RESEARCH ARTICLES

User embracement in care for families at an intensive care unit

Silvia da Silva Santos Passos^I; Juliana Oliveira da Silva^II; Valdenice dos Santos Santana^III; Vanessa Marques do Nascimento^IV; Álvaro Pereira^V; Luciano Marques dos Santos^VI

^I Nurse. M.Sc. in Nursing. Assistant Professor at the Health Department of the State University of Feira de Santana. Ph.D. Candidate in Nursing at the Nursing School of the Federal University of Bahia. Brazil. E-mail: ssspassos@yahoo.com.br
^II Nurse. Has an Expert Degree in Intensive Nursing from Faculdade Nobre of Feira de Santana. Teaches at the Professional Technical Center Profissional. Nurse T the family Health Program of Feira de Santana. Bahia, Brazil. E-mail: julianna_sillva@hotmail.com
^III Nurse. Has an Expert Degree in Intensive Nursing from Faculdade Nobre of Feira de Santana. Coordinates the Multidisciplinary Team of Native Brazilian Health – Missão Evangélica, Health Ministry. Feira de Santana, Bahia, Brazil. E-mail: valdenicesantanna@gmail.com
^IV Enfermeira. Especialista em Enfermagem Intensiva pela Faculdade Nobre de Feira de Santana. Enfermeira da Clínica Médica do Hospital Municipal José Maria de Magalhães Neto em São Gonçalo dos Campos. Bahia, Brasil. E-mail: venf.nessa@outlook.com
^V Nurse. Ph.D. in Nursing. Adjunct Professor IV of the School of Nursing of the Federal University of Bahia. E-mail: alvaro_pereira_ba@yahoo.com.br
^VI Nurse. M.Sc. in Nursing Teaching Assistant in the Nursing Program of the State University of Feira de Santana. Bahia, Brazil. E-mail: lucmarxenfo@yahoo.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2015.6259

ABSTRACT

This qualitative, descriptive study described how nurses appropriate user embracement in caring for families in the ICU. Data were collected through semi-structured interviews of six nurses working in the ICU of a public hospital in Bahia from May to June 2011. From thematic content analysis of the transcripts, three categories emerged: welcoming the family in the ICU; relating to families in the ICU; and caring for families in the ICU. The results highlight that nurses understand the family as a unit of care, but feel unprepared in user embracement, which is thus restricted to applying case history and anamnesis on admission, and providing updates on patient clinical condition during visits.

Keywords: Intensive care unit; family nursing; user embracement; nurse-patient relations.

INTRODUCTION

Patients in serious conditions in need of intensive care must be in high tech environment, which can favor their treatment and recovery. The Intensive Care Unit (ICU) differs from other internment units. Found aggressive and invasive, treatment in that environment is translated for its highly intensive and complex events and situations for both patient and patient's family. It can be less hostile in case health professionals acknowledge the unique and specific needs and character of each human being¹.

The ICU is regarded as the place where massive technological resources can be found, which can be surrounded by pain and suffering, a place where techniques and machines prevail and technological skills and knowledge are required.

However, to put together technological resources and humanitarian values has become a challenge to the health team, under continuing interaction with care technologies and techniques required for life preservation and imminent death.

Human values in the ICU care are acknowledged with the engagement of health professionals with patient and patient's family. At that point emotional needs and the use of technology can be dosed off².

To clients and their family members, hospitalization at the ICU is a stressful and unique experience, caused by factors such as death risk; unknown treatment response and unpredictable recovery; fear of failure or of a bad prognosis or even of the unknown; anxiety; sadness; suffering; helplessness, and finally the imposing limitation from the detachment of family members off that scene³.

In that sense, in view of a relative's internment at the ICU, family members show signs of depression, anxiety, and post-trauma stress. The need to be close to patient and to receive adequate information, to have the chance to spell out their feelings and to obtain answers to their questions increases family's satisfaction⁴.

Therefore, strategies must be used to attenuate family's suffering over the internment of a dear one under intensive care. This way, incorporation in practice of effective embracement must allow for the setting up of a close relation between the health professional and those in need of care so that focus is not exclusively on disease. That practice at the ICU must be encouraged in view that the place holds massive technological apparatuses affecting interpersonal relations negatively.

Most times, family members are lost for ignoring ICU routine and having no guidance from health professionals. The nurse in charge for assistance and care has a work overload and usually has no opportunity to address the family's questions⁵.

In that context, our interest in the theme was spurred in the course of academic activities when we realized family members were kept apart from the nursing team. Having in mind that the relation between family members and nursing team must involve humanized care, our guiding question here can be thus formulated: How can the nurse use embracement in family care at the ICU of a state-run hospital in the backlands of the state of Bahia, Brazil? Therefore, the study aimed at describing how the nurse gets hold of family embracement at the ICU of a state-run hospital in the backlands of the state of Bahia, Brazil

User embracement is part of the National Humanization Policy in charge of ensuring citizens' rights to attention to their claims, and to user embracement so that they have adequate access to all units across the public health system, and can clarify their questions and attenuate their fear and anxiety with corresponding assistance to their needs and respect to their rights⁶.

