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A Natural Synergy in Creating a Patient-Focused Care Environment^*

The Critical Care Family Assistance Program and Critical Care Nursing

^* From the American Association of Critical-Care Nurses, Aliso Viejo, CA.

Correspondence to: Justine Medina, RN, MS, AACN, 101 Columbia, Aliso Viejo, CA, 92656; e-mail: justine.medina{at}aacn.org

Key Words: advocacy • American Association of Critical-Care Nurses • family satisfaction • family stress • patient-focused

	Introduction

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When the American Association of Critical-Care Nurses (AACN) was first established in 1969, thanks to the efforts of nurses and the support of physicians who understood the need for qualified nurses with the specialized skills necessary to provide complex care for critically ill patients, it was organized as the American Association of Cardiovascular Nurses. At that time, the purpose of the association was to help educate cardiovascular nurses working in newly developed ICUs and cardiac care units. In 1971, the association adopted its current name, the American Association of Critical-Care Nurses, to include all nurses who care for acutely and critically ill patients. In the 3 decades since the establishment of the association, through its leadership, partnerships, educational programs, and resources, it has kept pace with the advances in medicine, nursing, and technology that affect the care of patients with complex problems.

Building on decades of clinical excellence, the AACN provides and inspires leadership to establish work and care environments that are respectful, healing, and humane. The key to the success of the AACN is through its members. Today, the AACN is the largest specialty nursing organization in the world, with 65,000 members representing > 400,000 nursing professionals who are charged with the responsibility of caring for the most critically ill patients. The members of the AACN come from every state in the United States and from 45 countries worldwide. Therefore, the AACN has committed itself to provide the highest quality resources to maximize the contributions of nurses to the caring for and improving the health of critically ill patients and their families.

Driven by patient-centered/patient-focused care, the AACN goal is to continue its commitment through validating, developing, and providing high-quality education and practice resources. The current areas of AACN focus and development of resources for nurses include the following:

Use of technology in clinical decision making;

Health-care finances;

Work shortages and the impact on nursing service;

Healthy work environments;

Evidence-based education models; and

Practice guidelines.

The AACN vision statement, "Dedicated to creating a health-care system driven by the needs of patients and families where critical care nurses make their optimal contribution," describes the driving dedication to the development of resources and our partnership with The CHEST Foundation in creating the Critical Care Family Assistance Program (CCFAP). The AACN has participated in the development of the criteria for the selection of sites and has been instrumental in looking for integration, and links to nursing resources and tools that helped many of the initial program participants ensure a strong collaboration, focusing on patient-focused and family-focused care delivery.

	Impact of the CCFAP on Critical Care Nursing

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Implications for Care Delivery and Satisfaction
The professional standards of acute and critical care nurses define the scope and responsibility of nurses as practitioners who practice in settings where patients require complex assessment, high-intensity therapies and interventions, and continuous nursing vigilance. To practice, critical care nurses rely on a specialized body of knowledge, skills, and experience to provide care to patients and families and to create environments that are healing, humane, and caring.¹ Above all things within the scope of the practice and standards of all nurses, and especially of critical care nurses, is a role as patient advocate. The AACN defines advocacy as respecting and supporting the basic values, rights, and beliefs of the critically ill patient. In this role, critical care nurses will do the following:

Respect and support the right of the patient or the patient’s designated surrogate to autonomous informed decision making;

Intervene when the best interest of the patient is in question;

Help the patient to obtain necessary care;

Respect the values, beliefs, and rights of the patient;

Provide education and support to help the patient or the patient’s designated surrogate make decisions;

Represent the patient in accordance with the patient’s choices;

Support the decisions of the patient or his/her designated surrogate or transfer care to an equally qualified critical care nurse;

Intercede for patients who cannot speak for themselves in situations that require immediate action;

Monitor and safeguard the quality of care that the patient receives; and

Act as a liaison among the patient, the patient’s family, and other health-care professionals.²

This professional responsibility for advocacy is directly aligned with the goals of the CCFAP. In the critical care environment, the care of the patient often requires the use of all of the resources available to nurses to assure positive outcomes, and it is the lack of time or coordination of other support services that is lacking or nonexistent. It is this focus of the CCFAP that completes the accountability of the system to making sure that those patients and families have an advocate and have their needs met. In hospitals where successful advocacy efforts have evolved, it is usually two or three physicians and a couple of nurses who have led the efforts.

