Introduction
Family-Centred Care
According to the Institute of Patient and Family-Centred Care, Family-Centred Care
(FCC) can be defined as an approach for the planning, delivery and evaluation of health
care which is based on mutually beneficial partnerships between health care providers,
patients, and families. In this sense, FCC redefine the relationships in health care
by emphasising collaboration with people of all ages, throughout all levels of care
and in all care settings (Institute of Patient and Family Centred-Care, 2018). This
model of care seeks to integrate the family as an integral part of the patient's care
process. In other words, families are not conceived as mere visitors, but are given
a place within the working dynamics of the care units (Hartog & Bodechtel, 2018; Wong
et al., 2015).
FCC originated in the convention on the rights of the child in 1990, where non-separation
of mother and child in paediatric units was promoted with benefits such as: involvement
of parents in the care of their children during admission, a decrease in the child’s
anxiety and better relationship between parents and professionals from work with paediatric
populations in the hospital setting (Hervás, 2017). Over time and with the increasing
presence of families within hospitals, this model has been extended to other age ranges
and other specialties, becoming integrated at the hospital level through the implementation
of protocols, specific interventions, and daily practices (Gooding et al., 2011).
In addition, this would help the well-being of family members, specifically family
members of a patient admitted to ICU as they have a high prevalence of post-traumatic
stress, anxiety and depression (Martín Delgado and García de Lorenzo Y Mateos, 2017;
McAdam et al., 2010).
Johnson and Abraham (2012) defined the postulates on which FCC is based, which can
be summarised as follows: Upholding the dignity and respect of both patients and their
families and their cultural beliefs and values, the sharing of complete and truthful
information, patient, and family empowerment to participate in decision-making, and
the collaboration of both patients and families with caregivers in the implementation
and evaluation of policies and interventions.
Intensive Care Units and Family-Centred Care
The transition towards the autonomy model began in 2001 in the USA, leaving behind
the paternalistic model, and it was at this time that the concept of patient-centred
care was incorporated (Rojas, 2019). In Spain, the humanisation of ICU care and FCC
were not standardised until 2016 when a roadmap was drawn up with the HU-CI project
(La Calle et al., 2020). In this context, Intensive Care Units (ICUs) have been the
protagonists of a transition movement from the traditional closed ICU model, in which
family visits were restricted, to an open ICU model (Ning & Slatyer, 2021; Riley et
al., 2014) where FCC has begun to acquire a more important role, even being considered
a quality criterion (Gooding et al., 2011; Riley et al., 2014). The HU-CI project
developed in Spain includes this FCC model as a key element, is the Humanisation of
Intensive Care Units (HUCI) project (Grupo de trabajo de certificación de Proyecto
HU-CI, 2019). This project arose in a hospital in Madrid in 2014 with the aim of drawing
up a roadmap to promote humanised care, to improve psychological and social support
for ICU users, with the primary involvement of patients and their families (Calle
and Lallemand, 2014).
In the ICU we find ourselves challenged by situations in which a patient cannot communicate
and thus, we must rely on family members to support medical decision-making as most
of the patients are intubated and connected to mechanical ventilation (Ten Hoorn et
al., 2016). The high level of responsibility they must face, added to the life-death
situation in which their loved one is kept, leads families to suffer a great impact
at a psychological level, which is diminished through the implementation of family-centred
policies and interventions (Davidson et al., 2017; Wong et al., 2015). Thus, FCC makes
the ICU more comfortable and humane (Escudero et al., 2014), improving family satisfaction
and the comfort of patients by having their family close at hand (Garrouste-Orgeas
et al., 2008). The involvement of families in the care of the ICU patients and FCC
are part of the holistic vision that characterises nursing care and, also, have a
positive influence on the recovery of the critically ill patient (de la Cueva Ariza,
2012).
COVID-19 and Family-Centred Care
On 11 March 2020, the World Health Organisation (WHO) declared a pandemic state due
to a new virus called SARS-COV-2 detected for the first time in the Chinese province
of Wuhan (World Health Organisation, 2020). This virus is the cause of the disease
called COVID-19 (Ministry of Health, Equality and Social Affairs, 2021).
Due to the high rate of contagion of this disease, we are currently facing one of
the greatest global health emergencies in history, with more than three million people
infected in Spain and more than 70,000 deaths (Secretaría General de Sanidad y Consumo,
2021). The fast and wide dissemination of this disease has led hospital services to
record high levels of saturation, being the ICU one of the most affected hospital
units (Haas et al., 2020; Phua et al., 2020; Secretaria General de Sanidad y Consumo,
2021).
