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Abstract |
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 Top Abstract Literature ReviewScaffold for Analysis: Model...MethodsResultsDiscussionReferences |
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• Objectives To describe behavioral responses of family members of patients and the interactions of the family members with nurses and the patient in the trauma room.
• Methods A secondary analysis was done of 193 videotapes of trauma room care. Of these, 88 tapes showed the presence of patients’ family members, for a total of 42 hours. Qualitative ethology and a model of suffering as a scaffold were used to analyze verbal and nonverbal interactions between nurses, patients’ family members, and patients. Behaviors and verbal interactions of patients and their families were coded as to persons who were enduring and persons who were emotionally suffering. Categories were described.
• Results Whether a patient’s family members entered the trauma room depended on the patient’s condition, the patient’s behavioral state, and the nature of the treatments. Categories of interactions were families learning to endure, patients failing to endure, family emotionally suffering and patient enduring, patient and family enduring, and resolution of enduring. The interaction style of the nurses involved was particular to each of these states. Two instances of inappropriate interactions occurred.
• Conclusions Nurses can use the Model of Suffering as a framework to assess behavioral and emotional states and to select appropriate strategies to comfort patients’ family members.
The conditions of patients admitted to the trauma room are usually unstable and critical. The onset of the conditions is generally rapid and, for both patients and their families, unanticipated. Families either accompany the patients to the hospital (ie, bring these patients in or follow the ambulance) or rush to the emergency department some time after resuscitation efforts have started. In both scenarios, the family members describe their emotional responses as incredulity and shock. They are stunned and have difficulty comprehending what is happening. Because of these responses, nurses are concerned that if a patient’s family enters the trauma room, the family members will require support that will distract from, or compete with, the patient’s urgent care. Needs and behaviors of family members, not the nursing support necessary, have been reported. Consequently, the purpose of this study was to describe interactions between nurses, patients, and patients’ family members. We did a secondary analysis of videotapes of 193 patients in the trauma room.3 Of these patients, 88 had family members who were present at some time during the filming. In this study, we examine the behavioral responses of the family members and their interactions with nurses and the patient in the trauma room.
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Literature Review |
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TopAbstractLiterature ReviewScaffold for Analysis: Model...MethodsResultsDiscussionReferences |
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Nurses remain ambivalent about admission of patients’ families into the trauma room. As noted, the family members of some patients desire access. However, the preferences of patients have never been reported in the literature. The perspective in the nursing literature generally is supportive of the presence of patients’ families. The underlying assumption is that having relatives in the trauma room is "a good thing."6 The position statement of the US Emergency Nursing Association is that the family of a critically ill patient needs to be with the patient; be informed, comforted, and supported; and feel that the patient received the best care.7 Additionally, the statement declares that presence of a patient’s family allows the patient and the family members to support each other, is helpful to the patient, and facilitates the grieving process in the situation of death and loss.7 Despite these points of view, change in this direction is slow and remains controversial; the delay in changing practice reflects reticence on the part of hospital staff. Furthermore, although the presence of patients’ family members is strongly advocated, few published reports have described the role of nurses, and we found no published reports describing interactions between nurses and the family members of patients in the trauma-resuscitation room of the emergency department.
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Scaffold for Analysis: Model of Suffering |
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TopAbstractLiterature ReviewScaffold for Analysis: Model...MethodsResultsDiscussionReferences |
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Research exploring behaviors of persons who are suffering8,9 revealed that suffering consists of 2 distinct behavioral states: enduring, a stoic state in which emotions are suppressed, and suffering, an emotional state in which the person may sob or cry. When a person is enduring, he or she suppresses emotion by focusing intensely on the present: The past or the future do not exist. This suppression of emotion also suppresses visible affect; the person’s voice is a monotone and facial expression is minimal, appearing wooden or "frozen." The person does not initiate conversation and replies by using monosyllables or short sentences. He or she stands erect and moves using a stiff, "chunky" gait, walking rather like a robot. Persons who are enduring stand apart from one another. The caregivers’ response is to be with the person in silence without touch.
