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Intensive and Critical Care Nursing (2005) 21, 16—23
ORIGINAL ARTICLE
Effects of nurse caring behaviours on family stress
responses in critical care
Barbara J. Pryzbya,b,∗
a St Mary’s Hospital, West Palm Beach, FL, USAb Florida Atlantic
University, Boca Raton, FL, USA
Accepted 30 June 2004
KEYWORDS
Intensive care;
Nurse caring behaviours;
Family perception;
Stress response
Summary Although nurses realise the importance of the
family in holistic care of the patient, often they are
reluctant to integrate family into the ICU environment.The family
role in patient healing has been minimised. There is incongruence
innurses’ assessments and families’ perceptions of what constitutes
caring behaviours.Traditionally ICUs have been primarily patient
focused; changing to family-centredwill require attitude changes
and a multidisciplinary team approach to care. Studieshave shown
families to be stressed and at significant risk for maladaptation
whenacute illness or trauma strikes. Nurses potentially may alter
family stress responsesthrough caring behaviours, and a
family-centred approach to care.© 2004 Elsevier Ltd. All rights
reserved.
Family integration into intensive care units (ICUs)and creation
of a family-centred approach to careare important in providing
holistic care to patientsand in helping families decrease their
stress lev-els. Family members of critically ill or injured
pa-tients become the representatives for the patientwhen
self-representation is not feasible due to thenature of the illness
or injury. Families confrontlife and death issues, role reversals,
financial con-cerns, and added family responsibilities, all
poten-tially major sources of stress, anxiety, and barriersto
adaptation (Leske, 2003). Anxiety and depres-sion are commonplace.
In Pochard et al. (2001) sur-vey that incorporated 43
ICUs, the results revealedthat greater than 60% of the family
members ex-
* Tel.: +1 561 439 6371.E-mail
address: [email protected] (B.J. Pryzby).
hibited anxiety and stress symptoms. Encompassingthe family into
the care of the patient and the in-tensive care environment may
represent a pivotalpoint for successful family adaptation and well
be-ing of its members.
Nurses may be reluctant, inconsistent or evenfail to consider
the implications of excluding thefamily (Tracy and Ceronsky, 2001).
ICU nurses arepositioned where caring is focused on the patient;to
provide holistic care however, caring cannot ex-clusively be
directed to the patient, especially inthe context of critical
illness. Care of the patientand care of the family become
intertwined. Whataffects one member potentially impacts the
entirefamily. ‘Caring for the family is a component of car-ing for
the patient and is achieved by supportingand involving the family
in caring’ (Beeby, 2000,p. 159). Not only is the well being of the
patient
0964-3397/$ — see front matter © 2004 Elsevier Ltd. All rights
reserved.doi:10.1016/j.iccn.2004.06.008
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Nurse caring and family stress responses 17
at stake, but also the family members are at sig-nificant risk
for maladaptation. Achieving holismand family-centredness depends
on the nurses’ re-sponses to family care and their willingness to
finda fit for the family in the ICU environment.
The purpose of this inquiry was to examine,through literature
review, the effects of nurse car-ing behaviours and a
family-centred approach tocare on family stress responses related
to acute ill-ness or trauma. The assumptions supporting this
re-view included the following:
• Families play a vital role in patient healing;
in-clusion is necessary in providing holistic care.
• Families coax, support and encourage the ill fam-ily
member enhancing earlier recovery potential.
• Families are at significant risk for health
conse-quences. Illness or injury does not occur in isola-tion but
involves the entire family.
• Nurses are positioned to support families in deal-ing
with stress. Nurse attributes and nurse caringbehaviours set the
stage to make it happen.