To mitigate the chain of infection, a series of exceptional contingency measures have
been taken by healthcare institutions. Within these, and with the aim of decreasing
the flow of people within hospital environments visits were totally restricted with
some exceptions that could vary from hospital to hospital, but the main exclusion
was end-of-life accompaniment, a measure that was also extended to Critical Care Units
(Ning & Slatyer, 2021; Rose et al., 2020).
In this way, the COVID-19 pandemic has reversed all the advances made in FCC within
these units, putting both families and healthcare professionals in a completely new
scenario (Hart et al., 2020; Montauk & Kuhl, 2020; Ning & Slatyer, 2021).
For all these reasons, the focus of this paper is on investigating strategies implemented
by Intensive Care Units to provide FCC in times of the COVID-19.
Objective
To describe clinical practice interventions aimed at providing Family-Centred Care
in intensive care units during the COVID-19 pandemic.
Methods
A systematic literature review was conducted, which seeks to bring together the existing
information on a specific topic. This review was based on the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology (Page et al.,
2021).
Search strategy
The PICO (Population, Intervention, Comparison and Outcome) strategy (Richardson et
al., 1995) was used to guide the information search process in formulating a research
question, and in turn, inclusion and exclusion criteria were established in relation
to each of the above points (Table 1
).
Table 1
PICO question analysis
PICO
Inclusion criteria
Exclusion criteria
Population
-
Adult patients and relatives.
-
Family members of patients admitted to adult Intensive Care Units (ICU), as well as
surgical, cardiac, or neurological critical care units during the SARS-COV2 pandemic.
-
Paediatric patients and minor relatives.
-
Relatives of non-intensive care unit patients.
Intervention
-
Studies addressing FCC interventions during the SARS-COV-2 pandemic.
-
Pilot tests, strategic and contingency plans, clinical experience, etc.
Scope
-
Adult intensive care units (ICU), surgical, cardiac, or neurological critical care
units.
-
Non-critical hospitalisation units.
-
Paediatric units.
-
Home care.
Results
-
Impact of interventions on outcomes for family members, patients, and healthcare staff.
Table 1. PICO question analysis
Since this is a newly emerging problem, a wide variety of study designs are included:
systematic reviews, pilot studies, mixed-method studies, qualitative studies, single-case
studies, descriptive studies, etc. This review also included articles published in
English, Spanish, Portuguese or Italian, as well as those with the option of English
translation.
Two methods were used to obtain the information for systematic search between March
2020 and March 2021. One search was carried out through several databases, including
Pubmed, Cinahl, Web of Science, Scopus, and Google Scholar. The other search was carried
out within the existing and available grey literature. For this last, resources from
various journals were explored, documents through the Scopus database, as well as
the websites of Intensive Care and Critical Care Medicine and Nursing associations
that share similarities with the European care model. A total of 11 associations and
22 online journals were consulted. In the case of associations, those presenting written
resources related to FCC and COVID-19 were chosen, with a total of 6 associations
selected.
Search
To focus the search for information in relation to the subject of the study within
the literature, the following terms were chosen: “Family-Centred-Care”, “intensive
care” and “COVID-19”, which were indicated in the field’s title/title, abstract/abstract,
and key words. At the same time, to narrow down the search further, Boolean AND and
OR operators were used. As an example, the search strategy for the WOS database can
be found as follows: TS= (family OR family centred) AND TS= (intensive care OR critical
care OR icu) AND TS=(covid 19 OR coronavirus).
Grey literature obtained from various websites of Intensive and Critical Care Medicine
and Nursing associations was explored in the section reserved for resources related
to coronavirus or COVID-19 in each of them.
Study selection
All studies retrieved through search strategy were imported in to MendeleyTM bibliographic
manager and removed duplicated studies. The resulting articles were sorted using ExcelTM
software for their selection. This document was composed of different sections: title,
authorship, type of resource, date of publication, aim/purpose, method used, results
obtained (and form of measurement, if any), professionals involved and country. Those
documents in which it was not possible to collect the data were eliminated from the
systematic review. Two reviewers (EFM and EAM) independently screened the studies.
Disagreements were solved by discussion.
Selected articles were analysed using a series of quality assessment checklists developed
by Joanna Briggs Institute (JBI) which analyse the reliability, relevance, and results
of published articles. The JBI quality assessment tool has nine items with response
option of yes, no, unclear or not applicable. In this paper we made use of the checklists
created for the assessment of systematic reviews (Munn et al., 2015), qualitative
studies (Lockwood et al., 2015), descriptive studies (Munn et al., 2015) and opinion
pieces (McArthur et al., 2015). Only articles that fulfilled the criteria on these
scales were selected.
Regarding the quality of the articles reviewed, those that did not respond to one
or more of the questions in the questionnaires assigned were excluded, and a total
of 11 documents were finally eliminated.
