Family Presence During Resuscitation After Trauma

Leske, Jane S. PhD, RN, ACNS-BC, FAAN; McAndrew, Natalie S. MSN, RN, ACNS-BC, CCRN; Brasel, Karen J. MD, MPH, FACS; Feetham, Suzanne PhD, RN, FAAN

Journal of Trauma Nursing:
doi: 10.1097/JTN.0000000000000271
Advanced Practice
Abstract

The purpose of this study was to examine the effects of family presence during resuscitation (FPDR) in patients who survived trauma from motor vehicle crashes (MVC) and gunshot wounds (GSW). A convenience sample of family members participated within three days of admission to critical care. Family members of 140 trauma patients (MVC n = 110, 79%; GSW n = 30, 21%) participated. Family members ranged in age from 20-84 years (M = 46, SD = 15, Mdn = 47). The majority were female (n = 112, 80%) and related to the patient as spouse (n = 46, 33%). Participating in the FPDR option reduced anxiety (t = −2.43, p =.04), reduced stress (t = −2.86, p = .005), and fostered well-being (t = 3.46, p = .001). Results demonstrate the positive initial effects of FPDR on family members of patients surviving trauma injury.

Author Information

College of Nursing, University of Wisconsin-Milwaukee (Drs Leske and Feetham and Ms McAndrew); Froedtert and the Medical College of Wisconsin-Froedtert Hospital, Milwaukee (Dr Leske and Ms McAndrew); Oregon Heath & Science University, Division of Trauma, Critical Care & Acute Care Surgery, Portland (Dr Brasel); and Children's National Health System, Washington, District of Columbia (Dr Feetham).

Correspondence: Jane S. Leske, PhD, RN, ACNS-BC, FAAN, 9398 Copper Canyon Ct, Naples, FL 34120 (jsl@uwm.edu).

The project described was supported by grant award number R21NRO11063 from the National Institutes of Health and the National Institute of Nursing Research. The content is solely the responsibility of the authors and does not necessarily represent the views of the National Institutes of Health or the National Institute of Nursing Research.

The authors declare no conflicts of interest.

Article Outline

Unexpected traumatic injury, subsequent resuscitation, and admission to critical care of a family member can be a cataclysmic event: the effects of which reverberate throughout the family unit. Annually, there are more than 41 million visits to the emergency department (ED), 2.5 million hospital admissions, and millions undergo resuscitation and survive traumatic injuries, producing major life changes for families (Centers for Disease Control and Prevention, 2016; National Trauma Institute, 2014). Trauma is a significant public health problem and most patients survive (Egol, Tolisano, Spratt, & Koval, 2011). Family presence during resuscitation (FPDR) is an innovative, multidisciplinary option that is intended to provide family-centered care early in the critical care experience, but the effects of FPDR on families of those critically injured from trauma have not been well studied.

The overall purpose of this multivariate, prospective, and comparative study was to examine the effects of the FPDR option on family outcomes in patients surviving critical injury after motor vehicle crashes (MVC) and gunshot wounds (GSW). The primary aim was to examine the effects of the FPDR option on family outcomes (anxiety, stress, well-being, and satisfaction) up to 72 hr posttrauma and compare those outcomes in families that participated in FPDR to those in families that did not participate. A secondary aim was to examine any moderating effects of family strengths (coping, resources, and communication) on family outcomes.

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BACKGROUND LITERATURE

The following review focuses on the conceptual framework, traumatic injury, prior research on FPDR, and family strengths and outcomes to critical injury.

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Conceptual Framework

A conceptual model of family adaptation in response to a stress event guided the selection of variables and measures used in this study (McCubbin, Thompson, & McCubbin, 1996). This model depicts the influence of family strengths on family outcomes. In this study, family strengths included coping, resources, and communication. Family outcomes consisted of state anxiety, state stress, well-being, and satisfaction (see Figure 1).

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Traumatic Injury

Traumatic injury is one of the most important threats to public health and safety in the United States, with an economic burden of $671 billion a year, including both health care costs and lost productivity (National Trauma Institute, 2014). Trauma knows no bounds of age, gender, race, or socioeconomic status and can happen to anyone at any time.

In 2014, the number of people injured in MVCs increased from 2.31 to 2.34 million, and 32,675 Americans were killed (U.S. Department of Transportation, 2016). Gunshot wounds are the next leading cause of critical injury deaths following MVCs (NCHS, 2016). Traumatic injuries constitute the third leading cause of death for people of all ages and the number 1 cause of death for those younger than 46 years (National Trauma Institute, 2014).

