family and Transform Nursing Practice 3 This chapter threads an exemplar case study of a hospitalized individual to illustrate ways to deliver family care effectively. Voices of family members and nurse describe thoughts, feelings, and elements of the acute care experience. As students read and consider the content of this chapter, encourage them to reflect on the positive and negative care aspects. Guide students to explore the experience of a family during an acute illness and hospitalization which can help them understand the responses, behaviors, and emotions of a family. Ask them to use critical thinking skills and clinical judgment as they list and weigh outcomes of alternative care approaches. The examples provided do not capture ideas about all possible acute care scenarios, but suggest some ways to consider unique situations, care needs, and care provision. Ideas from this chapter can be compared to clinical or simulation experiences as students are encouraged to think family in the midst of uncertainty and stress of acute illness. Acute Care Settings Acute care settings pose unique challenges to family focused nursing. Technological advances, electronic medical records, policies, and legislation protecting health care information can seem like obstacles that hamper care delivery. Nurse s abilities to satisfy some needs of an individual and a family during an acute care stay can seem almost impossible. Multiple demands in this setting mean nurses often have only small amounts of time to spend with each individual and demands from family members can then seem to be additional stressors and burdens. Students must learn that caring for a family is crucial to quality care and even brief nurse-family interactions and nursing actions that reflect family thinking can make a difference in the patient and family illness experience. Care demands interrupted by family questions or requests can be challenging and stressful for nurses. Nurses beliefs about appropriate family roles in managing illness or injury may be contrary to family expectations that their role is to be a protector for their Family-Focused Nursing Care 2015

Family-Focused Nursing Care: Think Family and Transform Nursing Practice 4 loved one (Astedt-Kurki, Paavilainen, Tammentie, Paunonen-Ilmonen, 2001; Eggenberger & Nelms, 2007; Vandall-Walker & Clark, 2011). Students need to learn that thinking family implies use of therapeutic communication and collaboration with family units during acute individual conditions. If nurses only focus attention on ill persons and view family members as visitors, background, external factors, or barriers to the acute situation then care delivery is less than optimal (Davidson, 2009; Verhaeghe, Defloor, Van Zuuren, Duijnstee, M., & Grypdonick, M., 2005). These beliefs interfere with health care professional and nurses capacities to provide family focused care in acute care. Acute care presents stresses not usually experienced and these events bring new worries, decision-making, and changes in family routines. Family members of an acutely ill individual often experience uncertainty, anxiety, emotional distress, and suffering while enduring the vulnerability and threats of a foreign hospital environment (Davidson, Jones, Bienvenu, 2012; Nelms & Eggenberger, 2010; Hirsch, Hoeksel, Dupler, & Kaakinen, 2010). A broad body of evidence suggests that nurses play pivotal roles in comforting the family, advocating for them, and developing a connecting presence whenever a person is in an acute care setting (Chesla & Stannard, 1997; Eggenberger & Nelms, 2007; Leahey & Svavarsdottir, 2009; Meiers & Brauer, 2008; Soderstrom, Benzein & Saveman, 2003; Tomlinson, Peden-McAlpine, Sherman, 2012; Wiegand, 2008; Wiegand, Deatrick & Knafl, 2008). Nurse educators must help students understand how their actions have a profound impact on family distress and family s ability to support the needs of their family members during an acute illness (Nelms & Eggenberger, 2010). Student nurses need to have behaviors represented of thinking family modeled. Nurses are well positioned to provide supportive care. They can form an individualnurse-family partnership that ease suffering and promote ill person and family unit health. Family-Focused Nursing Care 2015

Family-Focused Nursing Care: Think Family and Transform Nursing Practice 5 Family focused care influences individual care outcomes because the illness or disease condition is a shared family experience, one outside of usual experiences and hospitalization can be overwhelming (Azoulay et al., 2005; Weihs, Fisher, & Baird, 2002). Nurses interactions influence outcomes linked with acute illness experiences for the ill person and the family. Acute illness hospitalization and care is more than a medical event, it is also a relational phenomenon. Formation of an individual-nurse-family collaborative partnership has potential to promote safety, reduce, medical errors, increase quality care outcomes, and enhance satisfaction. Teaching Students about Nurses Acute Care Roles Nurses play crucial roles in helping a family manage difficult acute illness experiences and can assist them to maintain a healthy family (Van Horn & Kautz, 2007). Nurses that are readily available and sensitive to family unit needs are more likely to be trusted because these relationships support therapeutic interactions. Individual and family member relationships with nurses and other health care team members can potentially help and support, but when not developed carefully acute care experiences can be threatening and magnify distress. Nurses are supportive when they reach out, include, welcome, comfort, and advocate for families during hospitalization, while nurses that fail to acknowledge, exclude, and have limited family interactions add to their distress (Abraham & Moretz, 2012; Nelms & Eggenberger, 2010; Vandall-Walker & Clark, 2011;). Family uncertainty can be diminished through provision of consistent and accurate information, caring interactions, and the development of collaborative partnerships that promote self-confidence (McMillan & Small, 2007). These skills are not natural attributes. Students need to be taught, mentored, coached, and supported as they learn ways to provide family focused care. Family-Focused Nursing Care 2015