Analysis process
In order to be able to describe and compare the different studies, a thematic analysis
approach was adopted, where the main themes of the articles were collected. To this
end, the matrix proposed by Webster and Watson (2002) was incorporated to help clarify
the concepts of the review. Subsequently, information from the included studies was
extracted, specifying: Name of the first author, year of publication, type of resource,
objective and relevant results of each document.
Results
A total of 209 resources were obtained from this search, 172 of them from scientific
databases, while the other 37 came from other sources (Figure 1
).
Figure 1
Systematic review flowchart
By screening the documents based on their subject matter, the target population and
compliance with a series of quality criteria, a total of 24 documents were obtained
and included in this study. Of these, 19 were obtained from the search conducted in
the different databases and five from the grey literature, as well as from other sources
(Table 2
).
Table 2
Selected document overview.
Author, year, and type of resource
Aim
Relevant results
(Taylor et al., 2020). Qualitative study
Pre-implementation evaluation of a programme aimed at training medical students to
promote the involvement of ICU patients' relatives during COVID-19 restrictions on
visits.
- Family involvement is considered an important component of quality care.- Rapid
training of facilitators provides them with necessary skills to inform families.-
The existence of a facilitator programme reduces the workload of the ICU care team.-
Attention to the needs of families is a major investment of time.
(Dhala et al., 2020). Descriptive study.
Describe in detail the adaptations of the virtual ICU for patient-centred care aiming
at the protection of healthcare staff and families.
-A virtual family visit was implemented via the Consultant Bridge application, and
at the same time, palliative care and specialist consultation was provided virtually.-The
opportunity to see their loved ones had a positive impact on the patients ‘emotional
state and mood.-Families were grateful for the possibility to see their relatives.
(Suresh et al., 2020) Qualitative study
Creation of a “COVID-19 Compassion Commission” made up of medical students, which
through videoconferencing aims to reduce the stress that relatives of hospitalised
patients may feel at not being able to see their loved ones.
The programme:- Reduces burnout of healthcare staff.- Improves communication with
relatives of COVID-19 patients.- Enables more sympathetic patient-centred care.
(Aziz et al., 2020) Quick guide of recommendations
To answer key questions regarding the management of COVID 19 emergencies in Intensive
Care Units.
Recommended:- The use of available technology (mobile phone, videoconferencing) to
connect families with patients and care staff.- Maintain lines available 24 hours
a day for information queries and to resolve doubts.- Involve families in rounds with
virtual presence.- Encourage the participation of other professionals in supporting
families: spiritual guides, social workers, ethics committees, etc.
(Cattelan et al., 2021). Descriptive study
Study of the levels of satisfaction and anxiety of relatives of ICU patients during
the stay and after 3 months.
83% and 73% of patient representatives report anxiety and depression respectively.The
role of patient representative in a remote communication context is seen as negative,
due to the specific responsibility it entails.
(Bloomer and Bouchoucha, 2021). Recommendations.
Guidelines for intensive care nurses to facilitate the presence of the closest relatives
of patients with COVID-19.
- Family visits should be limited to one person. Any type of limitation must be justified.-
Visiting hours should be agreed between the professional team and the families.- The
visit should be always guided by the care staff.- Prior psychological preparation
of the family member must be carried out before entering the box.- ICU staff must
be prepared to offer psychological support to the family.
(Piscitello et al., 2021). Retrospective descriptive study.
To assess the number of videoconferences, in-person or telephone meetings with family
members of intensive care patients during COVID-19 pandemic visitation restrictions.As
well as to assess changes in patient care goals based on whether meetings with family
members are conducted in person or by video, their duration, racial differences, and
time spent by palliative care teams.
- Reduced communication with families can potentially affect patient mortality.- Meetings
with family members have decreased during the pandemic and most of them occur via
videoconferencing.- Fewer changes in patient care goals occur when meetings are by
video call compared to face-to-face visits.- Use of palliative care teams as a source
of counselling is minimal and is associated with premature initiation of life-sustaining
treatments, prolonged use of life-sustaining treatments and delayed referral.
(Valley et al., 2020). Descriptive study
Study changes in visiting policies and strategies in ICUs to maintain communication
with families due to COVID-19.
- All the hospitals surveyed showed changes in their visiting policy.- In 31% of the
hospitals a family member was allowed to visit at the end of life.- The change in
communication strategies of healthcare professionals with relatives was the use of
the telephone and virtual communication systems.- Videocalls were the most frequently
used strategy to establish communication between patient and family.
(Rascado et al., 2020b). Recommendation guide
Recommendations for an adequate, programmed and organised response to the health care
of patients with severe COVID-19, coordinated with the Scientific Societies of SEMYUC
and SEEUC, along with the Spanish health authorities.