Any illness severe enough to require admission to an ICU is life-threatening and can precipitate severe stress within the family system. The stresses produced by critical illness vary in intensity and duration but undeniably can create a heavy burden for families. The sources of this stress include fear of death, uncertain outcome, emotional turmoil, financial concerns, role changes, disruption of routines, and unfamiliar hospital environments. Stress can interfere with the ability of family members to receive and comprehend information, maintain patterns of family functioning, use effective coping skills, and provide positive support. As family members struggle to cope with the stresses, the critical nature of the illness may lead to changes within the family unit. Whether these family changes are beneficial or adverse depend, in part, on the type of help the family receives from health-care professionals.³⁴⁵

In the critical care setting, families appear to have a profound beneficial impact on the response of the critically ill patient to illness. Families act as buffers for patient stress and serve as valuable resources for patient care. However, when families have high levels of stress, they may be unable to provide support and may transfer their stress to the patient. Unmitigated family stress can manifest itself as distrust of hospital staff, noncompliance with the treatment regimen, and even lawsuits.⁵

Because the responses of families to critical illness and psychological stress have implications for the family, the patient, and the health-care staff, it is advantageous for everyone to provide family-focused care so that optimal levels of family functioning are supported. Family-focused care means that nurses assess the needs of each family and devise interventions to beneficially affect the outcomes of the patient and the patient’s family. Nurses who support a family-focused practice model report higher autonomy and job satisfaction.⁶⁷ This is especially critical for the nurse who cares for these most vulnerable patients and families. The family remains the most important social context for health-care professionals to positively influence patient outcomes.

All nurses should develop competency in assessing the needs of families and in intervening to address those needs. Family assessment and intervention demand expertise and theoretical knowledge. Acquiring this expertise and knowledge requires active listening and observing of the interactions between patients and their family members. Nurses must have good interviewing techniques to generate family interventions in a professional manner. Almost all nurses benefit from education on (1) understanding the nurse-family relationship, (2) coping with the situations that evolve from family interactions, and (3) improving the satisfaction of families with care delivery.⁸⁹

Numerous studies have been performed to determine the various needs of family members when one member is hospitalized in a critical care unit. Most results are based on data obtained by using the critical care family needs inventory or a modified version of this instrument.¹⁰¹¹ The results of these studies suggest that the family members of critically ill patients have a well-defined predictable set of needs. These needs are grouped into the following five major areas and are universally experienced by most family members:

1. Receiving assurance. The need for assurance reflects keeping or redefining hope about the patient’s outcome.
   
2. Remaining near the patient. The need to visit reflects linking and maintaining familial relationships.
   
3. Receiving information. The need for information reflects the goals of understanding the patient’s condition and lays the foundation for decision making.
   
4. Being comfortable. The need for comfort reflects the importance of the reduction of distress.
   
5. Having support available. The need for support reflects seeking or accepting expert help, assistance, or aid.
   

Promoting proximity between the patient and family members is an important component of family-centered care. In a landmark study by Leske,¹⁰ visiting needs are clustered with other selected information needs and are termed proximity, the need to have personal contact and to remain near the critically ill person physically and emotionally. Thus, facilitating visiting between the critically ill patient and family members is a process of instituting change in order for family members to interact with their critically ill loved one.¹²

In the current health-care environment, systems and resources are not optimal to ensure that patient-centered care models are successful in meeting the needs of patients and their families. Nor are these systems assisting health-care providers in meeting those needs. The CCFAP has shown that bringing together an interdisciplinary health-care team to develop processes, structures, and relationships can facilitate satisfaction and, ultimately, positive outcomes. When the entire team is engaged to advocate for patients and their families, each member provides a skill and service that would be impossible to reproduce if the responsibility to provide those was limited to one group, namely, nurses. In the CCFAP, every member of the team benefits from the efficiencies and shows dedication to a directed goal, to meet the unmet needs of families of critically ill patients through education and family support resources. The widespread adoption of the "lessons learned" and best practices of the CCFAP hospitals can greatly improve communication with patients, families, and the entire team. The successes in interdepartmental and interdisciplinary communication have led to a great coordination of efforts, which is known to improve satisfaction and retention efforts in the nursing workforce.¹³