Family-Focused Nursing Care: Think Family and Transform Nursing Practice 6 Multiple opportunities to support a family from the times of diagnosis to death through transitions of a chronic or acute illness exist (Bakitas, Kryworuchko, Matlock, & Volandes, 2011; Wiegand, 2012). Caring exchanges of needed information can help build a trusting relationship that informs decision making processes. Practice models that include shared decision-making, support for decisions, and informed choices are proposed as best practices (Bakitas, Kryworuchkio, Matlock & Volandes, 2011). Individual-nurse-family connections during each decision point that occurs during an illness experience may minimize family suffering and improve the processes (Wiegand, 2006; Wiegand, 2008). Students are sometimes intimidated by families. Faculty that provide safe non-threatening active learning opportunities to practice think family skills encourage and support family focused care (Eggenberger & Regan, 2010). Nursing research documents the distress of families (Buckley & Andrews, 2011; Davidson, 2009; Davidson, Jones, & Bienvenu, 2012) and concerns about how to best communicate with families (Coyne, O Neill, Murphy, Costello, O Shea, 2011). Faculty can support students as they learn to communicate in awkward or uncomfortable situations. Role play, simulation, unfolding cases, and reflection are just some of the tools that teachers can use to help students gain confidence and refine skills. Family Focused Nursing Practice in Acute Care Settings When possible, hospitalized persons should be asked to identify who is in their family and how they prefer members to be involved in their care (AACN, 2011; Hirsch, Hoeksel, Dupler, & Kaakinen, 2010). Nurse educators need to role model for students the act of initiating intentional individual-nurse-family conversations while other tasks are being accomplished. Identification of family member beliefs about care needs can also help a family move toward consensus about needed nursing actions (Wright & Bell, 2010). The Illness Beliefs Model Family-Focused Nursing Care 2015

Family-Focused Nursing Care: Think Family and Transform Nursing Practice 7 suggests that nurses can assist individuals and family members identify beliefs that create barriers to solutions and encourage actions that promote family health and healing (Wright & Bell, 2010). Students need to learn deliberate questioning techniques, such as asking, If you could have just one question answered during our time together what would that question be? This question provides an initial understanding about concerns, needs and beliefs (Duhamel, Dupuis, & Wright, 2009; Wright and Leahey, 2013). Asking, What beliefs about your family and this illness are influencing you at this time? may provide additional information. Early, consistent, and ongoing communication throughout an acute care stay can support persons receiving care and guide family members in deciding ways to participate in care while in an acute care setting. Equally important is the care coordination information and skills needed at discharge for care management and support in the family household. Students need to practice these types of family focused nursing actions and skills in the acute care setting during clinical, simulation or role play situations. Nurses who recognize that family focused care can occur in short time periods and that even in brief moments of care offer opportunities to initiate communication can create trust needed for an individual-nurse-family partnership (Martinez, D Artois, & Rennik, 2007). Even brief family conversations or interaction can be useful. Conducting 15-minute family interviews (Wright & Leahey, 2013) and brief therapeutic conversations have been implemented in hospital units with families and nurses reporting positive outcomes (Benzein & Saveman, 2008; Martinez, D Artois, & Rennik; Svavarsdottir & Jonsdottir, 2011; Svavarsdottir, Tryggvadottir, & Sigurdardottir, 2012). Key ingredients of this family interview include manners, commendations, therapeutic questions, and conversations (Wright & Leahy, 2013). Helping students gain skills in communicating with families during stressful and uncertain times is important. Although Family-Focused Nursing Care 2015