- Relatives should receive daily information outside the unit and informed and informed
of any changes in accompanying policies.- Family members should be trained in advance
in the use of personal protective equipment in case they enter to see the patient.-
The transmission of information must be accurate, transparent and calm.- The accompaniment
policies of each ICU will be assessed according to their structure and the presence
of a SARS-COV-2 case.Visits to COVID-19 patients will be assessed according to ethical
criteria (e.g. end-of-life situation).
(Lipworth et al., 2021). Pilot programme.
Development of a Remote Link programme for communication between ICU teams, palliative
care teams and patients' relatives during the COVID-19 pandemic.
- The model allows for the training of a wide range of caregivers in supporting the
families of critically ill patients, thus relieving ICU professionals of the burden
of care.- This model allows the training of people who have had no contact with critical
care or palliative medicine.
(Griffin et al., 2020). Action guide.
Creation of a series of protocols focused on infectious control, challenges in clinical
management, ICU capacity building, staffing, ethics and staff welfare.
- Technology was promoted to facilitate family involvement and decision-making at
the end of life.- Limited number of family members able to speak to the physician.-
Families were offered support from palliative care teams.- If visits were not possible,
staff contacted families via video call.- A companion is allowed to visit in end-of-life
situations.
(Mendiola et al., 2021). Qualitative study.
A Programme for improving communication, satisfaction, and healthcare experience
- Video visits allowed relatives to have a closer view of their loved one's progress.-
Virtual family visits enabled informed decision-making about the care of the patient.-
A support system was established in collaboration with the palliative care teams.
(Sasangohar et al., 2020). Qualitative study.
Collect the results of the interviews with patients' relatives in three categories:
feelings experienced during the visit, barriers or challenges, and points for improvement
in care.
- The experience during the virtual visits was rated in most cases (86%) as positive.-
The main obstacles reported were inability to communicate with loved ones due to their
condition, technical difficulties, lack of contact and physical presence, frequency
and clarity of communication with the care team.- Suggestions for improvement included:
access on demand, improvement of technical services and feedback systems, and better
communication with care staff.
(Kennedy et al., 2020). Qualitative study.
To describe the experiences and attitudes of physicians and ICU patients’ families
in relation to telephone and video calls during the COVID-19 pandemic in the context
of visiting restrictions.
- Participants rated the phone and video call experience as effective, but much less
so than the face-to-face experience.- Phone calls were preferred for minor updates
and general information.-Video calls were preferred when making clinical decisions.-
Suggestions for improving remote communication by relatives and professionals included:
identifying a family reference person, maintaining frequent contact, ensuring the
family's level of understanding, or using the video camera to allow relatives to see
their loved one by providing time alone.
(Rascado et al., 2020a). Recommendations guide.
Development of a contingency plan to respond to the needs arising in intensive care
units in the management of COVID-19.
- It is advisable to reduce accompaniment by relatives in the ICU.- Face-to-face visits
should only be allowed in specific cases, whether for clinical, ethical/humanitarian
reasons, etc.-Families should be provided with daily information on the clinical situation
of their relative and on any changes in the unit.
(Rose et al., 2021) Cross-sectional mixed-method study.
Collect the ways of communication between relatives, patients and ICU team during
the COVID-19 pandemic.
- Visits were forbidden in most of the hospitals.- Nursing was less involved in communication
with relatives during restrictions.- In 50% of the hospitals a family liaison team
was formed.- Virtual visits were the most used mode of communication.- Benefits of
virtual communication included: improved stress (78%), increased morale of care staff
(68%) and better management of patients with delirium (47%).
(Lissoni et al., 2020). Qualitative observational study.
To observe the psychological needs of both healthcare professionals and relatives
of patients with COVID-19 and to describe different interventions implemented to address
these needs.
- Among the needs detected in the relatives are the need for information, reassurance,
support and listening, maintaining the connection with their loved one or the need
for accompaniment in the grieving process.- Interventions include daily phone calls
to families, clear and truthful information, accompaniment by psychologists, training
of care staff in communicating bad news.
(Creutzfeldt et al., 2020) Qualitative study.
To explore the experiences of relatives of severely brain-injured patients with a
focus on the impact of their presence in hospital.
It was observed that visits by relatives encouraged coping with the situation, generated
a bond of trust with the professionals and allowed them to receive emotional support
from the ICU team.
(Wendel et al., 2020) Qualitative study.
Description of the formation and implementation of a Family Medical Communication
Team to liaise between families and intensive care teams.
- Families appreciated the constant communication and the importance of this in alleviating
their fear of leaving their loved one alone.- The programme provided families with
a system of information and documentation about the patient's care.-Families benefited
from understanding the type of care being offered to the patient.
(Mistraletti et al., 2020) Action guide.
A document to help teams of professionals in communicating with relatives of completely
isolated patients.
