EBP Journal Article

Leadership Team

Feature

©2020 American Association of Critical-Care Nurses doi:https://doi.org/10.4037/ccn2020644

Background Organizations motivated to provide high-quality care in the intensive care unit are exploring strategies to engage families in patient care. Such initiatives are based on emerging evidence that family engagement improves quality and safety of care. Objective To gather family feedback to guide future nurse-led quality improvement efforts to engage families in the intensive care unit setting. Methods The Critical Care Family Satisfaction Survey, which consists of 20 items rated from 1 (very dissatisfied) to 5 (very satisfied), was paired with open-ended questions and administered to families during the intensive care unit stay from March through December 2017. Content analysis was used to identify themes regarding the family experience. Results Responses were collected from 178 family members. The mean (SD) score on the survey was 4.65 (0.33). Five themes emerged regarding the delivery of family care in the intensive care unit: family interactions with the interdisciplinary team, information sharing and effective communication, family navigation of the intensive care unit environment, family engagement in the intensive care unit, and quality of patient care. Conclusions This quality improvement project provided foundational information to guide family engage- ment efforts in the intensive care unit. Real-time solicitation of feedback is essential to improving the family experience and guiding family-centered care delivery in this practice environment. (Critical Care Nurse. 2020;40[6]:42-51)

Natalie S. McAndrew, PhD, RN, ACNS-BC, CCRN-K Laura Mark, PA-C Mary Butler, PhD, MSN, RN, FNP-C

Timely Family Feedback to Guide Family Engagement in the Intensive Care Unit

A ctively engaging families in the intensive care unit (ICU) may improve the quality and safety

of care.1-3 An interdisciplinary ICU committee at an academic, tertiary care medical center recog-

nized the need to capture timely family feedback to guide nurse-led initiatives aimed at enhanc-

ing family engagement and the delivery of family-centered care.

The organization’s current process for gathering data about the ICU experience is focused solely on

the patient perspective, collects data after discharge from the hospital, and includes few questions about

the patient’s ICU stay. This approach to data collection is limited for a number of reasons. First, ICU

patients typically transfer from the ICU to an inpatient floor before discharge, and their subsequent inpa-

tient experience may eclipse their memory of their ICU stay. Additionally, the duration from ICU stay

until receipt of the survey at discharge could be several weeks, affecting patient recall. Finally, patients

may have limited memories of their ICU stay owing to their illness severity and/or sedation requirements,

42 CriticalCareNurse Vol 40, No. 6, DECEMBER 2020 www.ccnonline.org

www.ccnonline.org CriticalCareNurse Vol 40, No. 6, DECEMBER 2020 43

making family members key informants of patient care

experiences. Therefore, the current patient-focused sur-

vey at the organization may not capture the full range of

the ICU family experience that is needed to guide family

engagement improvement initiatives. To seize potential

opportunities to improve family care in this health care

organization, we developed a quality improvement proj-

ect to better understand the family experience in ICUs

from the family’s perspective. This project was the fi rst

step in an ongoing family engagement improvement

program in the organization’s ICUs.

There is a growing body of research on the family

experience in the ICU and how it affects both patient

and family outcomes.4-6 Family presence in the ICU has

been associated with decreased patient delirium and

anxiety,7 and family-centered interventions may shorten

the patient stay, reduce hospital costs, and improve patient

and family satisfaction and mental health.4,8 As a result,

the quality of care delivered to families has become increas-

ingly valued by health systems.9-11

Family engagement, defi ned as the opportunity for

families to partner with the health care team in ICU

patient care and decision-making, is an important vehi-

cle to achieving patient- and family-centered care in the

ICU.1,12,13 Despite interprofessional recognition that fam-

ily care in the ICU is important, evidence has emerged

that basic family needs are not consistently met.10,14-16

Patient- and family-centered care practice guidelines

recommend fl exible family visitation and family pres-

ence at the bedside; however, family access to patients

is not always a priority for ICU clinicians because of

competing patient care responsibilities.17-19 Organizational

and unit culture may not fully support family engage-

ment in care.18,20-22 Therefore, determining the current

state of family care in the organization’s ICUs is an

important fi rst step to improving family engagement.

Study Framework and Specifi c Aim The framework for this study was based on the inte-

gration of a concept from the organization’s relationship-

based care model (building therapeutic relationships

with patients and families as the primary goal)23 and a

current defi nition of family engagement: involvement

of families in the ICU through ongoing collaboration to

improve patient care and promote respect (Figure 1).1,13

In this framework, partnership building between health

care professionals and families leads to ongoing collabo-

ration in patient care and decision-making, with the

desired outcomes of mutual respect and therapeutic rela-

tionships (optimal patient and family experiences).

The quality improvement framework was the plan-do-

study-act model conceptualized by William Edwards

Deming.24,25 Improvement efforts were based on a goal

of transforming a primarily patient-focused practice area

into one of family engagement.