Traumatic injury is a potential crisis situation for family members when the patient is admitted into critical care (Agård & Harder, 2007; Auerbach et al., 2005; Azoulay et al., 2005; Jones et al., 2004; Soderstrom, Saveman, Hagberg, & Benzein, 2009; Winston, Baxt, Kassam-Adams, Elliott, & Kallan, 2005). During the critical care period, families must deal with many stressors including role changes, financial concerns, uncertain prognosis, isolation from other family members, dramatic disruptions in daily routines, making decisions, and unfamiliar critical care environments (Baumhover & May, 2013; Davidson, 2009; Davidson et al., 2007; Figely & Barnes, 2005; Leske, 2000). Health care professionals (HCP) expect families to absorb highly technical and potentially devastating information while making rapid decisions when they face the critical injury of a family member (Blom, Gustavsson, & Sundler, 2013; Eggenberger & Nelms, 2007; Leske, 2000). Challenges in forming and maintaining relationships with other family members and HCP are the most frequently cited family stressors (Azoulay et al., 2001; Rodriguez, 2005; Wong, Liamputtong, Koch, & Rawson, 2015).

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Prior Research About FPDR

Use of FPDR in the clinical arena has been debated in the literature around the world for the last 20 years; predominately, discussion has been around family benefits, concerns of HCP, and family expectations (Porter, Cooper, & Sellick, 2013; Porter, Cooper, & Sellick, 2014).

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Family Benefits

Researchers report that there are some benefits for families that are present during the resuscitation of a family member (Egging et al., 2011; Holzhauser, Finucane, & DeVries., 2006; Macy et al., 2006; Morse & Pooler, 2002; Terzi & Aggelidou, 2008; Weslien, Nilstun, Lundqvist, & Fridlund, 2006). These benefits include knowing that everything possible was being done for the patient; feeling of being supportive and helpful to the patient and staff; sharing critical information about the patient's condition; maintaining family–patient relationships; closure on a life shared together; and fostering grieving (Terzi & Aggelidou, 2008; Weslien et al., 2006).

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Concerns of HCP

There also are a variety of reasons from HCP for not providing the FPDR option that include (a) concern that the event may be too traumatic for the family; (b) clinical care might be impeded; (c) family members may become too emotional or out of control; (d) staff may experience increased stress; (e) staff are focused on the patient and may not be available to assist the family; (f) nursing shortages; and (g) the risk of malpractice suits (Basol, Ohman, Simones, & Skillings, 2009; Compton et al., 2006; Demir, 2008; Fisher et al., 2008; Ganz & Yoffe, 2012; Itzhaki, Bar-Tal, & Barnoy, 2011; Kirchhoff et al., 2007; Madden & Condon, 2007; Mortelmans, Cas, Van Hellemond, & De Cauwer, 2009; Twibell et al., 2008; Walker, 2008). A recent systematic review of the attitudes of HCP regarding FPDR indicated that a between and within disciplines difference in attitudes exists; specifically, perceived burden on staff, perceived effects on family, and lack of hospital policy influenced attitudes toward FPDR (Howlett, Alexander, & Tsuchiya, 2010). Lack of empirical support for FPDR contributes to the controversy among HCP for offering the option (Oman & Duran, 2010). Effects of FPDR on families of patients who survive have not been well studied.

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Family Expectations

Despite the concerns of HCP, families report that they want to be present again if a similar event occurred (Duran, Oman, Abel, Koziel, & Szymanski, 2007; Mcmahon-Parkes, Moule, Benger, & Albarran, 2009; Mortelmans et al., 2009). Family members not only emphatically reported the right to be present but also stated that FPDR was important and helpful to them (Davidson et al., 2007; Leske, McAndrew, & Brasel, 2013). Prior research results indicate that when the option of FPDR was provided, there were no adverse psychological effects for family members and the operations of the HCP were not disrupted (Compton et al., 2006; Oczkowski, Mazzetti, Cupido, & Fox-Robichaud, 2015; Oman & Duran, 2010; Pasquale, Pasquale, Bage, Eid, & Leske, 2010). Although participating in the FPDR option may not be appropriate for every family, most believe that they have the right to be present (Albarran, Moule, Benger, MaMahon-Parkes, & Lockyer, 2009; Boucher, 2010; Mortelmans et al., 2009).