The hosting act becomes an alternative to those professionals who pursue the revitalization of humanistic health care².

LITERATURE REVIEW

User embracement involves listening, that is, attempting at understanding what is said, the development of a listening skill. The embracement and listening act involves a relation between those involved in the process. In other words, actors involved must be committed to the true caring act⁷.

User embracement requires a leading role from each and every professional engaged in the health process, as well as their open mindedness and decisive valuing of their encounter with others, with a listening and committed attitude. A multi professional team must facilitate collective formulation of proposals and elaboration of therapy projects. Services must be reorganized to ensure that change as well as the very embracement of the professionals in their professional needs⁸.

A holistic approach has stood out in the search for improvement of care to patients in critical conditions. Patient and family-centered care has increased and aims at the improvement both in treatment quality and in patient and family's satisfaction⁴. Intensive care units prove to be one of the most stressful and complex hospital places when it comes to anxiety and depression levels among family members of patients staying at the ICU⁹.

Therefore, to embrace a family under intensive care must be a continuing practice integrating relevant care at the ICU. Nursing must review its relevant role for it can encourage humanization by means of educational initiatives.

Thus, to receive information on one's family member staying at the ICU, to be exposed to high tech environment and equipment, unsureness, and lack of communication with professionals are factors which cause uncertainty, anxiety, and stress to the families of patients staying at ICU.

In that context, user embracement is a humanitarian exchange relation, an activity that includes both the subjects and their social context, environment, service organization, the relation between professionals Thus, embracement is essential to the dialogue between professionals, patients and their families.

It is also an intervention mechanism which allows for health care process analysis with focus on relations and which presupposes the change in both professional/user/social net and professional/professional relations by means of technical, ethical, humanitarian, and solidarity parameters, which acknowledge user as subject and active participant in health production process¹¹.

Thus, humanization in health care assistance, especially that provided at the ICU, depends on work conditions professionals share as well as on their skills, including those in human relations. Care humanization in Nursing proves decisive to set up interaction and rapport with users of health care, including their family members¹².

To some family members, feeling embraced equals having support and attention from each and every professional, as well as having answers to all questions, even if they are not the desired ones. Humanization aims at putting care production into practice so that best technology available and embracement promotion are brought together in the work spaces favoring good technical exercise and satisfaction of both professionals and users¹³.

To weaken the present model and strengthen relations by means of the humanization of hospital services, the Health Ministry created the National Program for humanization and Hospital Assistance (PNHAH) in 2000. Such initiative includes integrated actions which make quality improvement possible as well as ensure the effectiveness of services, aiming at the betterment of interpersonal relations. Humanized actions, in this sense, aim at the integration of technical and scientific efficiency, ethics, respect, and the needs to client⁶. That program addresses humanization as a whole, and not specific activities as those in the intensive care units.

It is a hard job to reorganize the work scene whose actions are still centered in the technically-oriented model concerned with the disease, not with the subject, and almost exclusively with the patient interned, irrespective of family members. It is a challenge to Nursing, especially that acting at high complexity units, as the ICU².

Therefore, two bases for supporting Nursing must be considered – the complexity of the ICU care and the value of life as moral and ethical support to work. That practice is regarded as the act of user embracement. This way, valuing embracement turns out to be an alternative to those professionals concerned with fostering humanistic health care⁴.

METHODOLOGY

This is a descriptive study with qualitative approach, conducted at the adult ICU of a state-run hospital in the backlands of the state of Bahia, Brazil. Subjects to this study were six female nurses assisting at ICU, whose work might require interface with patients staying in hospital.

Data were collected from May to June, 2011, by means of semi structured interviews, on the basis of a script to the guiding question: How does the nurse conduct user embracement in family care at the ICU?

Data collection started upon approval by the Human Research Ethics Committee at the Faculdade Maria Milza, with protocol number 048/2011, in accordance with Resolution number 196/96 of the National Health Council. All participants signed two copies of the Free and Informed Consent Term and were identified by codes. Codes were represented by both the professional category (ENF) and the sequence number in the conduction of interviews.

Reports were recorded after interviewees' consent, and were later transcribed by the research team. Data were treated on the basis of theme contents analysis¹⁴, which requires a few preliminary steps, as follows: Preliminary analysis of subjects' speeches where family embracement by the nurse at the ICU is highlighted by means of the floating reading of all material collected.

