The Impact of Family Engagement on Anxiety Levels in a Cardiothoracic Intensive Care Unit.

Abstract

Having a loved one in the intensive care unit (ICU) can be stressful and anxiety inducing. Anxiety rates in family members of relatives in the ICU have been documented at 80%.1 Often family needs are not met during the ICU stay, and unmet needs can contribute to increased anxiety. Higher anxiety levels in family members have been reported to persist even 3 months after their relative is discharged,2 and development of these adverse psychological outcomes is being called post–intensive care syndrome-family.3A recent review4 of studies on effective nursing interventions for meeting family members’ needs in the ICU published between 2000 and 2013 revealed that high-level evidence from experimental studies is lacking. Facilitated sense-making (FSM) is a relatively new strategy and middle range theory that can guide nursing interventions to support and engage family members of patients in the ICU.5 A review of MEDLINE and CINAHL up to August 15, 2015, revealed only a feasibility study conducted by Davidson and colleagues,6 who reported that FSM was both feasible and helpful to family members of ICU patients receiving mechanical ventilation.The theory of FSM is based on the concept that family members need to make sense of the ICU and discover their new roles as caregivers.5 If this goal is not achieved, a family member’s ability to cope with the critical illness may be altered and adverse psychological events such as anxiety may result. The nurse engages the patient’s family in the sense-making process through a series of specific nursing interventions: assisting the family with understanding the ICU environment, identifying and meeting the family members’ information needs, coaching them on how to visit and meet their own needs, providing family support, and providing activities to perform at the bedside. In publications that address family satisfaction in the ICU, each of these interventions has been identified as necessary by family members.4 Intermediate goals include meeting the needs of patients’ family members and continued communication. Outcomes include decreased anxiety and increased comfort and satisfaction.The purpose of this study was to increase engagement of patients’ family members by implementing FSM in a cardiothoracic ICU and to measure the effect of FSM on family members’ anxiety levels. It was hypothesized that implementing the FSM interventions with patients’ family members would decrease their anxiety levels during the ICU stay. A secondary aim was to assess for differences between sexes or races in anxiety levels before and after FSM.This study was approved by the institutional review boards at Sacred Heart University and Montefiore Hospital. Patients’ family members completed the State-Trait Anxiety Inventory (STAI) before and after experiencing FSM.The setting was a cardiothoracic ICU in Montefiore Hospital, a large regional heart center in New York City that treats a large nonwhite, culturally mixed population of patients. The patients admitted to the cardiothoracic ICU were, in general, older adults who had several comorbid conditions and underwent scheduled cardiac surgeries.Family members and patients who met the following criteria were invited to participate: patients 12 hours or less after cardiothoracic surgery who were admitted to the cardiothoracic ICU and 2 or more family members at least 18 years old who spoke English and had at least a sixth grade self-reported reading/writing level. Prior estimates of the effect size of FSM on anxiety were not available, so a medium effect size, which is considered reasonable for studying most nursing phenomena, was selected. A paired samples t test was used to compare anxiety scores from before to after FSM. By using an effect size of .50, α = .05, and a power of 80%, it was determined that a sample size of 64 patient/family member dyads was sufficientAnxiety was measured by using the STAI form Y.7 State anxiety is temporary anxiety in response to some threat that is perceived to be present. Trait anxiety describes a personality characteristic of being anxious on a day-to-day basis rather than a temporary feeling of anxiety. Form Y is the most popular version of the instrument and comprises a scale for assessing state anxiety and another scale for assessing trait anxiety, each consisting of 20 statements.For state anxiety items, participants report how they feel right now by rating the intensity of their anxiety feelings on a 4-point Likert scale: (1) not at all, (2) somewhat, (3) moderately so, and (4) very much so. For trait anxiety items, subjects report how they “generally” feel by rating themselves on a 4-point Likert scale: (1) almost never, (2) sometimes, (3) often, and (4) almost always. The 2 scales are not meant to be combined, and scores can range from 20 to 80 for each scale. The higher the state or trait score, the greater the anxiety level. The STAI form Y has well-established reliability and validity.Demographic and baseline characteristics were obtained by self-report from each family member and included age, ethnicity/race, family member’s relationship to the patient, social support, education level, employment status, past or present use of anxiolytic agents, and past or present anxiety. These data