Reducing Stress and Anger Among Family Members.

Abstract

Patients’ family members are often stressed, and sometimes they get angry with nursing staff. What is the best way to respond to those feelings?Janice Linton, DNP, APRN, ANP-BC, CCRN, ACHPN, replies:Clinicians in hospitals provide medical care and intervention to improve the outcomes of sick and injured patients. Hospitals—especially intensive care units (ICUs)—can, however, be a frightening place that causes anxiety, uncertainty, and stress among patients and their families. Among persons receiving ICU-level care, 1 in 5 will die in the hospital or soon after being discharged.1 Families entering an ICU are often overwhelmed by unfamiliar sights and the sounds of alarms and medical jargon, and they are blindsided by the image of their critically ill loved one receiving life-prolonging care.In these unfamiliar spaces, family members are frequently stressed and sometimes become angry with the nursing staff who approach them for an urgent consent for blood transfusion, for example. Families grapple with the complexity of their loved one’s illness and struggle to make decisions about medical matters they may not understand. Families often lack a basic understanding of their loved one’s medical condition, options for care, and prognosis even after being exposed to the ICU environment for 48 hours.2The action plan set forth in Healthy People 2020 to improve health literacy charges clinicians with the responsibilities of communicating and delivering health information in understandable ways, and assisting patients and families in making informed decisions.3 Nurses are integral to the health literacy initiative. Early, clear, and purposeful communication with families about their loved one’s medical condition and its trajectory, treatment options, and prognosis improve health literacy and reduce family members’ stress and anger as they deal with the acute crisis in the ICU setting.4According to the crisis theory put forth by Erich Lindemann,5 crisis often manifests as disturbed equilibrium. As family members endure the situational crisis of having a loved one in the ICU, they ride the uncertain roller coaster of hovering, seeking information, tracking, and garnering resources.6 Hovering, the initial phase of stress, manifests as worry and anxiety about their loved one’s medical condition and the ICU environment. While seeking information, families ask multiple questions but report that clinicians share limited information, thus amplifying the hovering phase. In the tracking phase the family evaluates the care and the caregivers. Garnering resources is the final phase, during which families seek tangible support to meet their emotional needs.6Studies demonstrate that family members attribute distress and dissatisfaction to low levels of family-clinician communication and poor emotional support from the medical team.7 Researchers used the Family Satisfaction With Critical Care Questionnaire to evaluate the experience of 29 family members whose loved ones received care in a trauma ICU. The study reflected high ratings for overall satisfaction with ICU care and staff competency and skills, but low scores for the frequency of communication from nurses and physicians, and for accessible, understandable information and compassionate family support (see Table). The participants reported anxiety, stress, and a lack of clarity and consistency in communication from clinicians.7 Anxiety and stress often ensue in family members when clinicians report results of quantitative laboratory tests and radiographic scans as “better”: a spouse just sees their partner, swollen, on a ventilator, and unresponsive to the familiar terms of endearment being whispered to them since their admission to the ICU. Who engages in the dialogue—and when and where— to quantify “better”?In the multicenter PARTNER trial (Pairing Re-engineered ICU Teams with Nurse-Driven Emotional Support and Relationship Building), researchers compared data from the intervention—a structured family support protocol implemented by the ICU team— with usual ICU care. Nurses who participated in the PARTNER trial received formal training about communication skills. The training focused on supporting families of critically ill patients and included role-play and structured feedback for quality improvement. The hospital settings also used standard protocols for clinician-family meetings that would occur within 48 hours of a patient’s admission. For the group who received the intervention, the results revealed better surrogate ratings for quality of communication and better patient and family-centered care. Patients whose families were in the intervention group also had shorter ICU stays than patients whose families were in the usual care group.1Skilled clinician communication is a valuable practice in response to a family’s stress and anger.Evidence from a systematic review of interventions to improve clinician-family communication supports the ability of both printed information and structured communication by specialty palliative care providers and trained ICU teams to reduce family stress and improve emotional outcomes.9 Board-certified palliative care providers are skilled at managing refractory symptoms and engaging in complex medical decision-making conversations. All clinicians should have primary palliative care skills such as basic knowledge of how to assess symptoms, how families cope, and how to initiate patient- and family-centered conversations.10Nurses in the ICU perceive their role as coordinators and advocates of family-centered communication, yet despite being vital members of the health care team, they report feeling undervalued and disempowered during family meetings.11 Nurses share vulnerable space with families who endure waves of anger, abandonment, distress, despair, and hope. They hear stories of wellness the patient once enjoyed. They listen to the family’s hopes for their loved one’s recovery and sense the family’s internal conflict as they consent to ongoing interventions that sometimes seem to be more burdensome than beneficial. They are at the forefront of the anger that is sometimes the sole emotion a family is capable of displaying. For patients and families, nurses are accessible, responsive collaborators in the daily delivery of care.In the era of heightened virtual engagement with online courses, nurses have favorable opportunities and multiple platforms through which to participate in asynchronous and synchronous communication skills training. The American Association of Critical-Care Nurses, Center to Advance Palliative Care, End of Life of Nursing Education Center, Hospice and Palliative Nurses Association, and Vital Talk offer online communication skills training courses for clinicians. Synchronous communication skills training would allow participants to engage in virtual role-play, share best practices, and receive, in real time, evaluative feedback from instructors and peers. Educating, training, and empowering nurses to engage in family-centered communication will improve their role as advocates and collaborators in reducing the stress and anger family members direct at nursing staff.