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Personal cost, caring and communication: an analysis of communication between relatives and intensive care nurses Philip A. Scullion Much of health care is seen as ‘communication-centred’ (Smith & Bass 1982) and the interpersonal nature of nursing gives this view particular relevance. The potential contribution to patient well-being which is offered by good communication is being recognised by professional service providers and consumers alike. Whilst relatives or ‘significant others’ have an important impact on patient well-being, recognition of their own needs is becoming more evident. This paper, therefore, is intended to focus attention on communication between nurses and patients’ relatives in critical care settings. Needs of relatives are discussed along with an analysis of nurses’ responses to these needs, and nurses’ apparent reluctance to be involved is explored. A critical appraisal of the literature reveals compelling arguments for a decisive contribution by nurses to this area of care. Initiatives aimed at placing communi- cation needs of relatives more firmly within a nursing remit are then explored. Whilst intensive care units (ICUs) may generally demonstrate good practice in relation to communicating with relatives it is suggested that exploration of concepts surrounding both the nature of nursing and caring may offer valuable insights into this aspect of critical care nurses’ role. INTRODUCTION transactional, purposeful and multi-dimensio- nal (Dickson Hargie 1989). In spite of the Communication is a vast phenomenon which has complexities, ‘communication’ is a process that is been studied in detail (Shannon & Weaver 1949, highly valued within health care and conse- Myers & Myers 1985) and while the concept quently features most prominently in complaints dealt with by defies universal definition (Brooks & Heath Ombudsman the National Health Service 1985) communication is usefully seen as being Philip A. Scullion RGN, BSc (Hans) Nursing studies, Cert Ed, Nurse Tutor, Continuing Education RELATIVES’ NEEDS IN ICUS Department, Coventry and Warwickshire College of Nursing and Midwifery, Coventry and Warwickshire Hospital, Coventry CVl 4FH. UK (Requests for offprints to PAS) Manuscript accepted 5 August 1993 64 Within intensive care communication features prominently amongst the needs of relatives that have been identified through research.

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Page 1: Personal cost, caring and communication: an analysis of communication between relatives and intensive care nurses

Personal cost, caring and communication: an analysis of communication between relatives and intensive care nurses

Philip A. Scullion

Much of health care is seen as ‘communication-centred’ (Smith & Bass 1982) and the interpersonal nature of nursing gives this view particular relevance. The potential contribution to patient well-being which is offered by good communication is being recognised by professional service providers and consumers alike.

Whilst relatives or ‘significant others’ have an important impact on patient well-being, recognition of their own needs is becoming more evident. This paper, therefore, is intended to focus attention on communication between nurses and patients’ relatives in critical care settings.

Needs of relatives are discussed along with an analysis of nurses’ responses to these needs, and nurses’ apparent reluctance to be involved is explored.

A critical appraisal of the literature reveals compelling arguments for a decisive contribution by nurses to this area of care. Initiatives aimed at placing communi- cation needs of relatives more firmly within a nursing remit are then explored.

Whilst intensive care units (ICUs) may generally demonstrate good practice in relation to communicating with relatives it is suggested that exploration of concepts surrounding both the nature of nursing and caring may offer valuable insights into this aspect of critical care nurses’ role.

INTRODUCTION transactional, purposeful and multi-dimensio- nal (Dickson Hargie 1989). In spite of the

Communication is a vast phenomenon which has complexities, ‘communication’ is a process that is

been studied in detail (Shannon & Weaver 1949, highly valued within health care and conse-

Myers & Myers 1985) and while the concept quently features most prominently in complaints dealt with by

defies universal definition (Brooks & Heath Ombudsman the National Health Service

1985) communication is usefully seen as being

Philip A. Scullion RGN, BSc (Hans) Nursing studies, Cert Ed, Nurse Tutor, Continuing Education RELATIVES’ NEEDS IN ICUS Department, Coventry and Warwickshire College of Nursing and Midwifery, Coventry and Warwickshire Hospital, Coventry CVl 4FH. UK (Requests for offprints to PAS) Manuscript accepted 5 August 1993

64

Within intensive care communication features prominently amongst the needs of relatives that have been identified through research.