In contrast to those who are enduring, persons who are emotionally suffering can no longer contain emotions. They may cry or sob, their faces are lined, and their posture is stooped. They are often held, supported, consoled, and comforted by others, including caregivers, who listen and use empathic statements. If a person who is enduring can no longer hold his or her emotions, breakthrough occurs, and the person begins releasing emotions, crying or sobbing.
The interrelationship between enduring and emotional suffering is described in the following model: Immediately after the crisis (trauma, illness, receiving bad news, etc), the person begins enduring and continues enduring until he or she is able to acknowledge the incident. Once the context allows and the person is "strong enough" to suffer, he or she may enter emotional suffering. However, he or she may move back into enduring or back and forth between the 2 states. Of importance, enduring and emotional suffering may vary in intensity and duration according to personal (including cultural), situational, and contextual factors.
In this study, this description of suffering behaviors was used as a scaffold to code the responses of the family members in the trauma room and to code the caregiver’s interaction with family visitors.
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Methods |
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We did a secondary analysis of videotaped data of 193 trauma care scenarios collected from emergency departments of 3 level I trauma centers in North America. In these scenarios, family members were brought into the trauma room in 88 cases, which then formed the data set. No new categories arose after 30 cases were viewed and analyzed; sampling ceased after 55 cases. The coding system was verified by coding the remaining 33 cases.
Data Collection
Data were obtained by using a video camera fixed on the wall. The camera was activated by a nurse researcher when a patient first entered the trauma room. Taping ceased when the patient left the room. A total of 40 tapes were recorded from site 1, 27 from site 2, and 126 from site 3. (Of the total sample, 32 tapes were erased because consent was not obtained. Reasons for not obtaining consent were as follows: the patient was unable to provide consent and his or her family refused [11], the patient refused [10], the patient was discharged [9], and the patient’s physician refused [2]. Two nurses declined to participate and were assigned to other areas during taping. Six patients consented to the study but denied public viewing of data.)
Use of videotaped data for observational research has both strengths and weaknesses. Recording from a remote camera is relatively unobtrusive, so behaviors are minimally affected. Furthermore, at 2 of the sites, staff were accustomed to being filmed because videotaping was routinely used for quality assurance. However, since the camera was fixed, often the view was obstructed by caregivers or equipment. Additionally, the requirements of the institutional review board to ensure patients’ anonymity required deleting identifiers, including obscuring the patient’s face and removing names. As a result, third-generation video (with poor quality) was used in the analysis. The most important restriction, however, was that data were limited to data that could be viewed on screen. Thus, we have no data on interactions among family members in the waiting room, on families entering the room, or even when family members stood off screen. Nevertheless, using video allowed us to pause, slow, and replay the scenes; to use microanalytic coding; and to obtain interrater reliability.
Ethical Considerations
As soon as their condition permitted, patients were informed that videotaping was in progress; written consent was obtained at that time or after transfer from the emergency department. Parental consent was obtained for minors, and assent was obtained from older children. Patients were asked to provide 2 types of consent: first, to have the cleaned tape (with identifiers removed) included in the study, and second, to allow use of the tape for educational or publication purposes. If a patient declined to participate, the tape was immediately erased. Written consent was obtained from all nursing staff. Releases for taping were obtained from all medical and technical personnel who provided care. Patients’ relatives were informed about the study before the relatives entered the room. Any person present, at any time, could request that recording cease. One nurse and one physician requested that taping be interrupted. Taping was also interrupted in 3 instances when police entered the room. No patients’ relatives requested that taping cease. Approval was obtained from the institutional review board for this secondary analysis.