Family-Focused Nursing Care: Think Family and Transform Nursing Practice 8 individuals and families are interested in medical outcomes, they are also concerned about relational ones. Follow-up to the Acute Experience Critically ill persons usually return home with family caregivers. Persons hospitalized are often still quite ill when they return home and require much family assistance, students need to learn ways to assure that families are fully prepared to satisfy care needs (Popejoy, 2011). Inadequate discharge planning often leads to readmission through emergency departments and return to acute care setting because family members lack the needed knowledge and skills for complex care needs at home (Popejoy, 2011: Weiss et al., 2007). Students need to understand ways family focused care can be used to coordinate care between acute and household settings. Students need to be prepared to teach families about things like implications of the diagnosis, expected prognosis, home management of medical treatments, finding available community resources, using family supports, and actions to take when questions arise. Individuals and families have unique needs that require intentional planning and a coordinated discharge (Marek, et al., 2010). Discharge information is often given in parts by various individuals over time. Nurse educators need to help students understand that things needed by a family are seldom covered in standardized prepared teaching materials distributed to families as they depart from the acute care setting. Thoughtful planning requires a cooperative effort among the individualnurse-family during the hospital stay, especially because the homebound care can be difficult, extended, and burdensome for family units. Thinking family implies family members are prepared for their caregiver and support roles during the acute care stay. Family-Focused Nursing Care 2015

Family-Focused Nursing Care: Think Family and Transform Nursing Practice 9 References Abraham, M. & Moretz, J. (2012). Implementing patient- and family-centered care: Part I understanding the challenges. Pediatric Nursing, 38(1), 44-47. American Association of Critical Care Nurses (2011). AACN Practice Alert: Family Visitation in the Adult ICU. Retrieved May 16 from: http://www.aacn.org/wd/practice/docs/practicealerts/family-visitation-adult-icupracticealert.pdf Astedt-Kurki, Paavilainen, Eija, Tammentie, T., & Paunonen-Ilmonen, M. (2001). Interaction between adult patients family members and nursing staff on a hospital ward. Scandinavian Journal of Caring Science (15), 142-150. Azoulay, E., Pochard, F., Chevret, S., et al. (2005). Family participation on care to the critically ill: Opinions of families and staff. Intensive Care Medicine, 29, 1498-1504. Bakitas, M., Kryworuchko, J., Matlock, D., & Volandes, A. E. (2011). Palliative medicine and decision science: The critical need for shared agenda to foster informed patient choice in serious illnesss. Journal of Palliative Medicine, 14(10), 11-0-1116. Benzein, E.G., & Saveman, B.I. (2008). Health-promoting conversations about hope and suffering with couples in palliative care. International Journal of Palliative Nursing, 14, 439-445. Buckely, P., & Andrews, T. (2011). Intensive care nurses knowledge of critical care family needs. Intensive and Critical Care Nursing, 27(5)263-272. Chesla, C. A., & Stannard, D. (1997). Breakdown in the nursing care of families in the ICU. American Journal of Critical Care, 6(1), 64-71. Coyne, I., O Neill, C., Murphy, M, Costello, T. & O Shea, R. (2011). What does family-centered Family-Focused Nursing Care 2015

Family-Focused Nursing Care: Think Family and Transform Nursing Practice 10 care mean to nurses and how do they think it could be enhanced in practice. Journal of Advanced Nursing, 67(12), 2561-2573. Davidson, J. E. (2009). Family-centered care: meeting the needs of patients families and helping families adapt to critical illness. Critical Care Nurse, 29(3), 28-34. Davidson, J. E., Jones, C., & Bienvenu, O. J. (2012). Family response to intensive care syndrome-family. Critical Care Medicine, 40(2), 618-624. Duhamel, F., Dupuis, F., & Wright, L. (2009). Families and nurses responses to the one question questions : Reflections for clinical practice, education and research in family nursing. Journal of Family Nursing, 15(4), 61-485. Eggenberger, S., & Nelms, T. (2007). Being family: The family experience when an adult member is hospitalized with a critical illness. Journal of Clinical Nursing, 16, 1618-1628. Eggenberger, S.K., & Regan, M. (2010). Expanding simulation to teach family nursing. Journal of Nursing Education. 49(10), 550-558. Hirsch, A. M., Hoeksel, R., Dupler, A. E., & Kaakinen, J. R. (2010). Nurses and families in adult medical-surgical settings. In Family Health Care Nursing: Theory, Practice, and Research (4 th ed.). F. A. Davis Company. Leahey, M., & Svavarsdottir, (2009). Implementing family nursing: How do we translate knowledge into clinical practice? Journal of Family Nursing, 15(4), 445-460. DOI: 10.1177/1074840709349070 Martinez, A.M., D Artois, D., & Rennick, J. (2007). Does The 15-Minute (or less) family interview influence nursing practice? Journal of Family Nursing, 13, 157-178. McMillan, S.C., & Small, B. J. (2007). Using the COPE intervention for family caregivers to improve symptoms of Hospice Homecare Patients: A clinical trial. Oncology Nursing Forum, 34(2), 313- Family-Focused Nursing Care 2015