The current relevant nursing literature from1999 through 2004
was searched using the elec-tronic databases CINAHL, MEDLINE,
PubMed andOVID Online in order to locate studies relevant tothe
selected topic. Key words and combinations of the key words
were used relating to adult ICU, nursecaring behaviours, family
stress and stress percep-tion, and family responses to members’
hospitali-sation. The focus of the search was narrowed and
the selected studies were critiqued. Research
withevidenced-based outcomes on how nursing, throughnurse caring
behaviours and a family-centred ap-proach to care, without
exclusion of any impor-tant members, conceptually and holistically
metfamily demands and decreased family stress re-sponses in adult
critical care were included. In ad-dition, abstracts were reviewed
in the Journal of Holistic Nursing, Dimensions of
Critical Care, andCritical Care Nurse in search of pertinent
studies.Studies that primarily examined family needs
wereexcluded.
Definition of terms
Nurse caring behaviours are a function of nursingattitudes,
skills, and knowledge employed in thecare of patients and families
that serve to positivelyinfluence, support, or enhance nursing
care. Per-ception of what constitutes nurse caring however
isdependent on the recipient of care. Family-centredcare is
inclusive of those persons significant tothe patient regardless of
biological relationship.Stress response is based on family stress
theory
(Patterson, 2002). Consistent with Patterson’s the-ory, families
work to balance demands with capabil-ities in order to achieve
adaptation. When demandsexceed capabilities, crisis results. In the
event of critical illness or injury, family function and
thehealth of family members are at risk.
Literature review
Nurses recognize the importance of nurse/familyinteractions to
the welfare of both the patientand family. More than 90% of
emergency room (ER)nurses, in an Icelandic study, acknowledged
fam-ily care taking as comprising a significant part of the
nursing role (Hallgrimsdottir, 2000). In a Finnishstudy of 165
hospital staff, two thirds of the respon-
dents felt nurse/family interactions to be vital inprovision of
holistic care for the patient and an im-portant determinant of
family health and successfulcare of the patient post-hospital
discharge (Astedt-Kurki et al., 2001).
A correlation was also discovered between theexperience of the
nurse and the perception of theimportance of the family to the well
being of thepatient. Nurses with less work experience tendedto
place less emphasis on nurse/family interactions(Astedt-Kurki et
al., 2001; Beeby, 2000). Experi-ence also seemed a determinant in
the ability of the nurse to provide emotional support.
Beeby’s
(2000) investigation revealed that the less experi-enced nurses
needed to develop expertise in phys-ical caring for the patient
prior to readiness foremotional care of the family.
Through nurses’ experiences of caring for familymembers, nurses
gain knowledge of the patient andcome to know the patient through
the insight pro-vided by family members. Nurse caring
behavioursbecome less mechanistic as nurses grow to knowthe patient
as a person instead of an object of care (Hardicre, 2003).
Benner’s reflection on car-ing (2003) offers insight
into the ontology of caring
and caring behaviours, what it means to care, andthe
possibilities inherent in the concept. Caring isconcern outside of
oneself about what matters, asense of connection that leads to
development of trust.
‘Because caring sets up what matters to the person,it sets up
what counts as stressful, and what optionsare available to the
person for coping. This is thefirst way in which caring is primary.
It determinesboth what will be stressful and what will count
ascoping.’ (Benner, 2003, p. 166)
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18 B.J. Pryzby
Family stress response
Nursing research has sought to illuminate family re-sponses and
functioning following critical illness of a family member
(Astedk-Kurki et al., 1999; Butteryet al., 1999; Hupcey and Penrod,
2000; Van Hornand Tesh, 2000a,b). When acute illness or
traumastrikes, families are caught off guard; life
becomesdisorganized and disrupted as demands exceed ca-pabilities.
The entire family is deeply impacted andmust find ways of dealing
with the associated stress.
Following Newman’s (1999) concept of rhythmi-cally
relating to another, families are in a sense‘dysrhythmic’ following
admission of a family mem-ber to ICU, often erratically thinking
and out of syn-chronisation. Perceived life-altering changes andthe
potential of death are issues the family mustconfront. The chaos of
seemingly endless decisionsfrom moment to moment while family
members at-
tempt to make sense of events increases familystress and may
overwhelm to the point of hinderingdecision-making and ultimately,
family function.Increased demands, an unfamiliar and
seeminglythreatening and hostile technological environment,in
addition to an array of prior life stressors, chal-lenge the family
attempt to expand capabilities tomeet demands.