Sample
A log was developed that listed all significant events, time and duration on the videotapes, and a summary of each patient’s scenario. From this log, all scenarios with family members of patients present were identified, which totaled 88. The presence of a patient’s family members varied with both the site and the patient’s age. Of the 40 tapes from site 1, 18 (45%) included patients’ family members; in these 18 instances, 7 patients were children. Two (7.4%) of the 27 tapes from site 2 included patients’ family members; both scenarios were with young children. From site 3, 68 (54.0%) of the 126 tapes showed the presence of patients’ family members, and 14 of these 68 patients were less than 16 years old. The initial 55 of the total 88 cases sampled were selected to include a range of patients’ ages and acuities, times of entry of family members and times they spent in the trauma room, family compositions, and sites, as follows: site 1 (n = 15), site 2 (n = 2), and site 3 (n = 38). Participants consisted of 32 male and 23 female patients (41 adults and 14 children). Videotaped recordings that were observed and coded totaled 42 hours 10 minutes 43.6 seconds. The length of time that a patient’s family members were at the bedside varied in each situation, from 20 seconds to 5 hours 29 minutes 45 seconds, with a mean of 46 minutes 0 seconds. Eight of the 55 families were present at the beginning of the taping; other families entered at a mean time of 35 minutes 51 seconds from the time that taping commenced. No new categories were developed after the coding and analysis of 40 scenarios. Coding continued with 15 additional scenarios. The remaining 33 videos of the sample were observed by one of us (C.P.) to verify the coding system and categories.
Data Analysis
Initial data analysis involved the development of an ethogram: a detailed textual description of behavioral patterns.12,13 Videotapes were played and replayed in order to observe and describe in detail the behaviors of patients’ family members, nurses, and patients. Behaviors and conversation were noted and were coded by using the theoretical framework of enduring and suffering and comforting. After the emergence of the main categories, sampling was done until further categories were developed and then saturated. Coding and description of behaviors was done by one of us (C.P.) for the first 20 scenarios to develop the coding system. Research assistants continued with the detailed coding, which was checked for reliability by one of us (C.P.), who watched video segments and verified the coding. Discussion between the 2 authors was ongoing. Any discrepancies in coding were discussed between us until 100% agreement was reached.
We assumed an attitude of inquiry, asking questions of data. Our first question was, Do patients or patients’ family members exhibit behaviors of enduring or suffering? We then asked further questions such as, What is going on here? How does this interaction compare with that interaction? What are the characteristics of this interaction? Preliminary categories were developed on the basis of the behaviors and characteristics. Field notes were compiled, and overall categories were then discussed and described. Categories were then compared and contrasted according to behavioral patterns and the common characteristics.
Aspects of analysis from the enduring and suffering model included the following for each patient:
Categorization of patients’ conditions and the responses of the patients’ families were not static. That is, the behavioral states and modes of interaction of patients and their families changed over time, through interactions, and with the patients’ acuity. Patients’ family members and patients showed both enduring and emotional release of suffering. Strategies that patients’ families, patients, and nurses used to enhance enduring were noted. Comparing and contrasting cases revealed that some patients were distressed and "failing to endure"; others were unresponsive or unable to lead the interaction because of their condition and care (eg, intubation, sedation, unconsciousness). In each instance, the age of the patient influenced both the patient’s ability to endure and the family’s requirement to suppress enduring. This pattern was noted particularly in young children who were distressed and whose parents maintained control. In a few cases, family members were very "familiar" with hospitalization, the illness, or both, a situation that influenced the interactions of family members with the patient and hospital staff.
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Results |
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TopAbstractLiterature ReviewScaffold for Analysis: Model...MethodsResultsDiscussionReferences |
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From our observations of behaviors and verbal interactions of patients and their family members, we were able to classify who was enduring and who was emotionally suffering. Persons who were enduring (either family members or patients) manifested stoic behaviors. Verbally, they were silent, used only single words or short sentences, or did not initiate conversation. When they did speak, their voices were monotonic, lacking intonation. Behaviorally, movement was minimal: patients lay still, regardless of positioning. For instance, if a nurse positioned an arm for a procedure, that position would be maintained even when the nurse moved away. Family members who were enduring stood erect and maintained a gap between each other and apart from the patient (Figure 1
). Posturally, family members often stood with their upper extremities crossed and their hands grasping their arms as if they were "holding themselves together." Staff refrained from touching these families and limited conversation and eye contact with them.