The specifi c aim of this project was to better under-

stand the family experience across ICUs to inform the future

development of an ICU family engagement program.

Methods Context

An interprofessional critical care committee made

up of ICU leaders and clinicians supported this quality

Authors

Natalie S. McAndrew is an assistant professor, College of Nursing, University of Wisconsin-Milwaukee, and a nurse-scientist, Froedtert Hospital, Froedtert & Medical College of Wisconsin, Milwaukee, Wisconsin.

Laura Mark is a physician assistant in the cardiovascular intensive care unit, Froedtert Hospital, Froedtert & Medical College of Wisconsin.

Mary Butler is an assistant clinical professor, College of Nursing, University of Wisconsin-Milwaukee.

Corresponding author: Natalie S. McAndrew, PhD, RN, ACNS-BC, CCRN-K, College of Nurs- ing, Cunningham Hall, 1921 East Hartford Avenue, Milwaukee, WI 53201 (email: [email protected]).

To purchase electronic or print reprints, contact the American Association of Critical- Care Nurses, 27071 Aliso Creek Rd, Aliso Viejo, CA 92656. Phone, (800) 899- 1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, [email protected].

Figure 1 Guiding framework for the study. Abbreviation: ICU, intensive care unit.

Partnership Building Support from ICU health care professionals

Bidirectional information sharing

Ongoing Collaboration Family involvement in patient care Shared decision-making in the ICU

Optimal Patient and Family Experiences Mutual respect

Theraputic relationships

44 CriticalCareNurse Vol 40, No. 6, DECEMBER 2020 www.ccnonline.org

Partnership building between health care professionals and families leads to ongoing collaboration in patient care and decision-making, with the desired outcomes of mutual respect and therapeutic relationships.

improvement effort. The project focused on the overall

family experience across 5 ICUs (medical, surgical, trans-

plant, neuroscience, and cardiovascular) at a tertiary

care academic medical center. During the study period

of March through December 2017, the total number of

ICU beds increased from 89 to 107, with at least 500

ICU admissions reported each month.

Intervention The family experience survey combined an existing

instrument, the Critical Care Family Satisfaction Survey

(CCFSS),26,27 with open-ended questions developed by an

interprofessional team as well as yes/no questions about

basic descriptive hospitalization information. The project

was led by a clinical nurse specialist (N.S.M.) who collab-

orated with the virtual ICU (VICU) nursing director to

implement the

project. Nurses

working in the

telemedicine

service (VICU)

were asked to

play a key role

in the collection

of this critical family feedback. This group was selected

to assist with survey administration to avoid any con-

flict of interest for bedside nurses caring for patients.

The VICU nurses have an ongoing patient monitoring

role in the ICUs and support early recognition of patient

status changes. The VICU nurses share their assessments

with the bedside nurses in the ICU and serve as a tele-

medicine care partner. Additionally, the VICU staff par-

ticipate in many organizational improvement projects

because of their virtual presence in the ICU setting and

interactions with ICU health care professionals. The VICU

nurse checks into each ICU room via camera as part of

their routine patient assessment. When performing this

assessment, VICU nurses may observe family members

visiting the patient.

For the current project, if a VICU nurse noticed a

family member in the room, they called the bedside

nurse to determine if the family member present was

involved in the patient’s care decisions and if it was an

appropriate time to offer family members the oppor-

tunity to participate. If so, the VICU nurse called the

family member on the patient’s phone in the room to

explain the purpose of the survey, assure them that it

was voluntary, and provide directions to interested family

members for survey completion. The VICU nurse called

the health unit coordinator to bring a printed copy of the

survey to the family member. The family member was

informed that, upon completion of the survey, it should

be placed in a sealed envelope and deposited into a locked

box at a central location in each ICU to ensure anonymity.

The VICU tracked whether a patient’s family had been

approached or declined to participate to avoid confusion

or burdening the family with multiple requests.

To optimize return rate, the VICU identified all new

admissions within 24 hours (because the stay might be

short) and continuously monitored for family presence

to identify opportunities to invite families to participate.

Staff nurses fielded the calls from the VICU nurses to

assess appropriate timing for inquiry about completing

the survey. The health unit coordinators in each ICU

answered questions about where to return surveys and

monitored the locked box in which surveys were to be

deposited. Data were entered by a staff nurse and the

clinical nurse specialist into Qualtrics, a secure data

management platform.

Study of the Intervention Measures. The CCFSS includes 20 items that are

rated from 1 (very dissatisfied) to 5 (very satisfied).26,27

These 20 items are grouped into 5 subscales related to

family care in the ICU: assurance about care of the criti-

cally ill patient, proximity to the critically ill patient,

information about the critically ill patient, family com-

fort, and family support. These important family needs

were first identified in the seminal work of Molter28 and

Leske.11,29 The CCFSS was selected because these subscales

target the specific areas the interprofessional ICU com-

mittee wanted to improve. Items on the tool include

statements about waiting time and requests for assistance,

obtaining information, ability to be with the critically

ill patient, family encouragement and resources, and the

comfort of the ICU waiting room.27 Reliability and valid-

ity of the CCFSS have been shown to be acceptable.26 In

previous studies, internal consistency as measured by the

Cronbach ranged from 0.71 to 0.96.26,30,31 The Cron-

bach for the CCFSS (overall total scale) in the current

quality improvement project was 0.88.