Interventions become paramount in facilitatingfamily efforts in
reaching a state of equilibriumand in regaining a sense of
synchrony in their livesthat has been swept away by the acute
illness
or traumatic event. Instead families wait and arekept ‘waiting
to know’ and may be treated as out-siders rather than included as
partners in care.Families struggle to find meaning and balance
inlife and ways of dealing with stress and upheaval(Patterson,
2002).
In the process, families experience a range of feelings
including aloneness, anticipation, sorrow,worry, anxiety, and
depression, each suffering in away unique to that individual
(Astedk-Kurki et al.,1999). In the investigation of Astedt-Kurki et
al. intothe experiences of the family when a member ishospitalised,
the immediate family members (87%)
who interacted on a daily basis and depended on thefamily member
for their contribution in daily livingwere more greatly impacted by
critical illness thanthose who spent less time in interactions. The
like-lihood exists that a spouse more than other familymembers will
suffer symptoms of anxiety, depres-sion, and stress (Leske,
2003).
Family response to stress and eventual cop-ing is dependent on
family perception of stress,strengths, and perceived lifestyle
changes associ-ated with critical illness (Patterson,
2002). Patter-son, using the Family Adjustment and
Adaptation
Response (FAAR) Model, defined family core func-tions and the
adaptation process family employ inreaching a level of adaptation.
Four concepts of family functions were designated as the core
func-tions: membership, economic support, socializationand
protection. Families derive situational mean-ings from the way they
view their world. When de-mands of daily living balance with
capabilities, theresult is adaptation; during times of crisis the
capa-bilities are outweighed by demands. At this criticaljuncture,
core family functions are significantly atrisk for disruption. The
predominant family questsare to restore balance and gain
resilience.
Families engage in tactics to ‘work through’ theissues in order
to balance demands, put the puz-zle pieces together and clarify the
issues that con-front them (Buttery et al., 1999). They experiencea
sense of aloneness; they must ‘endure’ and shoul-der all the
responsibilities (Hupcey and Penrod,
2000). Physical and emotional health is impactedas eating and
sleeping patterns become sporadic(Van Horn and Tesh, 2000a,b).
Van Horn and Tesh(2000a), utilizing the Iowa ICU Family Scale
(IIFS),explored variations in health habits, role changes,and
support systems during family members’ hos-pitalisation. The IIFS
instrument uses a Likert scaleto compare pre-hospitalisation
behaviours with cur-rent behaviours. In this study of a
non-probabilitysample of 50 family members of ICU patients,
56%experienced changes in family roles. More than 80%were at
significant risk for illness based on sleep
deprivation and impaired nutrition without consid-eration of the
stress component of illness.Van Horn and Tesh (2000a) also
established a cor-
relation between the frequency of visitation andstress scores.
Those who visited the patient morefrequently had higher initial
stress scores, levellingoff after about 20 days length of stay.
Highest stressscores and more health habit changes came fromwomen
in the 19 to 29 and 30 to 39 age groups.Young families who have the
added responsibilitiesof children may feel changes in roles and
respon-sibilities more severely, accounting for the higherstress
scores.
Pre-existing family stress may influence the abil-ity of the
family to cope with current stressors. Ina comparison study of
family stress and strengthsfollowing surgery and trauma, Leske
(2000) foundmechanism of injury had an insignificant
bearingon strengths and adaptation. However, prior stresswas found
to be more a determinant of copingability than the current illness
event. When fam-ily stress and strengths after various modes
of trauma, surgery and gunshot wounds (GSW) werecompared,
families of GSW victims were likely tohave more prior stress and
fewer coping skills. The
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20 B.J. Pryzby
experience (Wolf et al., 2003). The CBI, also basedon Watson’s
theory of caring, categorizes nurse car-ing into five main areas.