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). When a person who was suffering was alone or clearly very distraught, the nurse assumed the comforting role (Figure 3).
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Major categories were developed according to the families’ states, the patients’ states, and patients’ conditions (see Table).
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Families learning to endure were focused on the immediate present and were unaware of the passage of time. Nurses provided factual information on the patient’s condition, such as the vital signs, but did not provide reassurance or discuss prognosis, nor were these types of questions asked. If emotional suffering surfaced or broke through enduring, the person experiencing this response moved away from the bedside and concealed these emotions from the staff. Occasionally, nurses moved in and comforted, especially if the family member was alone or was a child.
Differences between the sexes were noted in postural behaviors and in receiving comfort. As the family gathered around the bedside, the women were more likely to assume the position at the head, whereas the men were more likely to stand at the foot or even away from the stretcher. Women were more likely to touch and talk to the patient, although at times behaviors changed or alternated. For instance, a mother became distressed and tearful and moved away from the bedside, and the father moved in to take her place.
Patients Failing to Endure
Patients who failed to endure were usually in pain and terrified, out of control, or afraid. When patients were terrified or out of control, their family members were not usually admitted into the trauma room. Family members were permitted to be present with patients who were afraid or in pain and emotionally suffering. In these instances, the family manifested enduring behaviors and worked with the nurse to promote enduring in the patient (see Table
). The nurse acknowledged the patient’s pain, provided brief explanations for discomforting procedures, and coached the patient to endure, urging him or her to wait, to hold on. Families observed the nurse’s "matter of fact" and unemotional behavior and followed the nurse’s lead. They mimicked the nurse’s tone and talk, through reassurance ("It’s okay"), affirmation ("We’re here"), and encouragement ("Just relax").
Families echoed the nurse’s directives ("Take a deep breath," "Lie still"). However, they were silent if the patient was swearing, noisy, or sobbing, although they sometimes assisted in restraining by holding the patient’s legs or hands. Many family members approached or touched the patient only after encouragement from the nurse to do so. They touched the patient with short and intermittent pats, rubbed the patient’s arms or leg, stroked the patient’s forehead or face, or held the patient’s hand in a perfunctory manner. They appeared to be going through the motions of comforting without the emotions.
Most patients who failed to endure were younger children or infants. Nurse-family-patient interactions differed in this age group. Children expressed their terror, fear, or pain by crying or screaming. Staff encouraged family members to stay and comfort the child, and nurses and parents took cues from one another in their attempts to console the child. Numerous comforting strategies were used; distraction, rocking, bargaining, cajoling, cuddling, reassuring, joking, and teasing were used intermittently by both parents and nurses. Parents concealed their distress and focused on the child.
Family Emotionally Suffering and Patient Enduring
In the category of family emotionally suffering and patient enduring, some family members were releasing emotions, and other family members, the patient, or the nurse attempted to ease their distress and promote enduring. For example, a policeman who was shot in the chest and was receiving continual assessment until his transfer to the intensive care unit comforted his wife and daughter, who were both sobbing: "There, there, I’m alright, I’m okay." Other patients attempted to relieve family members’ distress through distraction (eg, discussing hockey scores), humor, or concealing the patients’ own discomfort. In these situations, the nurse was involved in the care and had limited time for the patients’ family members. Nurses monitored interactions between patients and the patients’ families and provided reassurance ("It’s okay") and information about tests and results.
In some instances, to alleviate their own distress and provide self-reassurance, family members clung to the patient as much as possible, considering the equipment and side rails. This emotional display was particularly evident when some members of the family were enduring. Those who were enduring either took the role of the comforter or stood back. They did not initiate conversation or eye contact with other members of the family; instead they maintained their distance and focused on the technology or equipment.