were collected to allow sample description and to determine if anxiety levels differed between sexes or races.Within 6 hours after cardiothoracic surgery, family members were approached by the principal investigator (M.S.) in the family lounge, where the study purpose was explained and written consent was obtained. At this time, family members were asked to complete the STAI and the FSM intervention was initiated. The FSM interventions were administered by the principal investigator, and each of the interventions was carried out with the participating family members. To improve intervention fidelity, the principal investigator gave each family member a laminated card (see Figure) that has the FSM interventions listed and a check box to record when they are done. Depending on the family’s needs, some boxes were left unchecked (eg, manicuring nails). The principal investigator met with each patient’s family members at least 2 times to address needs and reinforce the FSM. The majority of family members completed the STAI after FSM on postoperative day 3 or 4, with only 3 family members completing the STAI after FSM on postoperative day 2.Data were analyzed by using SAS 9.3 (SAS Institute, Inc). The level of significance for all tests was set at a P of .05. Descriptive statistics were used to summarize the demographic and baseline characteristics. A dependent t test for continuous measures and a χ2 test for categorical measures were used to test for differences between measures before and after FSM.Data were collected from May 2014 to August 2014. A total of 64 family members completed the STAI before FSM, and 56 family members completed the STAI before and after FSM. For this study, the internal consistency for the state and trait anxiety levels before and after FSM was excellent (α = .99 for both). Test-retest reliability was evaluated by using the Pearson product-moment correlation coefficient, r. A weak correlation was observed between the state anxiety before and after FSM (r = 0.317, N = 56, P= .01). These results indicate a large decrease in state anxiety in the majority of family members after FSM implementation. A very strong correlation was observed between trait anxiety before and trait anxiety after FSM (r =0.922, n = 56, P = .001). These results indicated that trait anxiety did not change in the majority of family members after FSM implementation. Thus trait anxiety is a stable measure; you would not expect a family member’s personality trait to change during the study period.Table 1 displays the self-reported demographic and baseline characteristics of all the family members. The majority of family members were nonwhite, married, and employed with some education past high school. Most of the sample reported no use of antianxiety medications, and only 8 family members reported a formal mental health diagnosis, with anxiety being the most prevalent. The mean age of the family members was 45.54 years (SD, 13.69 years).Table 2 displays the mean levels of state and trait anxiety overall by sex and race before and after FSM. Overall, mean levels of state anxiety decreased after FSM, whereas the mean trait levels before and after FSM were similar. The mean state anxiety levels in both females and males decreased after FSM. Trait anxiety levels did not change from before to after FSM in either sex. The mean state anxiety levels in both whites and nonwhites decreased after FSM, whereas the trait anxiety levels stayed the same.Table 3 displays the results of the dependent-samples t tests comparing mean state and trait anxiety levels before and after FSM overall and state anxiety level for each of the demographic variables. The overall mean state anxiety levels decreased significantly after FSM (P= .001). The overall mean trait anxiety levels before and after FSM did not differ significantly (P= .46). Females, males, whites, and non-whites all had a significant reduction in their mean state anxiety level after completion of FSM. For these subgroups, mean trait anxiety levels were similar before and after FSM.State anxiety levels were significantly higher in females than males both before FSM (t52 = 2.10, P = .04) and after FSM (t52 = 2.57, P= .01). Trait anxiety levels were significantly higher in females than in males both before FSM (t52 = 3.63, P< .001) and after FSM (t52 = 3.06, P=.003).No significant racial differences (white vs nonwhite) were found in mean levels of state anxiety before FSM (t52 = 0.80, P= .42) or after FSM (t52 = −0.02, P = .98). Trait anxiety levels were significantly higher in nonwhite than white family members both before FSM (t52 = 2.10, P= .04) and after FSM (t52 = 2.03, P=. 