Open-ended questions were developed in an attempt

to better capture the complex experiences of the family.

Open-ended questions were as follows: (1) What do you

www.ccnonline.org CriticalCareNurse Vol 40, No. 6, DECEMBER 2020 45

want us to know about your family member’s stay in the

ICU? (2) How do you think we could improve care for

families in the ICU? (3) What did the ICU team do well

while your family member was in the ICU environment?

(4) Is there anything else you want to share with us? Yes/

no questions captured whether a family conference had

taken place, previous ICU experience, and length of time

in the ICU.

Analysis. Data were exported from Qualtrics into IBM SPSS Statistics, version 24. Descriptive statistics were

used to examine CCFSS scores (subscales and overall).

Differences in CCFSS scores by ICU type were determined

with analysis of variance. Independent t tests were used

to compare scores on subscales on the basis of whether a

family conference had taken place, as well as whether the

patient had been in the ICU before.

Content analysis, based on the methods described

by Erlingsson and Brysiewicz,23 was used to analyze

responses to open-ended questions. In this approach

to qualitative analysis, data are first condensed into

meaning units, and then codes are formulated to label

these meaning units. Related codes are grouped into

categories, which are then merged into themes that

refl ect the overall meaning of the data.23 Each of us inde-

pendently analyzed the data, and then we used an itera-

tive process to develop consensus on the themes. One of

us (L.M.) completed an additional analysis on the

basis of techniques described by Krippendorff32 to

determine the percentage of feedback that supported

high performance in family care and the percentage

that highlighted opportunities for improvement.

Ethical Considerations This study was designated by the organization’s

institutional review board as a quality improvement

project and therefore was exempt from further

review (PRO00028444).

Results Participants

Of the approximately 400 family members who were

approached to participate, 178 completed the survey, for

a response rate of almost 45%. Patients had been in the

ICU an average of 5.85 (SD, 7.72; range, 1-82) days at the

time the survey was completed. Characteristics of family

respondents are shown in Table 1.

CCFSS Responses The mean CCFSS scores (subscales and overall) are

shown in Table 2. CCFSS scores had a negative skew

(–1.41); these scores did not differ signifi cantly on the

basis of ICU type (Table 3). Those who had a family

conference had signifi cantly higher scores on the prox-

imity subscale than those who did not (P = .03; Table 4).

No signifi cant differences were found in CCFSS scores

according to whether the patient had been in the ICU

before (Table 5).

Qualitative Responses In response to the 4 open-ended questions, family

members wrote 592 comments. Because responses to

each question were related, comments were analyzed as

a whole rather than by individual question. Family com-

ments were primarily complimentary. Among the com-

ments, 62% described a positive experience. The remainder

of comments were either negative (22%), neutral (12%),

Characteristic

Intensive care unit (ICU) Cardiovascular ICU Medical ICU Surgical ICU Transplant ICU Neuroscience ICU Missing

Did a family conference take place? Yes No Missing

Has your family member previously been in the ICU? Yes No Missing

No. (%)

56 (31.5) 47 (26.4) 34 (19.1) 9 (5.1) 23 (12.9) 9 (5.1)

55 (30.9) 120 (67.4) 3 (1.7)

80 (44.9) 95 (53.4) 3 (1.7)

Table 1 Characteristics of family respondents (n = 178)

CCFSS

Assurance, mean (SD), range

Proximity, mean (SD), range

Information, mean (SD), range

Comfort, mean (SD), range

Support, mean (SD), range

Overall, mean (SD), range

Score

4.61 (0.41), 1-5

4.61 (0.43), 1-5

4.75 (0.36), 1-5

4.22 (0.88), 1-5

4.76 (0.34), 1-5

4.65 (0.33), 1-5

Table 2 Subscale and overall scores for the Critical Care Family Satisfaction Survey (CCFSS)

46 CriticalCareNurse Vol 40, No. 6, DECEMBER 2020 www.ccnonline.org

or a combination of both positive and negative (3.4%).

Examples of neutral comments included statements such

as “Not sure” or “Nothing I can think of at this time.”

Figure 2 portrays the 5 interrelated themes that infl uence

the overall ICU family experience: family interactions

with the interdisciplinary team, information sharing and

effective communication, family navigation of the ICU

environment, family engagement in the ICU, and quality

of patient care.