In the organization phase, theme or recurrent frequency was sought, which involved the collection of record units in the interviews. A categorizing system was elaborated, which involved the grouping of similar and dissimilar data in speech contents. Thus, categorization allowed for the definition of three categories: family embracement at the ICU; connection with families at the ICU; and family care at the ICU, all of which discussed below.

RESULTS AND DISCUSSION

At the ICU this study is concerned with, nurses interviewed do not seem to be using embracement of the family experiencing disease and hospitalization process, considering that is associated either to institutional projects or personal attitudes

Category 1 –Welcoming the family to the ICU

To family members of those patients staying at the ICU, embracement is not a common condition, the sharing of health skills and knowledge within that space. Nurses' acknowledgement of family embracement proves to be unanimous, although they show difficulties embracing and directing family members.

That might sound contradictory because they highlight nothing is under way in that respect, as stated by one of the interviewees.

Well, embracement as such we have done no projects, no work on it. But within the unit a few nurses and a few technicians show embracement by means of talking, of calming down, of clarifying, but technology takes us away from that activity because we're concerned with the part of mechanical control. (ENF 1)

Priority ascribed to embracement, according to interviewee, is related to equipment utilized in immediate assistance and in monitoring patients in critical condition. The relation between health workers and patients staying in hospital is vertical, structured knowledge-centered (technical operations, machinery, equipment, regulations, and routine). There is little valuing of the human relation, which is reduced and fragmented in favor of the privilege of just the physical aspects about caring¹⁵.

Nursing care and technology are interrelated, for professional exercise is committed to principles, laws, and theories, whereas technology can be regarded as the expression of that scientific knowledge, and in its own transformation¹⁶.

However, a contradiction can be registered among interviewees about conceiving family embracement. Upon admission, all one of them asks is the patient's name, providing any type of direction to another professional; another one mistakes the patient's admission interview for a form of user embracement. Here are the reports:

[...] user embracement happens upon patient's admission to the ICU, then, together with the patient, we receive the family member to have the interview with him or her, collecting patient-related data [...] which are important to admission, and, in addition to that, showing the routine-related issues at the ICU [...]. (ENF 2)

It is a highly limited relationship, we only get close at the moment of admission, and after that at the time of the visit, many a time we only get around and ask the patient's name; the family brings in questions, asks the technician, asks the nurse and what I can hear – wait until a doctor comes to talk to you after the visit – that's what usually happens as routine. That relationship is extremely limited, all one asks is what patient is coming in and who the family is visiting; the family comes in for the visit, waits over there, while the doctor reviews the records, the family leaves, that's it. (ENF 6)

In that context, nurses' workplace has not shown enough concern for the intersubjective context. Superficial interaction prevails, as a personal shortcoming from the nurses. That is underlined by the institutional routine which requires from them the conduction of bureaucratic activities. The complexity of routine activities inside the ICU seems to pull nurses apart from personal contact with their clients, rather than bring them together. Thus, user embracement is compromised¹⁷.

Work overload and long hours account for the restriction of contact with family to minimum necessary levels. As spelled out by the nurse:

[...] to begin with, time family has with patient is limited, so we do not have to be there, talking [...] we kind of see them to the bed and usually we always ask if they have questions. They look at the monitor and ask what that is, the beeping, then we tell them [...]. (ENF 4)

The moment the family is visiting the patient at the ICU is extremely important for nurses. Having to account for embracement and directions, they play a mediating role between the patient and the family, in an environment with machines and equipment, which make family members curious about and show the stressful conditions both are under⁵.

Thus, user embracement is not a place or space, but an attitude which implies the sharing of knowledge as well as the commitment of a multi professional team in charge of listening and solving users' problems⁶.

An additional regard for family embracement is tied in with the organizational aspect of care. The nurse uses the first contact with the family, after patient's admission to ICU to obtain information related to patient's health and disease background so that guidance on the unit's norms and clarification of possible questions the family as for the machines at ICU. Here is an additional report:

It's a highly limited relationship. I guess we just get close upon admission and during visits. Many times all we do is ask the patient's name. [...]. (ENF 6)

Institutional routine has pulled nurses and family members apart despite the on-going state of the art on families experiencing disease and hospitalization of their members. Attention focus of several nurses in intensive care still revolves around ICU technology apparatuses, which, in fact, increases their detachment from families

Category 2 –Connecting with families at the ICU

Data under this category evince that to the nurses interviewed the demand at the unit increases the detachment between professionals and family and that they acknowledge the need to offer attention to the family. According to the interviewees, directing or chatting with the family depend on routine at unit, since contact with family occurs when their hours on duty allow for that.

[...] depending on demand at work [...] the team conducts counseling, talks to family, and directs them [...]. Whenever demand at work is high we fail [...] then the family is an appendix; is part of the patient we must also be committed to them. (ENF 1)

[...] a better connection with patients' family should occur. [...] (ENF 2)

Care actions, one of the major elements in health work, especially on the scene investigated, must not be restricted to technical procedures, for impersonal and mechanical techniques can cause detachment from those receiving care⁷.