Nurse caring responses in-clude those that demonstrate respect of
the client,provide assurance, offer a positive sense of connec-tion
to others, pay attention to the needs of others,and use skills and
knowledge in caring behaviours.
Other studies have suggested the perceived im-portance of
individuality on the patient concept of what constitutes
caring. A British study by Attree(2001) on nurse caring
behaviours from the familyand patient prospective described ‘good’
and ‘notso good’ quality care. Patient focused care relatingto the
patients’ needs and described by the patientsas ‘made you feel like
you were the one that counts’ranked highly on the list. The
interpersonal aspectsof caring were defined as the most significant
topatients and relatives in this qualitative study.
Supportive of this research is the study of
Dingman et al. (1999) concerning patient satisfac-tion with
care after implementing a caring modelbased on Watson’s caring
attributes. As nursesshowed more concern for individual patient
identi-fied needs, overall satisfaction with care improved.The
exploration of Hegedus (1999) into caring
be-haviours also revealed agreement between nursesand patients on
the importance of the concept of in-dividuality. While both groups’
perceptions differedon what constitutes the most caring
behaviours,both ranked ‘treatment as an individual’ as themost
important caring behaviour.
Showing individual concern does not need to en-compass a vast
quantity of time. Addressing thetime factor needed to care, in
Dingman et al.(1999) survey of patient satisfaction
with hospital-isation, the importance of a caring moment
wasdemonstrated. The quality of communication farexceeded the
importance of length of time spentin the endeavour. Five minutes
spent with the pa-tient or family explaining the plan of care for
theday brought satisfaction and an expressed sense of feeling
cared for.
For caring to be meaningful, both the carerand the one being
cared for must share common
perceptions. In comparison studies of nurse car-ing examined
from patient and staff perspectives,incongruence was evident
(Hegedus, 1999; vonEssen and Sjoden, 2003). Eighty-one patients
and105 staff from six hospitals participated in von Es-sen’s
project. Using a CARE-Q instrument, whichidentified 50 nurse caring
behaviours, divided intosix categories, behaviours are chosen in
rank or-der according to specific sets of instructions.
Fromnursing’s perspective, affective behaviours such aslistening,
touch, assurance, allowing for individual-ity and spending time
with the patient were con-
sidered the most important caring behaviours. Incomparison,
patients rated the technical aspectsof care more highly. Perception
of patient and staff differed on greater than 50% of the items
on theCare-Q scale. Consistently, in both studies, nursesrated
affective behaviours more highly than did pa-tients.
Meeting family needs
The categorical needs of family members of criticalcare patients
have been well established throughprior research. These include the
need for infor-mation, proximity to the family member,
assurancethat the best possible care is given to the familymember,
support, and comfort (Leske, 2002). Leskerefined the previous work
of Molter, which identi-fied 45 family needs into a quantitative
measure,
the Critical Care Family Needs Inventory (CCFNI).Now an
evaluation of nursing in meeting identifiedneeds, examining the
progress that has been made,is being addressed in nursing research.
Unmet needsmultiply family stress responses. Kosco and
War-ren’s (2000) evaluation of 45 family members in aLevel 3
trauma centre discovered that families andnurses do not always
agree on the perception of needs as met. Only 4 of the 10
family needs identi-fied on the CCFNI were ranked as being met.
Nurse caring behaviours in family care, ideallywould be directed
toward fulfilling families’ identi-
fied needs. The studies by Hallgrimsdottir (2000)and
Astedk-Kurki et al. (2001) confirmed nurses’acknowledgement of the
importance of family inprovision of holistic care. However, nurses
are in-consistent in meeting family needs mainly becauseof
differing beliefs in obligations to family care(Hallgrimsdottir,
2000; Hupcey, 1999; Tracy andCeronsky, 2001).