Family Interactions With the Interdisciplinary Team. The theme of family interactions with the interdisciplinary

team describes how families value their relationships

with ICU staff and recognize that productive interactions

with the team contribute to the delivery of high-quality

patient care. Reflecting on their interactions with mem-

bers of the team, families used the terms friendly, attentive,

professional, caring, skilled, knowledgeable, supportive, warm,

respectful, concerned, helpful, compassionate, and encourag-

ing. Respondents repeatedly emphasized the infl uence of

CCFSS

Overall Between group Within group Total

Assurance Between group Within group Total

Proximity Between group Within group Total

Information Between group Within group Total

Comfort Between group Within group Total

Support Between group Within group Total

P

.43

.94

.81

.06

.51

.41

F

0.97

0.19

0.40

2.30

0.82

1.00

MS

0.10 0.10

0.03 0.16

0.07 0.17

0.26 0.16

0.63 0.77

0.10 0.10

SS

0.39 16.46 16.85

0.12 26.52 26.64

0.28 28.48 28.75

1.06 18.59 19.65

2.55 125.77 128.33

0.42 16.98 17.40

df

4 164 168

4 164 168

4 165 169

4 162 166

4 162 166

4 163 167

Table 3 One-way ANOVA results for the effect of ICU type on CCFSS scores

Abbreviations: ANOVA, analysis of variance; CCFSS, Critical Care Family Satisfaction Survey; ICU, intensive care unit; MS, mean square; SS, sum of squares.

CCFSS

Overall

Assurance

Proximity

Information

Comfort

Support

In ICU before

4.61 (0.26)

4.55 (0.47)

4.58 (0.45)

4.72 (0.39)

4.11 (0.90)

4.71 (0.38)

Not in ICU before

4.68 (0.31)

4.64 (0.34)

4.63 (0.42)

4.77 (0.34)

4.32 (0.85)

4.79 (0.31)

P

.15

.12

.47

.38

.12

.18

t

–1.44

–1.59

–0.73

–0.89

–1.57

–1.36

df

170

171

171

169

168

170

Table 5 Comparison of CCFSS scores by whether the patient had been in the ICU beforea

Abbreviations: CCFSS, Critical Care Family Satisfaction Survey; ICU, intensive care unit. a

Data are presented as mean (SD).

CCFSS

Overall

Assurance

Proximity

Information

Comfort

Support

Family conference

4.69 (0.30)

4.59 (0.46)

4.71 (0.37)

4.79 (0.34)

4.25 (0.74)

4.79 (0.30)

No family conference

4.62 (0.35)

4.61 (0.38)

4.55 (0.45)

4.73 (0.37)

4.21 (0.94)

4.74 (0.37)

P

.23

.74

.03b

.27

.75

.36

t

1.22

–0.33

2.22

1.10

0.32

0.91

df

170

171

171

169

168

169

Table 4 Comparison of CCFSS scores by whether a family conference was helda

Abbreviation: CCFSS, Critical Care Family Satisfaction Survey. a

Data are presented as mean (SD). b P < .05.

Figure 2 Model of themes that relate to the family’s experience in the intensive care unit (ICU).

ICU family experience

Quality of patient care

Family engagement in the ICU

Family interactions with interdisciplinary

team

Family navigation of the ICU

environment

Information sharing and

effective communication

www.ccnonline.org CriticalCareNurse Vol 40, No. 6, DECEMBER 2020 47

The 5 themes that influence the overall ICU family experience: family interac- tions with the team, information sharing and effective communication, family navigation of the ICU environment, family engagement in the ICU, and quality of patient care.

nurses on their overall ICU experience. As one family

member wrote, “Care and compassion from the nurs-

ing staff was key in making [me] feel comfortable and

confident leaving [my] husband.” Another respondent

echoed the prominent role of nurses, explaining:

The nurses watched and monitored my husband’s

condition very attentively and carefully. Each mem-

ber of the nursing staff was friendly, assuring,

explained medicines and procedures to him and

[our] family and went to great lengths to make

sure that all of my husband’s needs and the needs

and concerns of the family were being met.

Respondents expressed their appreciation for per-

sonalized interactions with physicians: “I loved the

doctor . . . (he) gave me his first name—not his last,

I’ve never had that before. It made it so personal and

provided so much confidence and trust.” Some com-

ments described positive interactions with ancillary

staff members, including environmental services staff,

patient care technicians, respiratory therapists, admin-

istrative assistants, and social workers.

Information Sharing and Effective Communication. The theme of information sharing and effective communi-

cation describes how families value the opportunity to

receive honest information from the ICU staff conveyed

in a compassionate manner, as well as the opportunity

to share information with the team about the patient

from the family perspective to enhance the quality of

patient care. Respondents expressed a desire for frequent

updates, and many were satisfied that this occurred: “The

team discussed and continually updated treatment plan.

Always fine tuning.” Other family members reported diffi-

culty with “get[ting] information from the MD if you

aren’t here when they are” and asked for more in-person

contact with physicians. Others suggested alternative

methods of communication, such as “a central place to

communicate online with staff and other family members

to keep up to date.” Respondents explained that it was

vital that families stay connected during an ICU stay to

share information and communicate with other family

members who are unable to be present.

