Nearing the end of a 12-hour shift, a patient's daughter asked, "Do you know who will be taking care of Dad when your shift is done?" This is a common question I have heard numerous times from families, and it caused me to ponder the myriad of emotions and feelings that lie behind it.
I have chosen to term the response trepidation. Trepidation is common among the families of critically ill patients who know that with every shift change, the possibility for new rules to be enacted is likely. Even with an open visiting policy, nurses have control over when, who, and how families are allowed to visit their loved ones.
An exhaustive review of literature revealed little research on the topic of family members' responses to shift change or inconsistencies in nurse-driven rules and information exchange in the intensive care unit (ICU). Current nursing literature lacks the term trepidation as a human response.
There is a large amount of literature regarding the needs and experiences of families in the ICU1-7 as well as literature regarding visiting policies in the ICU.8-13 The literature within these 2 categories connects to aspects of family members' feelings of trepidation in the ICU.
Qualitative research has focused on the nurse-family relationship2 and perceptions of the impact of critical care hospitalizations by nurses, patients, and family members.6 This research has stressed the importance of the nurse-family relationship and identified strategies used by nurses and families that either develop or inhibit the development of the nurse-family relationship.2 Incongruence among perceptions that exist among family members and between nurses and patients, spouses, and children has been identified. Nurses' perceptions of the impact of critical care hospitalizations have been found to be more congruent with the perceptions of patients than with the perceptions of family members.6
Other qualitative research has focused specifically on nurses' perspectives of close relatives in critical care14 and nurses' experiences of caring for families with relatives in the ICU.15 Focus group discussions revealed that the presence of close relatives was taken for granted by critical care nurses, and information from close relatives made it possible for critical care nurses to create individual care for the critically ill person.14 Interviews of 12 ICU nurses found that nurses caring for families who have relatives in adult ICUs face a fundamental conflict both between role expectations and patient care and between professional ideals and being a human. This role conflict may contribute to occupational stress.15
Two quantitative approaches were found in the literature review that identified the needs of families of critically ill patients5 and determined nurses' perceptions and practices of family-centered care.16 The Critical Care Family Needs Inventory was modified to include questions about family members' level of satisfaction with how their needs had been met. The inventory was then administered to both critical care nurses and family members. Results of this research showed that both groups rated importance of needs significantly higher than satisfaction, an indication that needs were not being met to the satisfaction of either the family members or the critical care nurses.5 The Family-Centered Care Questionnaire was used to survey nurses in the areas of neonatal ICU, pediatrics, and pediatric ICU. Analysis of the survey results concluded that although nurses agreed with the identified elements of family-centered care, they do not consistently apply those elements in their everyday practice. Nurses' years of experience and clinical work setting influenced both perceptions and practices of family-centered care. Although this study was conducted outside the context of an adult ICU, the difference in nurses' perceptions and practice of family-centered care is an interesting finding and should be further studied on an adult population.16
DESCRIPTION OF TREPIDATION
Trepidation, by comparison, often presents itself in questions from patients' families. Questions such as "Will I be able to sleep in the room tonight?" "Are you going to be working tomorrow?" "When does the next nurse come on?" are all commonly asked. The tone to families' voices when these questions are asked reveals a lack of confidence, a hesitancy to ask, and nervousness in the quality of their words.
Nurses are the gatekeepers of information in the ICU. The exchange of information between nurses and families can vary and be inconsistent. Feelings of trepidation can surface in a family member who counts on explanations of cares, tests, and patient responses when this information is not provided consistently. Family members who are already coping with the stress of a loved one's illness deal with uncertainty every 8 to 12 hours when the next nurse becomes the new gatekeeper.
To understand and explain the feeling of trepidation in family members of ICU patients, it is helpful to analyze the definition of the word trepidation. Merriam-Webster's online dictionary17 defines trepidation as "timorous uncertain agitation." The word timorous can be defined as "expressing or suggesting timidity."18 The context of the word agitation in the definition of trepidation can be defined as "emotional disturbance or excitement."19
Based on these definitions, the response of trepidation has 3 main components. These components are (1) an aspect of timidity, (2) an unknown, and (3) an emotional disturbance or excitement. I can appreciate families' feelings of trepidation with greater strength at the beginning of a shift with a patient whom I have not taken care of before, and when my shift is nearing its end.