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Family Strengths
Coping

Family coping refers to strategies, patterns, and behaviors designed to (a) maintain and/or strengthen the family, (b) maintain the emotional stability of family members, (c) obtain and/or utilize resources to manage the situation, and (d) initiate efforts to resolve family stress (McCubbin et al., 1996). How families cope with a stress event can adversely affect their health (Littleton, Horsley, John, & Nelson, 2007; Rodriguez, 2005). Emotional reactions of family members during hospitalization also are found to directly influence patient-coping responses (Agaibi & Wilson, 2005; Davidson et al., 2007). However, prior research findings with trauma patient's family members indicate that they are able to initially cope with the critical injury (Leske, 2000,2003). Therefore, coping strategies may serve as a guide for further understanding the effect of FPDR on family outcomes after trauma.

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Resources

Resources are an essential factor in determining family adaptation (Agaibi & Wilson, 2005; Littleton et al., 2007). Personal, family system, and social support resources have particular relevance for family health (McCubbin et al., 1996). Families possessing a large repertoire of resources more effectively manage a stress event than those families with few resources (Leske, 2000,2003; McCubbin et al., 1996). Family resources are especially needed in the early stages of patient injury and are found to reduce the postcrisis stress of families (Agaibi & Wilson, 2005; Patterson, 2002). The importance of accurate understanding of family resources is necessary for appropriate patient/family assessment, intervention, and discharge planning. In addition, adequate resources may be the key ingredient for positive family outcomes (Lefebvre & Levert, 2012).

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Communication

The family's ability to organize a stressor into manageable components, identify alternative courses of action, and cultivate patterns of communication needed to gain control over the situation refers to problem-solving communication and is strongly related to positive family outcomes (McCubbin et al., 1996). Understanding the medical condition and having information about the patient's progress are necessary for appropriate family problem solving to occur (McCubbin et al., 1996; Verhaeghe, van Zuuren, Defloor, Duijnstee, & Grypdonck, 2007).

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Family Outcomes

The stress event of traumatic injury exerts a powerful influence on family outcomes (Figely & Barnes, 2005). Physical and emotional health of family members suffers during patient hospitalization (Auerbach et al., 2005; McAdam & Puntillo, 2009; Rodriguez, 2005).

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State Anxiety

Prior research indicates that anxiety is common among family members during the critical care experience (Azoulay et al., 2005; McAdam, Fontaine, White, Dracup, & Puntillo, 2012; Norup, Siert, & Lykke Mortens, 2010; Paparrigopoulos et al., 2006; Pochard et al., 2005; Rodriguez, 2005). At least one-third of family members of critical care patients suffer from symptoms of anxiety (Fumis, Martins, & Schettino, 2012; McAdam et al., 2012). The family's anxiety focuses largely on concerns for the patient's survival and is often exacerbated by physical separation from the family member who is in critical care (Leske, 2000). Some families report more anxiety than patients (Paparrigopoulos et al., 2006; Pochard et al., 2005). When families face this level of anxiety, they may be unable to support the patient or make decisions, and they may transfer their anxiety to the patient (Anderson, Arnold, Angus, & Bryce, 2009; Holden, Harrison, & Johnson, 2002). In addition, high family anxiety may lead to prolonged patient recovery (Lefebvre & Levert, 2012; Paparrigopoulos et al., 2006; Pochard et al., 2005; Young et al., 2005). However, state anxiety appears to decline when information is provided to family members during the critical care period (Chien, Chiu, Lam, & Ip, 2006; Friedemann-Sanchez, Griffin, Rettmann, Rittman, & Partin, 2008).

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State Stress

Any clinical course that runs counter to the family's expectations for a positive patient outcome is an important contributor to critical care–related stress (Auerbach et al., 2005; Azoulay et al., 2005; Norup et al., 2010). These researchers suggest that about three-fourths of family members are at major risk for stress-related symptoms. Higher rates of stress have been reported among family members who felt that information received in critical care was incomplete or dissatisfactory and/or of patients with higher severity of injury (Auerbach et al., 2005; Azoulay et al., 2005; Fox-Wasylyshyn, El-Masri, & Williamson, 2005; Friedemann-Sanchez et al., 2008; Verhaeghe, Defloor, & Grypdonck, 2005). Stress levels of the family tend to rise when their needs are not met (Davidson et al., 2007; Fox-Wasylyshyn et al., 2005). However, little is known about the stress of family members of trauma patients.