Respondents valued clear, honest, consistent, and

open communication with the team. One family mem-

ber reported that “. . . [staff ] were always honest and

open with me, they were never harsh or impatient—

always taking the time to answer my questions and

explain everything to me.” When confusion arose,

family members expressed their appreciation for the

clinicians who answered their questions:

The doctors also explained to my husband and

family members tests and findings, the plan of care

going forward, and made sure they answered our

questions and let us know that they were available

to answer any additional questions the family

might have.

Respondents emphasized that effective communi-

cation included not only answering questions but also

ensuring that those answers were understood.

The perceived quality of communication among health

care providers was also related to families’ appraisal of

effective communication. Some family members reported

that the information they received from various provid-

ers was not always in alignment, resulting in confusion

and distrust. One respondent shared: “It is OVER-

WHELMING to hear from so many doctors, nurses, tech-

nicians and put it in order. Too often they don’t agree

on treatment and we are confused as to what to trust.”

Family Navigation of the ICU Environment. The theme of family navigation of the ICU environment

describes how families perceive the challenges of manag-

ing as a family within the complex environment of the

ICU and how

this affects

their ability

to provide

supportive

care to the

patient. Some

respondents

described

challenges in obtaining access to their critically ill fam-

ily member. Others expressed frustration about being

limited to only 2 family members at the bedside. Family

members who wanted to spend the night in the ICU

were dissatisfied with hospital policy that discouraged

overnight stays. Family members reported logistical

challenges finding accommodations, as well as psycho-

logical strain on themselves and on patients when

48 CriticalCareNurse Vol 40, No. 6, DECEMBER 2020 www.ccnonline.org

separated. The desire for unrestricted stay in the ICU

was noted most frequently among family caregivers.

One respondent shared: “We (my husband and I) are

the guardians for our son. . . . We are his voice and know

him the best. We don’t care at all for this rule.”

Some family respondents requested a more robust

orientation to the ICU space, policies, and practices: “I

feel we had to figure out a lot of things on our own. . . .

I would like to have an initial introduction or orientation

to resources and facilities available for our family.” For

some families, lack of orientation to the ICU contrib-

uted to misunderstanding about ICU expectations. One

family member explained, “the rules are different in the

ICU [than] in other wings.”

Some respondents described difficulty meeting their

own needs due to the ICU physical environment. The

waiting room was described by some as small, cramped,

cold, and noisy. Others, however, did not share this per-

spective and described the ICU environment as “com-

fortable” and “great.” Respondents who were dissatisfied

with the ICU built environment described important

ways to improve family comfort, including comfortable

seating in the

ICU patient

rooms; private

or semiprivate

space outside

the ICU for

waiting, resting, and sleeping; and easily accessible

bathrooms and showers that would not require check-

ing in and out of the ICU. Families also wanted to be

self-sufficient in meeting their own basic needs near

the ICU, including having convenient access to an ice

machine, cold water, coffee, and a microwave, as well

as phone chargers. Some also requested a faster inter-

net connection.

Family Engagement in the ICU. The theme of family engagement in the ICU describes families’ desire

to be a partner in care. Families want to feel heard, par-

ticipate in patient care, remain present with their criti-

cally ill family member during some procedures, and

have caregiver consistency to facilitate the family

engagement process. Family members possess unique

knowledge of patients that is valuable in guiding care.

One family member wrote, “Staff should always listen

to family about the patient’s status changing . . . as we

know the patient’s ‘normal’.” Respondents viewed them-

selves as experts on their critically ill family member,

with clinically important knowledge deserving of atten-

tion. Much of this knowledge was tied to family mem-

bers’ roles as caregivers at home. When describing a

change in patient status, one family member commented

that (s)he “[has] all the answers—like if it happened

before or what worked.” Similarly, another family mem-

ber wrote: “We know my son, the patient best. . . . Listen

to him and us. We have a lot of knowledge about my son.”

As caregivers, family members may have encountered

similar scenarios to those that occur in the hospital and

want to share that experience to improve patient care.

In addition to contributing to patient care through

knowledge sharing, family members wished to directly

participate in care. For example, one respondent wrote:

“I would love for the family to be able to be in the room

for certain procedures and to be able to do things like

suctioning . . . .” Family members viewed access to patients

as essential for their own peace of mind but also for

patient well-being. One husband wrote that his “wife

had just been told that she has cancer” and that he

“should have been able to spend the nights with her,

to reassure her that she is not alone.”

Family engagement was enhanced by consistency

in providers and nurses. One family member shared,

Having the SAME NURSES caring for him is the

best part of your ICU. I felt the nurses were always

able to answer my questions and calm me when

I was freaking out because they knew all his issues

and he was also comfortable because he was

familiar with those caring for him.

Another explained, “the continuity and consistency

in care has been comforting and a real support to me.”