- Family members should receive information daily.- The professional in charge of
communication must be properly trained. Exhausted staff must be protected from carrying
out communication tasks.- The professionals and the hospital should work together
to establish the most effective communication system.- The mental and emotional health
of health workers must be taken care of.- Written communication (email/letter) is
helpful in allowing families to re-read information about their loved one.- Communication
should be truthful, direct as well as accurate and adapted to the comprehension abilities
of each family member.-Always consider the patient's preferences.-Allow time alone
between family and patient whenever possible.
(Intensive Care Society, 2020) Good practice guidelines.
Good practice guidelines on the use of video call systems in Intensive Care Units.
- Good practices include the following:- Preventing and managing possible discomfort
generated by the video call.- Choosing the right place and time for the video call
to take place.- Adapting video calls to the work dynamics of the unit, so that these
are not affected.- Assessing the patient's condition when establishing communication.-
If a video call is not available, always encourage the use of audio systems.-Identify
the reference relative.- Choose a single means of communication to facilitate the
acquisition of skills by professionals.- Always take the patient’s preferences into
account.- Document everything that happens during the video call.
(Selman et al., 2020). Literature review.
Review of bereavement risk factors in COVID-19 and evidence-based recommendations
on support for family members.
Among the activities to be carried out before death:- Plan in advance of the patient's
situation and goals of care.- Communicate proactively, respecting the time and feelings
of the relatives.- Choose the person of reference.- Work together with the palliative
care teams.- Ensure emotional, psychological and spiritual support for families.Among
the activities to be carried out after the death:- Offer relatives the patient's personal
belongings.- Assess relatives at risk of complicated bereavement.- Provide psychological
and emotional support.- Make use of professionals from other specialties for the emotional
management of relatives.
(Hwang et al., 2021a). Descriptive study.
To investigate changes in communication with ICU patient relatives during the COVID-19
pandemic.
- Visiting policies varied from hospital to hospital, with end-of-life situations
being the major exception.- At least half of the hospitals allow a relative to visit
non-COVID patients at a certain time.- 95% of the hospitals used videoconferencing
as a means of communication with families.- The ratio of devices per ICU bed was 1
in 13.
(Hwang et al., 2021b). Cross-sectional study.
To describe the impact of COVID-19 on the participation of families in a multi-centre
FCC project implementation project.
- The COVID-19 pandemic has prevented the implementation of projects.- Units with
sufficient communication devices must be available to cope with restriction policies.-
Adequate numbers of personal protective equipment are required for face-to-face visits.
Table 2. Selected document overview.
All included studies were subjected to quality review. These data can be found in
Appendix 1, which includes the database for each of the documents, author, date of
publication, journal and country, and the score obtained based on the quality checklist.
In general, all the selected studies have a quality of more than 70% except for two
papers, which have a quality of 60 and 67%. In terms of the countries of origin of
the selected documents the highest percentage of these, 50%, were published in the
United States, followed by the United Kingdom (25%), Italy (8%), Spain (8%), France
(4%), Australia (4%), and finally Canada (4%).
Similarly, in relation to the publication date of the documents collected, 41.6% of
these were published in the second half of 2020, 25% in the first half of 2020 and
33.4% in the first three months of 2021.
According to the typology of the resources obtained, we found: Qualitative studies
(eight), protocols and recommendations from official bodies (seven), mixed-method
study (one), descriptive studies (five), cross-sectional study (one), pilot program
(one) and literature review (one).
After a thorough reading of all the documents, the information contained within them
was subjected to a thematic analysis from which repeated patterns emerged in four
main groups: the use of communication systems, multidisciplinary interventions, the
promotion of family engagement and family support (see Table 3
).
Table 3
Concept matrix identifying main themes
Study
Theme
Communication systems
Multidisciplinary interventions
Engagement of families
Family support
(Aziz et al., 2020)
X
X
X
X
(Cattelan et al., 2021)
X
X
(Dhala et al., 2020)
X
X
X
X
(Mistraletti et al., 2020)
X
(Suresh et al., 2020)
X
X
X
X
(Wendel et al., 2020)
X
X
X
X
(Hwang et al., 2021b)
X
(Intensive Care Society, 2020)
X
(Piscitello et al., 2021)
X
X
X
X
(Valley et al., 2020)
X
X
(Griffin et al., 2020)
X
X
X
(Mendiola et al., 2021)
X
X
X
(Kennedy et al., 2020)
X
X
(Sasangohar et al., 2020)
X
X
(Selman et al., 2020)
X
X
X
(Taylor et al., 2020)
X
X
X
X
(Lipworth et al., 2021)
X
X
(Suresh et al., 2020)
X
X
X
(Rose et al., 2021)
X
X
(Rascado et al., 2020b)
X
X
(Creutzfeldt et al., 2020)
X
X
(Hwang et al., 2021a)
X
X
X
(Rascado et al., 2020a)
X
X
(Lissoni et al., 2020)
X
(Bloomer and Bouchoucha, 2021)
X
Table 3. Concept matrix identifying main themes.