	The Impact of the CCFAP and Continued Partnership for Patient-Focused Care

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The nursing science and the professional obligation of the nurse to provide patient-centered care are so closely aligned with the goals of the CCFAP that the AACN has supported and assisted in the distribution of the CCFAP replication toolkit. We have developed resources to help inform and educate nurses, and some of these resources may provide some hospitals with tools and support in implementing patient-focused care strategies. We will continue to partner with The CHEST Foundation and the American College of Chest Physicians in developing new resources and new programs, and in recognizing those hospitals that have implemented patient-focused, patient-centered care models. The systems, structures, and processes that are known to have positive satisfaction outcomes need to be continued, developed, and disseminated throughout the hospital environment.

In January 2005, the AACN developed the "AACN Standards for Establishing and Sustaining Healthy Work Environments." This document embodies six essential standards for establishing and sustaining healthy work environments. The standards identify systemic behaviors that are often discounted, despite growing evidence that they contribute to creating unsafe conditions and obstruct the ability of individuals and organizations to achieve excellence.¹⁴ The CCFAP and the AACN recognize that health-care institutions are instrumental in providing an environment in which patient advocacy is expected and supported.

	Footnotes

 
Abbreviations: AACN = American Association of Critical-Care Nurses; CCFAP = Critical Care Family Assistance Program

	References

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1. Medina, J eds. Standards for acute and critical care nursing practice. 2000 American Association of Critical-Care Nurses. Aliso Viejo, CA:
2. American Association of Critical-Care Nurses. Critical care nursing fact sheet: the American Association of Critical-Care Nurses public policy resource. Available at: http://www.aacn.org/publicpolicy. Accessed February 4, 2005
3. Alpen, MA, Halm, MA Family needs: an annotated bibliography. Crit Care Nurse 1992;12:32,41-50
4. Bahnson, C The impact of life threatening illness on the family and the impact of the family on illness: an overview. Leahey, M Wright, LM eds. Families and life threatening illness 1987,26-44 Springhouse. Springhouse, PA:
5. Danielson, CB Hamel-Bissell, B Winstead-Fry, P eds. Families, health, and illness: perspectives on coping and intervention 1993 CV Mosby Co. St. Louis, MO:
6. Feetham, SL Meister, SB Bell, JMet al eds. The nursing of families: theory/research/education/practice. 1993 Sage. Newbury Park, CA:
7. Halm, MA, Titler, MG, Kleiber, G, et al Behavioral responses of family members during critical illness. Clin Nurs Res 1993;2,414-437[Abstract/Free Full Text]
8. Creating a healing environment: protocols for practice. Chulay, M Titler, MG eds. Family visitation and partnership in the critical care unit 1997 American Association of Critical-Care Nurses. Aliso Viejo, CA:
9. Wright, LM Leahey, M eds. Nurses and families: a guide to family assessment and intervention. 1994 FA Davis. Philadelphia, PA:
10. Leske, JS Needs of adult family members after critical illness. Crit Care Nurs Clin North Am 1992;4,587-596[Medline]
11. Leske, JS Comparison ratings of need importance after critical illness from family members with varied demographic characteristics. Crit Care Nurs Clin North Am 1992;4,607-613[Medline]
12. Leske, JS Family member interventions: research challenges. Heart Lung 1991;20,391-393[ISI][Medline]
13. Larrabee, JH, Janney, MA, Ostrow, CL, et al Predicting registered nurse job satisfaction and intent to leave. J Nurs Adm 2003;33,271-283[ISI][Medline]
14. Barden C, ed. AACN standards for establishing and sustaining healthy work environments: a journey to excellence; 2005. Aliso Viejo, CA: American Association of Critical-Care Nurses. Available at: www.aacn.org. Accessed February 4, 2005

This Article Full Text (PDF) Free Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Article Archive Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Medina, J. Search for Related Content PubMed PubMed Citation Articles by Medina, J.