Quality of Patient Care. The theme of quality of patient care describes how families perceive the quality

of care their critically ill family member is receiving in

the ICU and is dependent on their interactions with the

interdisciplinary team, information sharing and effec-

tive communication, navigation of the ICU environment,

and family engagement. The quality of patient care was

perceived positively by the majority of family member

respondents. Many respondents used the open-ended

questions as a means to express gratitude for the quality

Respondents viewed themselves as experts on their critically ill family member, with clinically important knowledge deserving of attention.

www.ccnonline.org CriticalCareNurse Vol 40, No. 6, DECEMBER 2020 49

Nurses play a vital role in the transformation of family care because of their ongoing presence and interactions with families.

of care. Exemplifying the sentiments of many, one

respondent described feeling “impressed and grateful

with level of attention and care my dad has received

since he entered the ICU.”

Addressing pain and comfort was particularly import-

ant to respondents. Many family members used the

question “What do you want us to know about your

family member’s stay in the ICU?” as an opportunity to

express their appreciation for the efforts of the health

care team to achieve patient comfort and manage pain.

One respondent shared: “Our family member was well

cared for. Her nurses and care team members made

every effort to make her comfortable and to address

her pain level.”

Beyond physical needs, families expressed their

gratitude that the health care team also met patients’

psychosocial needs and treated them with respect.

One person shared,

He (patient) was very anxious to be staying in the

hospital and not knowing how long he would be

waiting for his heart transplant. Everyone was very

encouraging to him. All the doctors and nurses

helped him feel at home.

Discussion The data analysis in this project revealed important

information to guide family engagement in the organiza-

tion’s ICUs. Although a large percentage of feedback from

families was positive, families also described challenges

in navigating the ICU environment, including policies

that, at times, hindered their ability to be present at the

bedside with their critically ill family member. Family

members with greater access to the patient have more

opportunities to develop relationships with health care

professionals and be engaged in care processes.33 How-

ever, in order to gain access the family must learn

the rules and practices of the ICU. Navigating the

ICU environment is a documented challenge for

families.34-38 A formalized ICU family orientation

program could help families overcome this challenge

so they can play their vital role in supporting patient

care. By revising policies and guidelines that might

hinder family engagement, such as restrictive and

ambiguous visiting guidelines, an organization could

shift the practice and culture of an ICU toward more

active family engagement.

Findings from this improvement project indicate that

families want greater empowerment in health care pro-

cesses. They want health care professionals to acknowledge

their unique experiences as a family system supporting

their family member during critical illness. Developing a

culture that supports family engagement is an important

aspect of

nursing’s

vision to

improve

the family

experience in the ICU. Family inclusion champions in the

ICU may be one way to shift the culture to forging partner-

ships between the interprofessional team and families.

This organization will begin to explore its family engage-

ment culture by asking the family experience committee

to hold focus groups with patients and families to deter-

mine strategies for family inclusion. Inviting families

to share suggestions could inform and accelerate the

improvement process.

The finding in this study that families want to be

involved is consistent with theoretical and empirical

literature on family engagement in the ICU.1,2,12,39,40 In

one study, family members who participated in patient

care rated family-centered care in the ICU higher than

those who did not participate in patient care.41 Having

ICU nurses develop a list of patient care activities appro-

priate for various levels of family involvement is a

beginning step toward engaging families in care and

individualizing family involvement practices.

Many families who participated in this quality improve-

ment project had not experienced a formal family meet-

ing with the health care team at the time of the survey.

An important finding from the analysis was that families

who had the opportunity to participate in a formal fam-

ily meeting with the health care team rated their proxim-

ity to the patient more favorably. Family meetings allow

family members to express preferences for their involve-

ment in the care of the patient. In turn, the family meet-

ing is an opportunity for the health care team to strengthen

relationships with the family, learn more about the patient

as a person and their role in the family system, and engage

in bidirectional information sharing. Although frequent

updates at the bedside are one way for families and health

care professionals to share information, formal family

meetings are needed to fully engage with families.42 In

one quality improvement project, early nurse-led family

50 CriticalCareNurse Vol 40, No. 6, DECEMBER 2020 www.ccnonline.org

meetings in a neuroscience ICU improved families’ per-

ception of communication and satisfaction.43 Because of

their close and frequent interactions with patients and

families, nurses play a critical role in helping the inter-

professional team develop supportive relationships with

families. However, there is evidence that nurses are not

always invited to play an active role in family meetings

with the interprofessional team.44 Empowering nurses

to lead regular meetings with families is an important

target for improving family engagement in ICU care.

The organization will explore its practices regarding

family meetings in the ICU, including frequency, con-

tent, and nurse involvement. Developing strategies to

increase active nurse involvement in family meetings

could improve the family engagement process.

Findings from this quality improvement project

are similar to others reported in the literature. Fami-

lies want emotional support from health care profes-

sionals, access to their family member, and frequent,

high-quality communication with the health care

team.16,45-47 Some of the family respondents who partici-

pated in the project shared the idea of developing

electronic communication platforms between family

members and health care professionals. With the

prevalence of mobile devices, creating apps for ICU

communication is a noteworthy area for research and

development. These apps could provide updates and

facilitate ongoing communication with family mem-

bers who may not be able to be present in the ICU, as

well as store shared information in one place.