Timidity can be observed in the way that families shyly ask questions regarding visiting hours, or how they approach the subject of "the next nurse" by exhibiting fear, or a lack of confidence in their words. When entering the room of a patient whom I have never taken care of before, I often feel that families are feeling me out to get a sense of how I act in the nursing role and how this fits with the routine they have been accustomed to thus far. Family members can be timid by quietly sitting in the corner of the room, trying to be as unobtrusive as possible.
The component of the unknown in the feeling of trepidation has to do with an entire set of rules and communication exchanges that can unpredictably change with every shift change. When the perceptions and experiences of families have been studied, the literature reveals that families feel a strong need to be near the ICU and their loved one and highly regard informational needs and information sharing from the nurses.1,4,5 Nurses in the ICU are the main sources of information for family members because they are present 24 hours a day. It is most often nurses who regulate rules pertaining to visiting hours, number of visitors, and how long visitors can be in the room. Inconsistencies in how these rules are enforced increase feelings of trepidation in family members.
Inconsistencies among nurses in how they apply the rules of the unit and how they communicate information to families are abundant. These inconsistencies can precipitate feelings of uncertainty or the unknown regarding which rules will be enforced and what information will be shared on a shift-to-shift basis. The second body of literature reviewed was useful in helping to describe the response of feeling trepidation that has to deal with visiting policies, the perceptions of these policies, and attitudes regarding these policies. Feelings of trepidation can precipitate in family members when the rules and policies regarding visiting family members are inconsistent. This body of literature was rich in information regarding the needs of the family members as well as nurses' attitudes and feelings toward an increasingly popular model of open visiting in the ICU.
In a literature review aimed at structuring the available scientific knowledge on the needs of family members of ICU patients, both qualitative and quantitative studies were examined and the needs of family members were divided into 4 categories: (1) cognitive, (2) emotional, (3) social, and (4) practical. Results of this review revealed that caregivers underestimate all the needs of family members and do not do enough to meet the identified needs.7
A review of literature conducted on open visiting policies concluded that the benefits outweigh the barriers of such policies. Problems arise, however, when not all nurses practice the same policy, and inconsistencies in enforcing policies can be confusing for patients and families and can lead to resentment.12 Challenges to consistent enforcement of visiting policies include (1) nurse experience, (2) workload, (3) personal beliefs, and (4) unit cohesiveness.
Research focusing on nurses' beliefs and attitudes toward visits and open visiting policy8 and nurses' perceptions of open visiting hours10 has shown that nurses favor policies that allow for individualized considerations based on patient circumstances. Although the ability to make individualized considerations is preferred, it also creates opportunity for inconsistencies and variability in the family members' experience.
To help identify how nurses implement visiting policies, one study asked nurses through a questionnaire what factors most influence them to make exceptions in the ICU visiting hours. Acuity/prognosis and patient/family needs, along with patient anxiety, special needs of the family, and travel distances of visitors, were given as examples. Other frequently mentioned exceptions related to staff and unit business, naming workload and number and acuity of patients as factors that influenced how visiting hours were implemented.18
Qualitative research approaches that examine integrating open visiting policies into the ICU have been conducted.3,9 Three important themes were identified in a study on nurse and family interactions in the ICU: (1) nurses maintaining a position of power, (2) families needing to remain on guard, and (3) families "enduring" the situation.3 In both studies, nurses described their role as a balancing act between caring for the patient and meeting the needs of the patient's family members.3,9
The third component of the feeling of trepidation is the demonstration of emotional disturbance or excitement. This is the part of the response that is the most variable and difficult to describe. The experiences of families with a relative in the ICU have been described and categorized. These 4 categories include (1) hovering, information seeking; (2) tracking; and (3) the garnering of resources.4 The emotional disturbance component of trepidation is evident when family members seem to be unsettled until they meet the next caregiver. Often, patient's family members stay until they can meet the oncoming nurse and then they may leave for the night. The same is true if they have spent the entire night at the hospital with an unstable family member. It seems they are able to leave the hospital for a break more assured when they have had a chance to meet the nurse who will be taking care of the loved one.