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INTENSIVE AND CRITICAL CARE NURSING 65

intensive care settings have in fact yielded a wealth of data concerning the needs of relatives which may reflect both the characteristics of ICU nurses and the nature of situations bringing nurses and relatives together. Although studies highlight different priorities of needs, there is considerable agreement. Molter (1979) in a major study in the USA, showed the three priority areas to be:

0 Need to feel hope l Need to feel that staff care about the patient l Need to be kept informed about progress etc.

In the UK Dyer (1991) has categorised needs, as reported by relatives from an ICU, in priority order as follows:

l Cognitive - concerning the ICU environ- ment, information about progress etc

l Emotional - contact with and contribution to the patient’s care

l Personal - facilities for use by the relative.

Personal needs were seen as least important and the priorities identified by Molter (1979) fall into the cognitive and emotional categories of Dyer (199 l), thus agreeing with this hierarchy of needs. Cognitive needs were also ranked highly by both nurses and relatives in a study by O’Malley et al (1991). In practice the categories of need overlap but effective communication of information is essential if any of these are to be addressed successfully.

CRITICAL CARE NURSES’ REMIT

The issue of professional carers communicating with relatives of patients is set within its historical and cultural context (Darbyshire 1987), whereby separation has been accepted as a necessary corollary to the practice of hospital-based high technology medicine and nursing. Patients requiring intensive care are further separated by segregation from the remnants of normality associated with a busv hosoital ward.

Role boundaries are not always clearly defined when it comes to communicating with relatives, especially when ‘bad news’ is to be conveyed (Laurent 1991, O’Malley et al 1991). In such situations the role may be shared with the physician or the chaplain. On less threatening topics, Gibbon (1990), in one of the few British studies, found that it was senior student nurses who frequently dealt with requests for informa- tion. Furthermore they most commonly used ‘referring’ upwards, within the prevailing healthcare hierarchy, in order to cope with such requests.

Clinical specialist roles related to death and dying that are emerging in the USA (McCord 1990) and the UK (Wright 1991) could pave the way for a de-skilling process affecting nurses. Furthermore, such specialists or consultant nur- ses may offer the opportunity for selective referral to be used as a coping mechanism by other nurses. Intensive care nursing, however, enjoys a high profile and attracts a high calibre of staff who derive a peculiar satisfaction from the intimacy with families required by their role. Even if a nurse is not coping well with the demands of relatives the very act of referral to a specialist may be viewed as failure, making this course of action unlikely.

Perhaps the task of speaking with relatives is seen as a low order activity by some people. Status may increase with the technical nature of the intensive care nurses’ role, giving rise to role conflict with the consequent danger of ‘losing sight of the bedpan’ (Dunlop 1986).

Supporting factors Increasing professional belief and commitment to an holistic approach (Hartley 1990), along with philosophical concepts underpinning nurs- ing models, have reversed the biological focus and placed ‘whole persons’ and their social context firmly onto the nursing agenda. Intensive care staff are thus not exclusively concerned with the technical aspects of the environment. Communication is viewed as a normal activitv of living. so the ‘uniaue function

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66 INTENSIVE AND CRITICAL CARE NURSING

of the nurse’ (Henderson 1969), and nurses’ not have enough spare emotional energy to look advocacy role (UKCC 1989) dictate that they for help, it has to come to them’ (Jones 1991), yet have an important contribution to make in terms according to Bond (1982) the onus to obtain of facilitating this activity. information, in practice, still rests with relatives.

Since most intensive care nurses work directly or indirectly for a Health Authority they have devolved responsibilities, as laid out explicitly in the ‘Patient’s Charter’ (DoH 1991) which pres-

RE-UCTANCE EXPLORED

tribes the establishment of systems for the provi- sion of ‘information to relatives and friends’.

The Charter standard is that health authori- ties should:

ensure that there are arrangements to inform your relatives and friends about the progress of your treatment subject, of course, to your wishes.

Views of the family

Much of the literature on communication with relatives recognises their potential role in influencing positively the outcome of illness or rehabilitation (Stroker 1983), highlighting again the importance of this issue, particularly within critical care. However a widespread assumption that family relationships are stable or ‘functional’ where ‘emotions and reasoning are balanced’ (Schlump-Urquhart 1990) is not frequently chal- lenged in the literature. The importance of assessment of the patient’s family when con- sidering the nurses’ role in this area of care, and information-giving being subject to the wishes of the patient as enshrined in the ‘Patient’s Charter’, is thus brought to the attention of practitioners.