The scores on this family-specific feedback survey were

substantially different from those routinely captured after

discharge at this organization. Similarly, Lah and col-

leagues48 found a low correlation between an ICU-specific

survey and a general hospital survey, and concluded that

the general hospital survey did not capture the experi-

ences of patients and families in the ICU. This quality

improvement project was the organization’s first step

in the development of a formal family engagement pro-

gram and validated the importance of soliciting timely

family-specific feedback in the ICU. There is a need to

develop instruments designed specifically to capture

the quality and quantity of family engagement in the

ICU setting. Such measures could serve as catalysts

and guides for health care organizations in the process

of improving ICU family engagement.

Limitations This study used a convenience sample, and the num-

ber of responses reflects a small percentage of the total

population of patients admitted to the 5 ICUs. Limited

demographic data were collected. In addition, there was

some variability in the length of time in the ICU before

completion of the survey. Finally, only 1 member of the

family completed the survey; therefore, the responses may

not represent the overall family system perspective.

Conclusions The interprofessional critical care committee of the

organization raised the visibility of the family experience,

and the unique data collected will help guide nurse-led

family engagement innovations in the ICU. Nurses play

a vital role in the transformation of family care because

of their ongoing presence and interactions with fami-

lies. The organization’s next steps include developing

evidence-based patient and family engagement guide-

lines for the ICUs, sharing the results with the organiza-

tion’s patient and family engagement committee for

further improvement input, and sustaining the new

method of eliciting timely ICU family member feedback.

The finding in this quality improvement project that

families want to play a more active role in patient care

supports the need for strategies to help clinicians engage

with families in the ICU. Giving families a voice and devel-

oping a metric to determine success is an important first

step in promoting ICU family engagement. CCN

Acknowledgments The authors thank the critical care nurses in the virtual intensive care unit and Erin Green, BSN, RN, Inception Health executive director of digital health clinical operations, for their vital role in data collection and project support. Appreciation is also expressed to Kaylen Moore, BSN, RN, CCRN, SANE-A, SANE-P, for her assistance with data entry. We would also like to acknowledge Mary- Ann Moon, MSN, RN, ACNS-BC, APNP, director of advanced practice nursing, research and innovation, and the interprofessional critical care committee for their support for this important family engagement improvement work.

Financial Disclosures None reported.

See alsoSee also To learn more about family in the critical care setting, read “Depres- sion and Change in Caregiver Burden Among Family Members of Intensive Care Unit Survivors” by Beesley et al in the American Journal of Critical Care, 2020;29(5):350-357. Available at www.ajcconline.org.

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www.ccnonline.org CriticalCareNurse Vol 40, No. 6, DECEMBER 2020 51

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Student Name:

EBP

J

ournal Article in APA format:

Is this an Evidence Based

Article?

Name of Journal and

Year article was written?

Yes/No

Name of Journal

Year:

.2

points

State the problem

What was the goal of the project

in the article

?

Does this project correlate with

your problem? State how?

What are you trying to achieve?

Does this article support this

goal?

Problem:

Goal:

State how this article correlates

with your group problem and

goal.

.2

points

Strengths (Internal)

What’s was good about your

article?

Why was this project

successful?

List attributes of the article,

i.e. support from

administration, councils,

colleagues, institutions

.

Did this impleme

ntation take

place on a unit or area like

yours?

.4

points

Weakness (Internal)

-

issues

Example: lack

of education,

lack of staffing, staff readiness,

lack of support

; size,

managerial style.

.4

points

Opportunities (External)

Example: Lack of supplies,

educational

needs,

stakeholders, baseline (your

baseline data), what needs to

be improved?

.4

points

Threats

-

(External)

Staff buy in, support,

limitations and barriers, supply

cost, cost of implementation,

time, money, realistic?

.4

points

Total Points = 2 points

Student Name:

EBP Journal Article in APA format:

Is this an Evidence Based

Article? Name of Journal and

Year article was written?

Yes/No

Name of Journal

Year:

.2 points

State the problem

What was the goal of the project

in the article?

Does this project correlate with

your problem? State how?

What are you trying to achieve?

Does this article support this

goal?

Problem:

Goal:

State how this article correlates

with your group problem and

goal.

.2 points

Strengths (Internal)

What’s was good about your

article?

Why was this project

successful?

List attributes of the article,

i.e. support from

administration, councils,

colleagues, institutions.

Did this implementation take

place on a unit or area like

yours?

.4 points

Weakness (Internal)- issues

Example: lack of education,

lack of staffing, staff readiness,

lack of support; size,

managerial style.

.4 points

Opportunities (External)

Example: Lack of supplies,

educational needs,

stakeholders, baseline (your

baseline data), what needs to

be improved?