This triadic interaction was directed toward the family member who was emotionally suffering and not toward the patient. Even nurses directed some attention and information to patients’ families through the patients (see Table).
Patient and Family Enduring
If a patient and his or her family members were all in the state of enduring, they all behaved stoically. The patient was quiet, maintained control, and relinquished himself or herself to the necessary care. Family members stood apart, sometimes on opposite sides of the stretcher, and observed the patient, the nurse, and one another. The patient and family members both quietly observed the nurse’s actions, silently searching for clues about the patient’s condition. At the same time, the nurse was observing the patient and the family. The nurse, at times, gave verbal recognition and praise for the state of enduring to the patient ("You’re a good and brave girl," "You’re doing fine") and the family reiterated ("We’re proud of you; you’re so strong").
In this category, when the patient and family were both enduring, interactions between the patient, family, and nurse were minimal. All interactions were to support enduring behaviors rather than interactions that would trigger emotional release of suffering (see Table).
Resolution of Enduring
Resolution of enduring occurred later in trauma care, when a patient’s condition was stabilized and it was no longer necessary for the patient’s family to endure. When a patient’s family members received the news that the patient was no longer critical, an obvious release of tension occurred, as indicated by sighs, stretching, and laughter. Family members relaxed their postures, smiled, and moved closer to one another, sometimes hugging and laughing. Tears sometimes flowed. When able, patients were a part of this interaction, and they sometimes joked with their families, despite the patients’ acuity and pending hospitalization. The family members then moved into the "waiting mode," as they waited for the patient’s transfer or discharge from the emergency department. The nurse became attentive to the family members, invited them to express their feelings, reassured them ("It’s going to be okay"), asked them how they were doing, and offered them tea or coffee. Occasionally, these behaviors by nurses occurred before the resolution of enduring but were ignored by the family members. In one instance, a nurse asked 3 times if the patient’s wife wanted a drink, without ever getting a response.
After the release of tension, little interaction occurred between nurses, patients, and patients’ family members. Family members appeared bored; some read a book, others left to watch television. They changed focus from the patient to themselves and their surroundings, and they became openly reflective of their own feelings. They gazed around the trauma room, observed the time, and planned their return to other activities, including work and child care. Some left the patient to telephone friends or go to the cafeteria (see Table). Families felt free to leave the bedside because vigilance was no longer required. At this point, interaction with nurses was minimal on the part of both family members and patients. Nurses were no longer vigilant and often updated charts or left the area to care for other patients.
Exceptions
Two exceptions to these patterns were noted. The first occurred when a patient’s family member was familiar with the hospital environment; the second occurred when the patterns and responses to enduring and emotional suffering within the triad were asynchronous.
Familiar Families. In some instances, a patient’s family members were comfortable with the hospital environment or the emergency department because of the patient’s previous admissions and course of illness. Some described themselves as "regulars" or "familiar" with the problem or with the emergency department. Other family members were health professionals and familiar with hospitals. Upon entering the trauma room for the first time, these family members walked with assurance, usually going confidently to the head of the stretcher without guidance. Once they had seen the patient, they often went and stood with the staff, even if they were not known as staff. These family members were noticeably "at ease" with the staff and equipment, and, at times, assumed care, such as adjusting the oxygen mask, informing the nurse of the patient’s needs, or looking for linen to wash the patient. These family members had expanded boundaries; they touched equipment, leaned on the counter, and answered questions for the patient, although not required to do so.
Familiar families were less vigilant, observing with interest or detachment rather than wariness. They did not focus on the patient, but looked around at the surroundings. Although they were attentive to the patient, they also voiced their own concerns, even when the patient was very ill. When one patient expressed that he was "not okay," his wife directed the conversation toward herself and commented that she needed "to go to work" and "wasn’t feeling well" herself.