04).Some family members stated that having a nurse to decode and interpret the cardiothoracic ICU environment at the bedside made them feel less anxious and concerned, and more comfortable. Other family members were afraid to touch their loved one because they feared they could cause harm while their relative was receiving mechanical ventilation and connected to various catheters, monitors, and intravenous medications. Family members were visibly relieved when they understood that the monitor alarms could be seen at the nursing station and these alarms were being evaluated even when the nurse was not in the room. Families expressed appreciation for the FSM laminated card because it gave them tangible resources.The overall mean levels of state anxiety decreased significantly after FSM, suggesting that FSM may be helpful for decreasing family members’ situational anxiety in a cardiothoracic ICU in the first few days. The overall reduction in anxiety of family members after implementation of FSM was similar to that reported in previous ICU intervention studies that evaluated the effect of needs-based education,8 family diaries,9 or brochures and family conferences10 on family member anxiety. However, the overall level of state anxiety observed in this study was higher than the mean level (45.41 [15.27]) reported in a study11 of a Canadian medical surgical ICU. The difference may be explained by different designs, sample sizes, and settings. In the Canadian study, a descriptive correlation design was used to assess 29 family members in the medical surgical ICU, whereas in the current study, state anxiety was assessed before and after FSM in 64 family members in the cardiothoracic ICU.Females, males, whites, and nonwhites all experienced significant reductions in their mean level state anxiety after the FSM. For females, males, whites, and nonwhites, mean levels of trait anxiety were similar before and after FSM. State and trait anxiety levels were significantly higher in females than in males both before and after FSM. No significant racial differences were found in mean levels of state anxiety before or after FSM. However, nonwhite family members had significantly higher levels of trait anxiety (eg, day-to-day anxiety) than did white family members.Few studies have looked at differences in family members’ psychological symptoms related to having a relative in the ICU with respect to the sex and race of the family members. For family members of ICU patients at high risk for dying, being female was associated with higher anxiety levels and being female and nonwhite was associated with higher levels of depression.12 Bailey and colleagues11 also reported that female family members had higher anxiety levels than did male family members.Few high-quality studies of the effectiveness of interventions for families in the ICU have been published. The most recent American College of Critical Care guidelines for support of families of ICU patients were published in 2007 and based on evidence published before 2004.13 A search for guideline revisions on the website of the Society of Critical Care Medicine revealed that revisions are underway. Although this study used a 1-group quasi-experimental design, anecdotal findings also support the FSM intervention. Communicating with patients’ families and teaching the family members how to participate at the bedside and how to perform personal care activities, such as applying lip balm around an endotracheal tube, and applying hand moisturizer to promote touch, made the family members feel comfortable and less anxious.The significant reduction in situational (state) anxiety levels that were observed in this study may in part be explained by the specificity of the interventions. Researchers in previous studies8,10 concluded that general interventions (eg, informational booklets and support groups) were not as effective as more individualized interventions (eg, targeting family members’ specific needs and using a specific proactive communication technique) for reducing the anxiety experienced by family members.The findings from this study are subject to several limitations. History and maturation were threats to the internal validity. Because no control group was used, it is possible that the situational anxiety (state) was reduced just by virtue of the patient’s condition improving several days after surgery, family becoming accustomed to the ICU, or some other factor not related to FSM. Time on the unit was not controlled for; however, most family members completed the STAI after FSM by postoperative day 3, suggesting that FSM may speed up the processes of reducing anxiety. Data were collected during the summer of 2014, and the number of cardiothoracic surgeries per day was lower than usual; some days, 4 surgeries were performed, and other days just 1 surgery was done.Results suggest that FSM can engage patients’ families in the care of their loved one and may speed up the reduction in situational anxiety experienced by family members in the ICU. The items shown in the Figure are the basis of the intervention, and they can be easily implemented in other ICUs with the help of the nursing staff. In addition to measuring situational anxiety level, it would be beneficial to measure family members’ satisfaction with FSM. To truly test the effect of FSM, future studies should use an experimental design with a control group.Because of the high anxiety experienced by family members of ICU patients, nurses have an opportunity to address these family needs in order to reduce this anxiety. Although few studies have addressed the most effective ways for nurses to help family members reduce their anxiety level, the FSM interventions may provide a framework for guiding the process and increasing engagement of patients’ family members. Findings suggest that FSM may engage families and speed up the reduction in situational anxiety in the immediate postoperative period in the ICU. Moreover, findings suggest that women may be a target group for future intervention.