Other examples of disparity exist between whatthe family and
patient consider the most importantand what the nurse considers
important (Kosco andWarren, 2000; Mi-kuen et al., 1999). In a study
of neurosurgical patients in Hong Kong, nurses tended
to underestimate those items that the family con-sidered most
significant (Mi-kuen et al., 1999).Nurses rated support and comfort
needs decidedlyhigher while the family valued information,
espe-cially from the same nurse, proximity to the pa-tient, and
assurance through offering hope.
A commonality and a frequent utterance of fam-ilies, as they
deal with the crisis brought on bycritical illness, was the need to
know (Bond et al.,2003; Hunsucker et al., 1999; Yin King Lee and
Lau,2003). Bond et al. (2003) found this especially appli-cable to
families of severe traumatic brain injured
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Nurse caring and family stress responses 21
patients. The need for consistent, accurate infor-mation was
important initially and remained impor-tant to the family over time
and throughout theICU experience. The findings of the survey
of YinKing Lee and Lau (2003) of 40 family
members of ICU patients concurred with Bond et al.
findings.Families ‘need to know’ held top priority. The needfor
information is a common thread as well in car-ing for rural
families. Hunsucker et al. (1999) es-tablished that
communication with the healthcareteam ranked one of the top ten
priorities of thesefamilies. The need for daily information
resoundedwith utmost importance. Updates given to them bythe family
member’s physician was especially val-ued.
Waters (1999) compared differences in familymembers
expectations across cultures of antici-pated professional nursing
support expected dur-ing critical illness. Whites, Hispanics, and
African
Americans, 30 from each cultural group, partic-ipated in the
quantitative comparison study. Re-sults confirmed that critical
illness produced familystress responses across cultures. However,
expec-tations of nurse caring behaviours were culturallyvaried.
Hispanics and African Americans held higherexpectations of critical
care nurses than did Whites.Providing information and keeping the
family up-dated on physical changes were the expected be-haviours
noted most frequently in all three culturalgroups.
Family integration into ICU
Families, as a rule, being secondary to patients, donot always
find easy entry into ICUs. Hupcey (1999)explored integration
of the family into the ICU. Inthis process, while the intention of
the nurse andfamily is to support the patient through the
illnessexperience, there is competition exhibited by theiractions
as nurses look out for themselves and seekto maintain control over
the family. For the fami-lies, looking out for themselves entailed
‘enduring’and trying to ‘find a niche’ in the ICU while being
‘on guard’ to protect the family member who couldnot fend for
himself. Some families never movedbeyond ‘staying on guard.’
In order to overcome objection and fit the fam-ily into the ICU,
creation of a family-centred criti-cal care environment is
paramount. Henneman andCardin (2002), speaking for the
American Associa-tion of Critical-Care Nurses (AACN), explained
thatfamily-focused care is more than theoretical andmust entail
commitment to the philosophy as wellas a thorough understanding of
a family-centred ap-proach to care. In addition, the domain of
nursing
need not go it alone but rather in a spirit of co-operation and
collaboration with other disciplinesfor successful implementation
of an approach tocare that is not yet widely accepted. Henneman
andCardin acknowledged that the patient is always thepriority;
family-centred care just goes a step be-yond by including those
persons significant to thepatient.
Nursing interventions to ease the transition
Interventions that go a step beyond to ease familystress, assist
the integration process of the fam-ily into the critical care
environment, and modifythe nursing focus to include the family
offer a be-ginning point in establishing optimal family
func-tioning. Leske (2002) examined practice protocolsbased on
identified family needs to decrease anxi-
ety. The research-based protocols of the AmericanAssociation of
Critical-Care Nurses address familyneeds and anticipated outcomes
as a result of spe-cific actions and behaviours on the part of
nursing.