At times, these family members gave the patient and other family members reassurance of the care being provided ("I’ve worked with these guys; they’re good"), encouragement ("Don’t worry; she’s heading in the right direction"), and information ("The analgesic will be working soon").
Of note, when a patient’s condition deteriorated, the change often led to loss of familiarity and transition to learning to endure. At these times, the family member stood back or left the bedside.
Sideswiping. Only 2 interactions noted between nurses and patients’ family members appeared to cause distress in the family member. Both instances involved nurses who made empathic statements that broke through family members’ enduring. In the first instance, a nurse said to the mother of a very ill child, "I know this is hard." At that point, breakthrough occurred (in which emotions can no longer be controlled and interrupt enduring). The mother nodded, eyes tearing, turned away, and took time to regain control before she went back to the bedside. In the second, which involved a patient who had attempted suicide, the nurse directed the attention of the patient’s wife to future implications and the need for psychiatric therapy. The wife immediately collapsed, kneeling down on the floor with her head down until her son helped her up and away from the bedside. Understanding of this event is gained through our suffering framework; moving the wife’s attention from the present focus of enduring, to the future, broke through her enduring and triggered overwhelming emotional release. In both of these instances, the nurses’ interactions caught the family members unaware, resulting in loss of endurance. We refer to this phenomenon as sideswiping.14
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Discussion |
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TopAbstractLiterature ReviewScaffold for Analysis: Model...MethodsResultsDiscussionReferences |
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Because the study did not include the observation of patients’ relatives before the relatives entered the trauma room, we cannot make recommendations predicting which members of a patient’s family should be admitted or excluded; this topic is one for future research. However, we can make recommendations about nurses’ interactions with patients’ relatives. From this study, it is evident that the use of empathy is inappropriate with persons who are emotionally suppressing and are functioning in a stoic, enduring mode. In our study, we observed 2 nurses’ empathetic statements result in transition from the stoic person, being there for the patient, to withdrawal, tears, and a focus on self. The transition to emotional suffering delayed or interrupted interaction with the patient. Elsewhere, Morse et al15 have discussed inappropriateness of a "carte blanche" application of empathy, and we urgently need to investigate and delineate when the use of empathy is appropriate and when it is inappropriate. This issue is critical to the current debate on permitting patients’ families to be present in the trauma room and the concern that the family members will lose control and occupy staff members at this critical time.
In this study, the approval from the institutional review board and the condition of anonymity did not permit the collection of demographic information; therefore, we could identify only visible minorities. It is recommended that cultural variation be considered in future studies.
The study reveals the usefulness of the model of suffering9 used as a scaffold to make sense of behaviors manifested during critical events. The fact that behaviors can be coded by using observational methods makes suffering an extraordinarily useful model on which to base nurse-patient-family interactions. Nurses will not only be able to overtly assess the behavioral and emotional states, they will also be able to select appropriate comforting strategies to support, to ease, and to relieve at this time. Furthermore, our results confirm several aspects of the model. For example, we previously reported that patients who were enduring and suppressing emotions remained focused on the present. In this study, the only relative who collapsed was forced from focusing on the present to focusing on the future by well-intended but inappropriate statements from the nurse about future ramifications of the suicide attempt. Appropriate and inappropriate communication strategies must be incorporated into basic, critical care, and emergency nursing textbooks and into in-service education. Furthermore, a need exists to explore situations, including factors preceding situations in which patients’ family members act inappropriately in the emergency department, so that we, as caregivers, may learn to avoid such incidents. The results of this study suggest that staff members may be inadvertently responsible for such events. On the basis of our results, we recommended that when patients’ family members are present in the trauma room, nurses’ interactions should go beyond providing information toward supporting enduring behaviors among both patients and patients’ family members.
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ACKNOWLEDGMENTS |
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To purchase reprints, contact the InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809–2273 or (949) 362–2050 (ext 532); fax, (949) 362–2049; e-mail, reprints{at}aacn.org.
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REFERENCES |
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