Family-Focused Nursing Care: Think Family and Transform Nursing Practice 11 Meiers, S. J., & Brauer, D. J. (2008). Existential caring in the family health experience: A proposed conceptualization. Scandinavian Journal of Caring Science, 22, 110-117. Nelms, T. P. & Eggenberger, S.K. (2010). Essence of the family critical illness experience and family meetings. Journal of Family Nursing, 16(4), 462-486. Popejoy, L. L. (2011). Complexity of family caregiving and discharge planning. Journal of Family Nursing, 17(1), 61-81. doi:http://dx.doi.org/10.1177/1074840710394855 Soderstrom, I., Benzein, E., & Saveman, B. (2003). Nurses experiences of interactions with family members in the intensive care unit. Scandinavian Journal of Caring Sciences, 17, 185-192. Svavarsdottir, E.K., Tryggvadottir, G.B., & Sigurdardottir, A.O. (2012). Knowledge translation in family nursing: Does a short-term therapeutic conversation intervention benefit families of children and adolescents in a hospital setting? Findings from the Landspitali University Hospital Family Nursing Implementation Project. Journal of Family Nursing, 18(3), 303-327. Tomlinson, P. S., Peden-McAlpine, C., & Sherman, S., (2012). A family systems nursing intervention model for a paediatric health crisis. Journal of Advanced Nursing, 68(3), 705-714. Vandall-Walker, V. & Clark, A. (2011). It starts with access!: A grounded theory of family members working to get through critical illness. Journal of Family Nursing, 17(2), 148-181. Van Horn, E.R. & Kautz, D. (2007). Promotion of family integrity in the acute care setting: A review of the literature. Dimensions of Critical Care Nurse, 26(3), 101-107. Verhaeghe, S., Defloor, T., Van Zuuren, F., Duijnstee, M., & Grypdonck, M. (2005). The needs and experiences of family members of adult patients in an intensive care unit: a review of the literature. Journal of Clinical Nursing 14, 501 509. Family-Focused Nursing Care 2015

Family-Focused Nursing Care: Think Family and Transform Nursing Practice 12 Weiss, R. S. (1974). The provisions of social relationships. In Z. Rubin (Ed.), Doing Unto Others (pp.17-26). Englewood Cliffs, NJ: Prentice Hall Wiegand, D. (2008). In their own time: The family experience during the process of withdrawal of life-sustaining therapy. Journal of Palliative Medicine, 11(8), 1115-1121. YES Wiegand, D.L. (2006). Withdrawal of life-sustaining therapy after sudden, unexpected life- threatening illness or injury: Interactions between patients families, healthcare providers, and the health care system. American Journal of Critical Care, 15(2), 178-187. Wiegand, D.L. (2012). Family management after the sudden death of a family member. Journal of Family Nursing, 18(1), 146-163. YES Wiegand, D.L., Deatrick, J.A., & Knafl, K. (2008). Family management styles related to withdrawal of life-sustaining therapy from adults who are acutely ill or injured. Journal of Family Nursing, 14, 16-32 Weihs, K. L., Fisher, L., & Baird, M. (2002). Families, health and behavior. A section of the Commissioned Report by the Committee on Health and Behavior: Research, Practice, and Policy, Division of Neuroscience and Behavioral Health and Division of Health Promotion and Disease Prevention, Institute of Medicine, National Academy of Sciences. Families, Systems & Health, 20(1), 7-46 Wright, L.M. & Leahey, M. (2013). Nurses and families: A guide to family assessment and intervention (6th ed). Philadelphia: F. A. Davies. Wright, L.M. & Bell, J. M. (2010). Beliefs and Illness: A Model of Healing. Canada: 4 th Floor Press. Family-Focused Nursing Care 2015