Communication systems
Within the selected documents, the use of telecommunication systems is the main mode
used to contact families (Aziz et al., 2020, Cattelan et al., 2021, Dhala et al.,
2020, Mistraletti et al., 2020, Suresh et al., 2020). In many cases, telephone calls
are used (Mistraletti et al., 2020, Wendel et al., 2020), although video calling is
the most recommended and used system when available (Hwang, Zhang, Andrews, Gonzalez,
et al., 2021; Intensive Care Society, 2020, Mistraletti et al., 2020, Piscitello et
al., 2021, Valley et al., 2020). Videocalls are used to connect families with their
loved ones, for contact with healthcare staff during rounds and for clarification
of doubts among other functions (Dhala et al., 2020, Griffin et al., 2020, Mendiola
et al., 2021). The benefits of videocalling include the possibility of a visualisation
of the patient and the attending staff, as well as their non-verbal language (Kennedy
et al., 2020). Applications such as Facetime, Skype, Youtube or applications developed
by the hospitals themselves are the most used through tablet or mobile devices (Dhala
et al., 2020, Sasangohar et al., 2020).
Other applications of the described communication systems include adapting available
resources within virtualised ICUs, such as video surveillance cameras or room microphones
to directly connect the family to the patient's room (Dhala et al., 2020, Sasangohar
et al., 2020). Written communication such as emails or letters were also recommended
(Aziz et al., 2020, Intensive Care Society, 2020, Mistraletti et al., 2020). If video
call or video conferencing systems are not available, the use of audio systems is
recommended, even in unconscious patients (Intensive Care Society, 2020, Valley et
al., 2020).
Regarding the communication process with families, the documents consulted highlight
the importance of its correct development. Thus, it is recommended that communication
should always be direct, clear, truthful, and adapted to the characteristics of each
family member (Kennedy et al., 2020, Mistraletti et al., 2020, Selman et al., 2020).
Among the various suggestions made is the use of checklists when establishing contact
with families by telephone or video, ensuring standardised information for all of
them (Mistraletti et al., 2020).
Similarly, the use of communication skills training for both ICU staff and professionals
from other specialties is considered important (Intensive Care Society, 2020, Mistraletti
et al., 2020, Sasangohar et al., 2020, Taylor et al., 2020), as well as taking care
of the mental state of the professionals in charge of this task. Some documents recommend
removing psychologically exhausted professionals from communication tasks (Mistraletti
et al., 2020).
Multidisciplinary interventions
To provide FCC during the pandemic, a number of figures emerged who could provide
support to ICU teams to enhance communication with the family, thus facilitating multidisciplinary
interventions. Among the selected studies, the figures mentioned were the Palliative
Care team (Griffin et al., 2020, Lipworth et al., 2021, Mendiola et al., 2021, Piscitello
et al., 2021, Selman et al., 2020), Social Work, Spiritual Guides, volunteers (Aziz
et al., 2020) or other medical specialties with reassigned roles due to the pandemic
(Suresh et al., 2020, Taylor et al., 2020, Wendel et al., 2020).
The main functions of these figures can be grouped based on three objectives: support
or consultation to the ICU team (Dhala et al., 2020, Piscitello et al., 2021), workload
relief to the ICU team (Lipworth et al., 2021, Suresh et al., 2020) and work integrated
into ICU dynamics (Aziz et al., 2020, Griffin et al., 2020, Mendiola et al., 2021,
Selman et al., 2020).
Engagement of families
Methods to encourage family engagement described in the reviewed literature include
the creation of liaison groups between intensive care units and families, which are
responsible for carrying out the process of communication and resolving doubts (Dhala
et al., 2020, Lipworth et al., 2021, Rose et al., 2021, Suresh et al., 2020, Taylor
et al., 2020, Wendel et al., 2020).
Another method of participation described is involvement in unit rounds either virtually
or in person, as well as in joint decision-making with the care team (Aziz et al.,
2020, Mendiola et al., 2021, Piscitello et al., 2021; Rascado, Ballesteros, Bodí Saera,
et al., 2020).