In addition to practice protocols, instituting for-mal staff
education programs have had positive ef-fects on both patients and
nurses. Implementinga caring model designed to highlight caring
be-haviours enhanced not only patient perception of caring
behaviours but also satisfaction with care(Dingman et al., 1999;
Yeakel et al., 2003). Partici-pation in a program designed to
develop emotional
self-control and improve communication skills en-hanced nurses’
competence and perceived commu-nication abilities (Garcia de Lucio
et al., 2000).Nurses simultaneously felt less anxiety in deal-ing
with families of critically ill patients whileexperiencing the
perceived ability to empathizeand listen. The patients benefited by
having amore relaxed nurse, and one more confidant innurse/family
interactions.
A further intervention, a supervised focus-groupprogram
utilizing patient narratives, helped nursesthrough reflection on
patient needs and the conse-quences of their actions toward the
family. Nurse
sensitivity and self-insight increased as a resultof reflection.
Nurses increased their awareness of family needs and became
more in touch with whatthe family was feeling. Nurses listened to
how theytalked to families and in doing so, became moretherapeutic.
Enhanced self-image, pride in the pro-fession, self-assurance and
increased readiness forthe professional role stemmed from the group
re-flection intervention (Lantz and Severinsson, 2001).
Along with reflection and formal education pro-grams that
increase therapeutic use of self, nursescan create an environment
of care for families
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22 B.J. Pryzby
that involves other consults on the healthcare team(Henneman and
Cardin, 2002). Nursing’s role is lim-ited; meeting family
needs requires a multidisci-plinary team approach. Referrals
including socialworkers, volunteers, and family advocates
supportnursings’ efforts in gathering resources for the pa-tient
and family.
Appleyard et al. (2002) explored a nurse-coachedintervention
through which family found comfort asthey sat in the waiting room
when their need forinformation was met. In this intervention,
nursesacted as preceptors to volunteers who manned thecritical care
waiting room and acted as liaisons be-tween staff nurse and
patient. Volunteers provideda human connection to their family
member. Fam-ilies reported feeling less anxious and better
in-formed as a result.
An alternative program designed especially forfamilies of
critical care patients in helping to bridge
the communication gap, utilised a family advocate,one who is
trained in crisis interventions, to meetfamily psychosocial needs
and improve customersatisfaction (Washington, 2001). Because
communi-cation is so vital, keeping the family informed
andimproving communication with the family and theother
professional team members are essential el-ements of the family
advocate role.
Exclusion of family during critical care hos-pitalisation
intensifies their anxiety, stress andaffects family functioning.
Family inclusion andparticipation in daily rounds in a Level 1
trauma
centre successfully addressed family need for in-volvement,
information, and communication withthe healthcare team (Schiller
and Anderson, 2003).Since 2000, families have been included in
dailytrauma rounds at Southern Illinois Trauma Centerin the USA.
Families are allotted time to ask ques-tions, and are updated on
the plan of care. Surveyfeedback thus far has been positive,
documentingimproved communication, better understanding of the
family member’s medical condition, and an in-creased sense of
satisfaction with care.
Conclusion
Evidence obtained through reviews of both quan-titative and
qualitative nursing research suggestthat nurse caring behaviours
influence patient andfamily satisfaction with care and the family
stressresponses associated with hospitalisation of a fam-ily
member. Incongruence and lack of consensuson the part of the family
and the nurse relevantto caring behaviours are also evident
throughoutthe nursing research. ICU nurses are positioned to
positively influence family stress responses
throughinterventions geared specifically toward meetingfamily
needs.
This review of nursing literature has sought tobring to the
forefront, the stress of the family andthe potential of the nurse,
to assist families throughthe stress associated with critical
illness or trauma.The initial step involves inclusion of the family
intothe circle of care. Treatment of the family as part-ners in
care, and a family-centred approach to careadditionally serve to
alter stress responses. Nursecaring behaviours, employing an
appropriate mixof skills, knowledge, and caring attitudes
influencefamily stress responses associated with critical ill-ness
or injury of a family member.
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