Research roundup: Supporting families with loved ones in the ICU

The mental health impact of hospitalization for a critically ill patient can be great, however, the impact for family members attempting to cope during and after the experience may be even greater.

Since the start of the pandemic, families with a loved one who has contracted COVID-19 often cannot provide physical and emotional support during intensive care unit (ICU) and hospital stays due to infection control practices. Family members are desperately seeking information about their loved ones’ health care status while simultaneously feeling helpless as their loved one is hospitalized.

The following studies explore how coping strategies and skills, searching for meaning in order to build resilience, and transitioning from the ICU to a less critical care hospital unit psychologically affects families who are caring for critically ill relatives. While none of these studies are specific to COVID-19, the findings are applicable broadly.

Rückholdt, M., Tofler, G.H., Randall, S., and Buckley, T. (2019). Coping by family members of critically ill hospitalised patients: An integrative review. International Journal of Nursing Studies, 97, 40–54. https://doi.org/10.1016/j.ijnurstu.2019.04.016

When family members successfully cope with a relative’s hospital stay, the ICU patient may experience better health outcomes.

The authors of this review screened 643 studies of adult family members of patients who had been admitted to the ICU to explore their coping styles and strategies during admission and discharge. Following a two-stage eligibility screening and a data quality evaluation process, 15 studies from varying regions around the world were included in the integrative review. The data analysis included the use of several matrix tables to compare the characteristics of each selected study and group together those with common themes that then allowed for the synthesis of common coping strategies and outcomes.

While an individual’s coping style is dependent on his/her personality and disposition, two main types of coping strategies he/she may implement include emotion-focused (attempting to reduce negative emotional responses associated with stress) and/or problem-focused (aiming to remove or reduce the cause of the stressor). The authors found that avoidant emotion-focused strategies, like denial and distraction, may be helpful at the outset, but their long-term implementation may be harmful and contribute to additional and/or more severe mental health issues. Incorporating both active emotion- and problem-focused coping strategies is most beneficial.

Wong, P., Liamputtong, P., Koch, S., and Rawson, H. (2019). Searching for meaning: A grounded theory of family resilience in adult ICU. Journal of Clinical Nursing, 28(5-6), 781–791. https://doi.org/10.1111/jocn.14673

When family members are supported during their relative’s admission to the ICU, they are better able to make sense of the situation, feel valued, and offer critical expertise to the health care team resulting in better health care for the patient.

Using a constructivist grounded theory, this study aimed to understand the multiple perspectives of family members’ experiences as they interacted in the ICU, and to provide an explanatory framework for their interactions. 25 adult family members of 21 patients, who were unexpectedly admitted to a generalized ICU in metropolitan Australia, were interviewed by a registered nurse on their experiences during their relative’s ICU stay. Data were collected in three coding phases: initial, focused, and theoretical.

The authors conclude that the unexpected hospitalization often causes family members to feel they have lost control which in turn contributes to greater feelings of anxiety and distress. This, then, interferes with the family members’ ability to contribute to decision-making and advocacy on behalf of the patient. As families regain control, often by discerning some meaning in the situation or for their role, they build resilience as well as the potential to better meet their family members’ needs.

Uncertainty about a critically ill relative’s health status leads family members to seek out information in various ways in order to make sense of the situation and find meaning. Family members cite needing to piece together information from various health care staff and sometimes still not being able to make sense of the bigger picture. This increases the potential for families to develop postintensive care syndrome (PICS-F), marked by anxiety, depression, and posttraumatic stress disorder.

By clearly communicating and engaging family members in patient care, the health care team can lessen the potential for PICS-F and help family members find meaning in the experience, in turn building resilience and better helping their family member.

Herling, S.F., Brix, H., Andersen, L., Jensen, L.D., Handesten, R., Knudsen, H., and Bové, D.G. (2019). Patient and spouses experiences with transition from intensive care unit to hospital ward—qualitative study. Scandinavian Journal of Caring Sciences. Advance online publication. https://doi.org/10.1111/scs.12722

When the health care team clearly and consistently communicates expectations to the patient’s family members, a patient’s transition from the ICU to a less-intensive hospital ward is smoother and recovery may benefit.

For this study, researchers interviewed patients and their close family member or spouse about their transition from the ICU to a less intensive hospital ward to assess how health care teams can best support patient recovery during this process. During a five-month period, researchers conducted semi-structured interviews with ten patients and their close family member at a Danish hospital. Patients were between 40 and 78 years old and in the ICU for at least three days. Interview data was analyzed using an interpretive description method.

The authors found three main themes regarding patients’ transition from the ICU to a hospital ward:

• Goals changed from bodily-functioning for survival to basic, everyday activities where the patient needed to begin rebuilding and taking control of their life.
• Dependent, round-the-clock care became independent, intermittent care.
• Integrated family members became regarded as visitors.

The ICU is an environment where patients and families are highly dependent on the health care team. The study highlights how transitioning to the hospital ward can be abrupt and little preparation is offered as patients are moved to the hospital ward, an environment that offers less personalized care and requires the patient and family to be more autonomous. To manage this transition, the health care team and patient’s family must work closely to benefit the recovery of the patient. This includes clear and constant communication, setting expectations, and knowledge of the various transitions a patient can expect throughout a hospital stay.

Uncertainty increases the likelihood for psychological distress and subsequent mental health implications for family members of critically ill patients. Taking steps to resolve uncertainty can help patients and their families cope and build resilience from the time of admission through recovery. Health care teams need to support family members by providing clear communication, information, and expectations and engaging them throughout their loved one’s hospital stay.

Given the current COVID-19 pandemic and physical distancing restrictions, family engagement does not look the same at every hospital. Unit staff that might normally engage and support families may not be available as they treat patients. Psychologists can find ways to bridge the gaps for families to continue to be involved so they can advocate for their loved ones. Psychologists affiliated with hospital treatment teams may wish to promote patient- and family-centered care, which promotes collaboration between the health care team, families, and critically ill relatives and support efforts for early discharge planning. Additionally, psychologists can help family members develop more effective coping strategies during the time of their loved ones’ care and recovery, and help these family members make sense of and find meaning during these uncertain times.

APA is continually updating its resources during the COVID-19 pandemic. Delirium, PTSD, brain fog: The aftermath of surviving COVID-19, may provide further insight on this topic.