Similarly, videoconferencing was used in the documents analysed as an alternative
to family visits from both the unit and the loved one's box (Creutzfeldt et al., 2020,
Griffin et al., 2020; Hwang, Zhang, Andrews, Gonzalez, et al., 2021; Hwang, Zhang,
Andrews, LaRose, et al., 2021; Kennedy et al., 2020, Mendiola et al., 2021; Rascado
et al., 2020; Valley et al., 2020). One of the most important aspects highlighted
in several studies is the end of life, where the possibility of an in-person farewell
by at least one family member is recommended (Hwang et al., 2021a, Piscitello et al.,
2021, Rascado et al., 2020b, Rascado et al., 2020a, Valley et al., 2020). At the same
time, prior training of the visiting family member in the use of personal protective
equipment is indicated, as well as psychological preparation prior to contact with
the patient (Rascado et al., 2020b, 2020a).
Support for families.
The admission of a loved one is defined as stressful and complicated for families
(Cattelan et al., 2021). In relation to their care, early identification of families'
needs from the moment of admission is recommended (Lissoni et al., 2020, Sasangohar
et al., 2020, Taylor et al., 2020, Wendel et al., 2020) as well as prevention and
early detection of possible psychological disorders (Bloomer and Bouchoucha, 2021,
Cattelan et al., 2021, Dhala et al., 2020, Rose et al., 2021, Suresh et al., 2020).
Another element described is the availability of psychological support, either by
the prepared ICU team (Creutzfeldt et al., 2020, Rose et al., 2021;) or by psychologists
(Aziz et al., 2020, Selman et al., 2020).
One of the most prominent moments within the documents consulted is end-of-life care,
where a different approach than usual is indicated, allowing in most cases a face-to-face
farewell by at least one member (Hwang, Zhang, Andrews, Gonzalez, et al., 2021; Piscitello
et al., 2021; Rascado et al., 2020; Rascado Sedes et al., 2020; Valley et al., 2020).
Discussion
A total of 24 documents describing interventions and recommendations related to FCC
in Intensive Care Units during the COVID-19 pandemic were selected for this review.
This search resulted in four groups which were: the use of communication systems,
multidisciplinary interventions, engagement of families and support for families.
The COVID-19 pandemic has created a complicated scenario for FCC as it was conceived
until now. The distancing and withdrawal of families from hospitals has turned their
maintenance and development into a new healthcare challenge in addition to those caused
by the disease itself.
Within the studies consulted, communication is conceived as the fundamental pillar
in preserving FCC in intensive care units, and this is the basis for most of the proposed
interventions and recommendations. Within this context we can see how special attention
is paid to the development of effective communication, which leads to relegating this
task to trained persons, and failing that, to the training of health care staff in
this area. This first aspect leads to synergy between the staff of critical care units
and other services such as the palliative care team or the team of psychologists,
among others (Pasricha et al., 2020), while the second aspect leads to the need for
a unified communication system that reinforces its basis in the use of checklists
in many cases.
There is a wide disparity of interventions and recommendations, which may be influenced
by various factors such as cultural factors (Al-Motlaq et al., 2019), but many of
them, according to the selected studies, are influenced by the number of resources
available in the units, ranging from the creation of support groups to the use of
the resources contained in the visualised ICU, among others. But despite the disparity
of interventions and recommendations, after analysing the texts, they reflect the
approach of four major thematic lines, which coincide with several of the postulates
proposed by the Society of Critical Care Medicine (Judy et al., 2017), including the
presence of families in the ICU, family support, communication with families, the
involvement of other specialist members together with the ICU team and the implementation
of environmental measures. The selected studies value communication as the most important
element within FCC. The need for communication has become visible with covid-19, as
families have been side-lined, in many cases completely, which highlighted the importance
of the family in meeting the needs of both the patient and the family itself. The
process of health information to patients and communication with relatives has also
been affected. Previously, information and visits were carried out in person, but
during the pandemic they have been carried out by telephone, and not always systematically,
given the pressure of care. Establishing channels of communication to provide health
information to relatives and achieving the closest possible communication between
patient and relatives, is essential to cover certain needs that arise in critical
situations (Allande Cussó et al., 2020). Not being able to cover this need is what
makes its essentiality so visible.
During the months of the pandemic, the importance of communication came to the fore,
and it was the failure to meet this need that made its essentiality so apparent (Allande
Cussó et al., 2020). Critically ill patients may often be incapacitated, and information
is often given to family members (Davidson et al., 2017). Communication skills are
a crucial element in the humanization process (Wilson et al., 2019). Excellent communication
is fundamental for recognising the patient as a person and placing them at the centre
of the system (Kiwanuka et al., 2019). Effective communication between professionals
and multidisciplinary teams is essential to improve patient outcomes and increase
family and professional satisfaction (Kim et al., 2010). Conflicts between professionals
in the ICU are frequent, many of them due to communication failures. They also threaten
the concept of teamwork and directly influence patient and family well-being, generating
professional burnout and negatively influencing outcomes (Azoulay et al., 2009). Information
is one of the main needs expressed by patients and relatives in the ICU (Alonso-Ovies
et al., 2014). The inability to communicate with many critically ill patients generates
negative feelings and is an essential source of stress and frustration for patients,
relatives and professionals (Happ et al., 2004). Fostering communication, tailored
to the needs of each patient, through communication systems is essential to humanise
care and allows the patient to participate in the critical process (Garry et al.,
2016). During the pandemic months, the same communication needs continue to exist,
but these were impaired by isolation measures to contain the spread of covid-19. This
is a fundamental pillar of FCC.