However, nurses participating stated a distant relationship is established with families, which runs contrary to family-centered care philosophy. Such detachment stems from barriers erected by health professionals, which compromises a good relationship between both parts.

Nurse professionals at the ICU use a few strategies to be detached from families, such as to step away from the unit to have meals during family visiting hours or to keep silent during the rendering of assistance, as evinced in the following speeches:

[...] many times in fact demand not being high, we are absent, succeed in committing the sin of being absent, use the moment the visit is going on to have some coffee, to chat with a colleague, to sit, that happens [...]. (ENF 1)

[...] the team itself sets up a barrier against family member, they go there to provide care and medication to the patient and the like, but usually with a serious and silent expression. [...]. (ENF 2)

Patient's admission to the ICU causes quick interventions, timed in face of his/her unstable condition, and the family can seldom communicate with the nurse The first contact between the family and the nurse at the ICU is charged with deep psycho emotional distress. It is at that moment that the nurse must get closer, guide the family on patient's condition and on regulations and routine at the unit, especially concerning visiting hours¹⁷.

Those facts are revealing that humanization is a challenge to that group. Investment in user embracement is still very shy. Additionally, physical and organizational structures do not favor incorporation of that action on that scene, which might suggest user embracement in most ICUs is a strategy still on the way to implementation. Further studies can bring in additional evidence to that suggestion, alien to the object of this present study.

Category 3 – Caring for the family at the ICU

To embrace patient's family, to provide directions and information on patient's health condition is part of nurses' daily care, as the following report has it:

[...] visits take place in the morning and in the afternoon; when the family member comes in the morning, I try to talk, if there is a question I can address it, I try to get closer to check if there's something the matter; at times they're uneasy. If there's some alteration, they get uneasy, then I keep on dropping by to clarify questions. They get very anxious about having information. But whenever they come in in the morning or even in the afternoon, before the doctor reviews the records, I pass on information off the records. (ENF 2)

Family embracement at the ICU is related to welcoming and to listening while meeting their needs. However, user embracement proves to be more than interested listening, and must not be limited to hosting at the admission desk. It includes a continuous set of listening activities, problem identification, and solution interventions. Ideas considered by nurses about user embracement must be added to notions of continuity, for welcoming practices, listening, and meeting family needs are actions to be carried out in every and each contact made with family members at the ICU¹⁷.

A few nurses have the necessary intervention skills to provide the family with during crisis¹⁸. This study shows a few professionals are concerned with family wellbeing, and help attenuate their distress, unsureness, anxiety, questions, and sorrow when they make use of care in holistic and humanized way.

It is relevant that family members are told the patient staying at the ICU has survival chances, as the following speech shows:

In practice, we try to calm them down, especially when it's their first visit! They get highly worried because they think to be there involves serious risks, that the patient is going to die. We usually calm them down, that part is done by the psychologist at the reception. (ENF 4)

Correct information is the shortest way to calm family members down; the humanizing act must be practiced by the entire multi-disciplinary team. However, theoretical basis for giving out patient's diagnosis is required so that incorrect information is avoided as well as the consequences that might cause to family members, such as anxiety, distress, and uneasiness. Unfortunately, however, high work overload prevents the nurse from doing much. They do enough in face of high demands to care, inform, embrace, humanize, and still take care of almost all paperwork, as the following nurse states:

[...] when the family member arrives, they usually think it's up to the nurses or to the doctors to pass on information, humanization is not just that, even the cleaning person can carry a humanized treatment, but I think that takes willingness, time [...] staff size drops everyday whereas work goes up [...] how can one give out humanized treatment if you are not treated in humanized ways, you see? (ENF 5)

Technology benefits at the ICU are undeniable. However, work dynamics usually pushes professionals into experiencing stressful situations, on account of the need for expert knowledge. Therefore, it is fundamental to highlight risks nursing professionals are exposed to, in view of the team's health and quality of care they give their clients⁵.

In view of the results attained, it has been found relevant that forming institutions should invest in meeting clients' needs, in developing skills of future nurses to make use of technological apparatuses. Assistance to family must also be valued, with priority to quality and humanization in critical care environment within hospital areas.

CONCLUSION

The attempt to describe the development of family embracement by nurses at the ICU and in view of the scope of this study, results show that user embracement is acknowledged by those professionals as an effective space for intervention with families, although nurses still do not feel prepared to make it routine; they prove to be the result of shy personal investment, in the sense that physical and organizational structures do not favor desired changes.

Nurses' work overload causes the accumulation of tasks, which, in turn, make them carry them out in technical and mechanical ways. A few nurses stand out for their ability to assist family members with clarification and direction.

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