It is accepted that admission of a family member to an ICU may seriously disrupt family dynamics (Brown 1987). Any pre-existing con- flicts may be magnified, leading to a pre-crisis state within the family unit. The nurses’ potential impact, in breaking the ‘crisis circle’ (Caplan 1961) and enhancing family stability, is evident. This is particularly so considering that seeking information and requesting reassurance are both identified by Schlump-Urquhart (1990) as common effective coping mechanisms used by family members of serious trauma victims. It is recognised that during family crises ‘people do

In spite of compelling evidence in support of a pro-active stance and a clear case for nurses having a major contribution to make in dealing with the needs of relatives (Murgatroyd & Woolfe 1985), it would appear that giving information to relatives is not an aspect of the nurses’ role that is enthusiastically embraced.

Dissatisfaction with information given is prob- ably more widesread than reports suggest, as the ‘captive’ client groups and their relatives may wish to avoid the consequences of being labelled ‘unpopular’ (Stockwell 1972). In spite of this some general dissatisfaction is evident, along with the view that there is a lack of serious attention to communication problems within healthcare settings (Hughes 1982, Bond 1982, Ley 1977).

Fox ( 1985) described appalling experiences as a visiting relative and identified that the relatives’ role in this particular instance was to ‘keep out of the way’ and not to ‘ask for information’. Whilst such anecdotal evidence cannot be generalised, it should not be dismissed as insignificant. The United Kingdom Central Council (UKCC) Code of Professional Conduct would not, of course, condone such complacency.

Tradition and ritual (Walsh & Ford 1989) may result in routines that serve the organisational or staff needs, rather than those of patients or their relatives. Hodgson (1983) highlights that ‘being busy can be a good smokescreen’ and sees information as ‘power’, which may partially explain the apparent reluctance on the part of nurses to convey information to relatives.

Menzies (1970), however, identified the nurse- patient relationship as the core of anxiety for nurses:

The closer and more concentrated this rela- tionship, the more the nurse is likely to experi- ence the impact of anxiety.

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INTEIU’SIVE AND CRITICAL CARE NURSING 67

If ‘relative’ is substituted for ‘patient’, as is often the case in an ICU, there is of course the potential for as much, if not more, anxiety since there may be less role constraints inhibiting relatives. So to suggest that nurses should extend their scope of caring to relatives may well give rise to some guilt and alarm, as the sorrow and anxiety associated with caring (Hodgson 1983) may be acutely unwelcome. Indeed resistance to any shift away from a task allocation system, such as primary nursing, may be explained with reference to the psychological protection afforded by such a system. Where contact relates to the death of patients, the incidence of burn- out is well documented (Wright 1991). This is supported by evidence that death and bereavement are consistently ranked as among the most stressful aspects of the nurses’ role (Birch 1979, Davies 1991). Clearly, intensive care nurses are, by virtue of the nature of their specialty, frequently close to both relatives and bereavement.

Compassion towards relatives may therefore be seen to be lacking as ‘nurses struggle to distance themselves’ (Walsh 1990), perhaps as a defence mechanism. Such an analysis should be addressed and the needs of staff considered when the apparent reluctance to become involved with relatives shows nurses in a negative light.

In all of our considerations on nursing the evidence has been largely North American, and this applies equally to recent developments in our approach to nursing. Miller (1985) flags up a warning about the uncritical acceptance of American theory in view of the more reticent British culture. Similarly the cultural, political and socioeconomic context in which nursing takes place must be acknowledged in the nurse- relative relationship. Transatlantic philosophi- cal transplants may serve to distort perceptions, raise nurses’own demands upon themselves and give rise to professional guilt and burn-out. Caution is called for in any analysis of the situation within the UK, if the well-being of nurses themselves is to be considered. Similarly, if the dangers and professional consequences of labelling relatives ‘unpopular’ (Stockwell 1972) are to be avoided, reflective analysis is called for.

PERSONAL FOCUS OF NURSING

Focus on the personal aspects of caring to communicate (Ashworth 1980) in addressing the needs of relatives, seen as ‘the essence of nursing’ by Dyer (1991), may prove fruitful in maintain- ing good practice or indeed providing a stimulus for improvement.

As nursing courses move steadily up the academic escalator and the search for a distinc- tive body of nursing knowledge continues, certain spin-offs of practical relevance to this topic are becoming evident. Chinn 8c Jacobs (1987) developed the work of Carper (1978) to provide a framework that identifies and legiti- mates ‘personal knowledge’ as a form of nursing knowledge to be valued and developed. It is suggested that in order to relate to another human being, personal knowledge must be developed. The shift of emphasis away from an exclusively scientific basis brings the care and communication needs of relatives back into focus.