In turn, the development of effective communication is seen as a key aspect of FCC,
which requires a trained team and, as previously recommended by Pasricha et al. (2020),
the use of guidelines or checklists to provide structured information to families.
Telecommunication systems are described as the most widely used and widespread mode
of communication, but as Hwang et al. (2021) reflect, the availability of these systems
is not uniform in all hospitals. The development of effective communication, which
requires a trained team and the use of checklists to ensure a comprehensive approach
to contacting families, is one of the most important aspects of communication in the
literature (Akgün et al., 2020; Lissoni et al., 2020, Mistraletti et al., 2020, Taylor
et al., 2020). Likewise, in relation to the care team, it is worth highlighting the
importance given to the team' s mental health when carrying out psychologically demanding
tasks such as communication, being again the multidisciplinary work a key point in
distributing the workload and offering the highest possible quality of care in these
situations of physical and mental exhaustion caused by the COVID-19 pandemic (Lipworth
et al., 2021, Mistraletti et al., 2020, Rose et al., 2021, Suresh et al., 2020).
In this challenging context, telecommunication systems have come to play an even more
prominent role within the dynamics of unit functioning, being conceived in most studies
as an important element to break down part of the barriers created by Covid-19 in
the implementation of FCC (Hwang et al., 2021a)(Hwang et al., 2021), thus favouring
the “virtual” approach of families to the ICU, with this approach having a great impact
on families and helping them to make decisions together with healthcare teams (Chapman
et al., 2016, Mangram et al., 2005).
In relation to the increasing importance of FCC during the COVID-19 pandemic, there
has been an increase in the number of articles published, reaching the point where
in the first three months of 2021 a greater number of documents have been published
in this regard than in the first six months of 2020. One of the main recommendations
is the use of telecommunication systems but it should be noted that these strategies
are highly dependent on the patient's or family's smartphones and computers, as well
as the stability of the internet. These strategies may lead to differential access
to FCC (Hart et al., 2020). Another issue regarding the communication of a multidisciplinary
team for family support is the drastic cessation of family support as soon as the
patient left the ICU or died (Klop et al., 2021).
Despite this terrible situation we have been able to learn about measures that help
to maintain FCC. Since covid 19, the need to respect the role of the family, the collaboration
of family and professionals and the maintenance of family integrity as far as possible
has been demonstrated (Hart et al., 2020). Innovative approaches that engage family
members in hospital care during the COVID-19 pandemic may lead to lasting progress,
rather than regression, from the family-centered standards of care that the health
care community has recently achieved (Hart et al., 2020).
Limitations
Despite the rigour with which this review was conducted some limitations need to be
acknowledged. Firstly, the recent emergence of the problem described in this paper
leads to a limited number of documents. Furthermore, the lack of a unified definition
of FCC requires the analysis of various types of interventions and recommendations.
With the selected keywords and the inclusion and exclusion criteria the results only
yielded Western studies. This may be due to the language of publication or to the
greater research on this topic in the West. We assume that in other countries the
situation will be similar due to restrictions on isolation as a gold standard measure
to curb covid 19 infection. Following these measures and the high hospital demand
with the increased burden of care make communication measures with the family difficult.
However, country-specific measures should be analysed in depth.
Conclusion
The findings of this review can help to understand, evaluate, and target interventions
during the pandemic, and guide the development of new strategies to provide delivering
quality care in the context of future pandemics with similar characteristics. There
is a great variety in the nature of interventions developed, with the use of telecommunication
systems in daily practice being the most repeated aspect. The main application of
the results of this research is to be able to respond to the needs of the family in
the best possible way, to ensure that they receive good care in the ICU in any similar
situations that may arise in the future. In this way, it is possible to have lines
of action for exceptional situations that allow, as far as possible, the family attention
and to be present in the patient's day-to-day life.
From the results obtained in the present work, the following recommendations for the
future can be made: (a) create protocols to establish communication with relatives
taking into account the resources of the centre,(b) including a checklist to inform
the family in a clear way so that they can be involved in decision-making, having
technological means to bring the patient and family closer together, (c) ensuring
the availability of material resources for face-to-face visits for infectious patients
and (d) counting on multidisciplinary teams in case of need for support.
Uncited references
Martín Delgado et al. (2017).