.4 points

Threats - (External)

Staff buy in, support,

limitations and barriers, supply

cost, cost of implementation,

time, money, realistic?

.4 points

Total Points = 2 points

Student Name:

XXXXXXXX

EPB Journal Article in APA format:

Sánchez, M., Suárez, M., Asenjo, M., & Bragulat, E. (2018). Improvement of emergency department

patient flow using lean thinking.

International Journal For

Quality In Health Care: Journal

Of The International Society For Quality In Health Care

,

30

(4), 250

–

256.

https://doi.org/10.1093/intqhc/mzy017

Is this an Evidence

Based Article?

Name of

Journal and Year article

was written?

Yes

Name of Journal

:

International Journal for Quality in Health Care

Year:

2018

.

2

points

State the problem

What was the goal of the

project?

Does this project

correlate with your

problem? State how?

What are you trying to

achieve? Does this

article support this goal?

Problem:

Delays in the ED compromise quality of care and patient

safety

while simultaneously increasing

mortality and healthcare costs.

Internal inefficiencies and poor resource utilization may contribute to

delays in care

and

overcrowding.

Goal:

The goal of this project was to achieve a target time of 160

minutes

(total)

, per patient in the ED.

·

80 minutes

of “added value” (i.e. specific amount of time

with a nurse and doctor

for assessment, treatment, and

education

)

·

60 minutes for lab results

·

20 minutes for treatment steps that could not be eliminated

using the Lean process

The goal of our group project is to propose a plan to decrease wait

times

and

improve flow to care areas. The

study

outlined

in this

article directly correlates with our group project in that

its aim was

to

tackle the issue of increased wait times leading

to delay of care and

negative outcomes, including decreased patient satisfaction and

the

increased

risk

for mortality. The goal of our group project is to

propose a plan to

reduce

wait times

in order

to improve patient

outcomes, which is exactly what the a

rticle’s research

ers

set out to do

by proposing the use of

l

ean

p

rinciples to eliminate

the

unnecessary

steps/processes that add to wait times.

.

2

points

Strengths (Internal)

What’s was good about

your article?

Staff Input

:

This project was heavily supported by the ED staff

and administration. In fact, the ED staff were empowered to make

the necessary changes by identifying steps

(waste)

that slowed flow

and hindered the care process

. They were also tasked with

recognizing

p

rocesses that could be standardized to improve

efficiency in care.

Leadership Style:

Furthermore, the researchers encouraged a

“bottom

-

up” approach (democratic leadership) to achieve a more

enthusiastic acceptance

and implementation of the plan.

The ED

ex

ecutive team acted as

consultants

to help support and foster the

new process

to reduce internal resistance.

.

4

points

Student Name: XXXXXXXX

EPB Journal Article in APA format:

Sánchez, M., Suárez, M., Asenjo, M., & Bragulat, E. (2018). Improvement of emergency department

patient flow using lean thinking. International Journal For Quality In Health Care: Journal

Of The International Society For Quality In Health Care, 30(4), 250–256.

https://doi.org/10.1093/intqhc/mzy017

Is this an Evidence

Based Article? Name of

Journal and Year article

was written?

Yes

Name of Journal: International Journal for Quality in Health Care

Year: 2018

.2 points

State the problem

What was the goal of the

project?

Does this project

correlate with your

problem? State how?

What are you trying to

achieve? Does this

article support this goal?

Problem: Delays in the ED compromise quality of care and patient

safety while simultaneously increasing mortality and healthcare costs.

Internal inefficiencies and poor resource utilization may contribute to

delays in care and overcrowding.

Goal: The goal of this project was to achieve a target time of 160

minutes (total), per patient in the ED.

 80 minutes of “added value” (i.e. specific amount of time

with a nurse and doctor for assessment, treatment, and

education)

 60 minutes for lab results

 20 minutes for treatment steps that could not be eliminated

using the Lean process

The goal of our group project is to propose a plan to decrease wait

times and improve flow to care areas. The study outlined in this

article directly correlates with our group project in that its aim was to

tackle the issue of increased wait times leading to delay of care and

negative outcomes, including decreased patient satisfaction and the

increased risk for mortality. The goal of our group project is to

propose a plan to reduce wait times in order to improve patient

outcomes, which is exactly what the article’s researchers set out to do

by proposing the use of lean principles to eliminate the unnecessary

steps/processes that add to wait times.

.2 points

Strengths (Internal)

What’s was good about

your article?

Staff Input: This project was heavily supported by the ED staff

and administration. In fact, the ED staff were empowered to make

the necessary changes by identifying steps (waste) that slowed flow

and hindered the care process. They were also tasked with

recognizing processes that could be standardized to improve

efficiency in care.

Leadership Style: Furthermore, the researchers encouraged a

“bottom-up” approach (democratic leadership) to achieve a more

enthusiastic acceptance and implementation of the plan. The ED

executive team acted as consultants to help support and foster the

new process to reduce internal resistance.

.4 points