The approach of Orlando (196 1) who sees, ‘nursing interventions as a significant thera- peutic interpersonal process’ further legitimises this focus and is being adopted within general and critical care nursing.

Theoretically therefore, nurses have a central role in communicating with relatives. However, translating theoretical perspectives into practice highlights a tension familiar to teachers and learners of nursing alike. This tension may, in part, be due to a perceived demand for time and energy to be spent on relatives that nurses see as more legitimately belonging to patients. This being the case, the registered nurses have clear direction and obligation to ‘make known to appropriate persons’ (UKCC 1984) any such serious situation.

In consequence of the lack of integration of theory and practice Kobinson 8c Thorne (1984) suggest that the relationship between health care professionals and relatives will develop through three stages:

l Naive trusting l Disenchantment l Guarded alliance

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68 INTENSlVEANDCRlTICALCARENURSlNG

All of these fail to meet their needs or achieve professionally acceptable standards.

INITIATIVES

National Health Service Trusts may strive for the ‘Chartermark’ (The Prime Minister’s Office 1991) in the light of the positive correlation between good communication and quality care. Along with the Post Registration Education and Practice Project (UKCC 1990) and the English National Board’s Framework (199 1) and higher award scheme, such initiatives will undoubtedly stimulate developments and improvements in the ways in which relatives are viewed.

Most ICUs already have written information available for relatives in the form of a booklet. Many are developing standards governing the provision of care and communication in relation to relatives and other visitors. It is nurses who are often assuming key roles in such initiatives and becoming change agents. (Harley 1990).

The role of nurse education Professional education at all levels has evolved to encompass families as legitimate subjects of nursing care. Relevant studies that may improve the coping abilities of learners and enhance the integration of theory and practice in this area of care are now well established. These include: family and group dynamics; self awareness; communication studies; bereavement; counsell- ing and stress management. Hentinen (1983) identified information needs of relatives as being neglected by nursing curricula. However the decade since then has seen the last of advice to students about maintaining a ‘professional’ dis- tance in terms of emotion.

The need for staff support systems is increas- ingly recognised and educational establishments usually have a counselling facility. It is conceded that there may be a need for subject specialists to bring the supporting strands together more coherently in educational programmes.

Such integration may be achieved in a variety of ways. Distinctive teaching sessions, dealing with ‘caring for relatives of critically ill people’

could make use of realistic videotapes. Students’ fears and stress management could then be explored in an experimental and relatively safe way.

Mentorship is an important part of the learn- ing environment and communication with rela- tives has been identified as one of the essential competences to be achieved by those under- taking specialist post-registration courses in critical care. Sensitivity to the needs of relatives may require the exclusion of learners from some interactions, and it is acknowledged that learners have no right to such experiences. But by pointing out the learning potential of such encounters, perhaps via the educational audit, this potential is more likely to be realised (Crossfield 1990).

The ‘lecturer practitioner’ has recently been accepted as one model which bridges the theory- practice gap and offers learners a role model who may be free from some of the constraints felt by mentors. The supportive-educative mode of Orem’s model (McCord 1990) may be employed to good effect.

Educational assessment plays a not insignifi- cant role in the experience of students and, in their perceptions, it may clothe elements of the curriculum with enhanced importance and rele- vance. This offers one further means open to educationalists to shape the nursing agenda and to highlight communication and relatives expli- citly within both theoretical and practical ass- essments.

CONCLUSIONS

Whilst communication skills training is advo- cated by many (Dickson & Hargie 1989) it is evident from a philosophical perspective that the attributes of human caring extend deeper into human experience than mere skills. This paper has explored the vulnerability of nurses asso- ciated with close encounters with relatives in critical care settings. Systems for student and mentor support are certainly necessary. An exploration of such issues can give students insights into the origins of caring as it extends to the patients’ relatives, particularly in relation to

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10s where the need for the ‘cold and imperso- nal world of science and technology to be infused by the things of the spirit’ (Hellegers 1975) could be seen as urgent. If the personal pattern of knowing is neglected we face the danger of our students developing what has been termed ‘commercialised compassion’ or ‘calculated kind- ness’ (Roach 1987), the value of which may evaporate when communicating with distressed families in a critical care setting. For at the very root of this analysis lie questions concerning the nature of nursing and the nature of caring communication that must be explored if students are to be adequately prepared to deliver a high quality service in what promises to be a very challenging professional future.

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