Other ways in which family members exhibit excitement is by sharing with the new shift nurse, who has never cared for their loved one, the idiosyncrasies of caring for that patient. This may include knowledge about which side they like to be turned to, what kind of music they like to listen to, or where they prefer the room temperature to be set.
RELATION TO THE UNCERTAINTY IN ILLNESS THEORY
Feelings of trepidation among family members are more likely to exist when there is uncertainty in a situation. There are aspects of the content and structure of Mishel's20 uncertainty in illness theory that can be related to the human response of feeling trepidation. This original theoretical work strongly supports subjects who are experiencing an acute phase of illness, as is the case in the population that I have described involving the response of feeling trepidation.20
The uncertainty in illness theory proposes that "uncertainty exists in illness situations that are ambiguous, complex, unpredictable, and when information is unavailable or inconsistent."21 The description of the situation in which uncertainty exists can be likened to the environment of the ICU. There are multiple complexities, those relating the complex disease process of the patient, and the complexities of technology in the equipment used in caring for the patient. Patients who are unstable can demonstrate unpredictable responses to medications and treatment courses. The information exchange between nurses and family members can be inconsistent or at times even unavailable if the nurse is unable to communicate with the family. All of these factors pave the way for uncertainty to exist in situations that family members of patients in the ICU find themselves in.
Stimuli frame is the primary antecedent variable in Mishel's21 model of uncertainty in illness. Stimuli frame has 3 components: symptom pattern, event familiarity, and event congruency.21 Event familiarity refers to patterns within the health care environment and is developed over time and through experience in a setting. Family members who find themselves in an environment that is characterized by ever-changing rules and inconsistencies in information exchange will have increased feelings of trepidation and uncertainty. With event familiarity, uncertainty can be prevented.21
Family members have expectations that include quality care, competence, and information exchange. They also develop patterns of visiting and participating in the care of their loved ones. Event congruence refers to the consistency between what is expected and what is experienced, and a lack of congruence can generate uncertainty.21 If family members have become accustomed to being able to visit the patient whenever they choose, and a nurse evokes the right to limit visiting hours, event congruence lacks. Another example of this can occur when family members assist the patient with personal care. Some nurses may be appreciative or accepting of this and others may be more comfortable if that work is left to the nursing staff. These examples serve as demonstrations of inconsistencies between what is expected and what is experienced and show a lack of congruence. Lack of congruence in nursing can generate the feeling of trepidation in family members who are on guard for an ever-changing system of rules and information exchange that may occur as frequently as every shift change.
A graphic representation of the relationship between feeling trepidation and Mishel's uncertainty in illness theory in displayed in the Figure.21 When the 3 components of timidity, an unknown, and an emotional disturbance or excitement come together, trepidation may be present. Uncertainty surrounds the family member who is experiencing a feeling of trepidation.
IMPLICATIONS FOR PRACTICE
In this age of providing family-centered care, research is needed to understand the experience of being a family member of the critically ill and the impact that shift change has on the family. Trepidation is just one of many responses that may be recognized among family members of critically ill patients. Nurses who have a better understanding of families' experiences can incorporate into their practice interventions that are sensitive to the family members' experience. An understanding of the families' experience with regard to shift change may enable nurses to collectively tailor their practice on individual, unit-based, and organizational levels to enhance the experience of being a family member to those who are critically ill. An understanding of the impact of shift change on family members may also have implications for practice that extend beyond the borders of the ICU environment.
CONCLUSION
Human responses are as unique as the individuals who produce them. Trepidation is one response that can be recognized in family members of patients who are in the ICU. High levels of uncertainty maintain a presence in the ICU environment, and feelings of trepidation can increase with uncertainty. Nurses in the ICU play a pivotal role in mediating family members' feelings of trepidation by what they do or do not do. Further research into family members' responses to shift change and into inconsistencies in nursing decisions regarding rules and information exchange in the ICU is needed to better understand the feelings that family members experience in the ICU environment and to motivate meaningful changes that will contribute to a clearer sense of purpose for family and their loved ones.
References