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Well-being

An imbalance among family strengths can be manifested in deterioration of family members' sense of well-being (McCubbin et al., 1996). Theory suggests that families use their strengths to maintain their overall well-being (McCubbin et al., 1996). However, the influence of family strengths on family well-being after trauma is not well known.

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Satisfaction

The Patient Protection and Affordable Care Act mandates the use of measures to assess patient satisfaction. In critical care, patient satisfaction data may be difficult to obtain; family satisfaction often is a substitute (Roberti & Fitzpatrick, 2010). Therefore, family satisfaction is an important outcome measure in critical care (Azoulay et al., 2001; Paul & Rattray, 2008; Roberti & Fitzpatrick, 2010; Wall, Engelberg, Downer, Heyland, & Curtis, 2007). Dissatisfied families are less able to provide positive support to the patient, less likely to trust HCP, and less ready to contribute if important decisions need to be made (Auerbach et al., 2005; Paul & Rattray, 2008). The most prominent source of dissatisfaction for families is the lack of information about the patient in critical care (Auerbach et al., 2005; Fox-Wasylyshyn et al., 2005; Hunziker et al., 2012). Providing interventions to promote family satisfaction may be important to improve patient care outcomes (Agaibi & Wilson, 2005; Auerbach et al., 2005).

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Summary

The review of prior research confirms increased risk for difficult family adaptation after trauma and also indicates that this outcome is not inevitable. Minimal research has been reported that contributes to understanding family outcomes after trauma. Previous studies (a) are largely without theoretical guidance; (b) rely on measures using only the spouse's perspective; (c) use descriptive or survey designs; (d) have small sample sizes in one setting; (e) include few diverse families; (f) do not use family measures; (g) include few family members of trauma patients; (h) reliability and validity of the survey instruments are not reported; and (i) primarily focus on outcomes related to patient's or spouse's psychosocial functioning as an influence on the recovery process. According to the model used in this study, positive family outcomes involve a process of adaptation (McCubbin et al., 1996). Family strengths either expand to meet the needs posed by trauma injury or the family is unable to manage the event (McCubbin et al., 1996; Soderstrom et al., 2009).

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METHODS

Design

A multivariate, prospective, and comparison design was used in this study. A strength of this study design was that it did not depend on family self-selection for the FPDR option, rather, it was the consensus of the trauma team and availability of family members in the ED at the time of the resuscitation that determined whether FPDR occurred. Because of the nonrandomized design, careful attention was paid to fidelity of the FPDR option and statistical covariate analysis.

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Setting

Subjects were recruited from southeastern Wisconsin's only adult Level 1 trauma center—part of a 516-bed Magnet designated tertiary care hospital that generally serves a suburban catchment area of approximately 3 million people. The FPDR option had been standard practice for more than 5 years at the study site.

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Subjects

Trauma patients were defined as individuals, 18 years of age and older, who survived resuscitation by the trauma team and were admitted from the ED to the 21-bed surgical intensive care unit (SICU).

Family was defined as a group of individuals bonded by biological, legal, social, or emotional relationships (Basol, Ohman, Simones, & Skillings, 2009; Davidson et al., 2007; Leske, 2003). Participants in this study were adult family members of critically injured trauma patients; spoke and understood English; and had no more than one critically injured patient in the family. They were eligible to participate in this study up to 72 hr after admission to SICU. Only one family member per trauma patient was enrolled.

Excluded from the study were family members of trauma patients: younger than 18 years, because they were unlikely to be present in the adult SICU; with cardiac, burns, and suicidal injuries, because they were admitted to other specialized facilities; and those who expired at the scene. Also excluded were family members of patients considered for possible organ donation (end-of-life), prisoners (cannot have visitors), and victims of domestic violence (injured by another family member; Leske, McAndrew, Evans, Garcia, & Brasel, 2012). Family members who were excluded from the FPDR option per hospital policy because of combativeness, agitation, extreme emotional instability, altered mental status, or intoxication were also excluded. An ED log was kept to determine family availability (Leske et al., 2012).

Calculation of sample size was based on the pilot study of the effect of the FPDR option on family outcomes (η2 = 0.06; f = 0.24; Leske & Brasel, 2010). Using this anticipated effect size, it was determined that a sample size of 70 per group (70 participating in FPDR and 70 not participating) was adequate to attain 0.80 power at the alpha level of .05.

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Procedure

Patients met criteria for physiologic or anatomic activation of the trauma team with subsequent resuscitation in the ED. At the time of trauma resuscitation in the ED, the physician and the team agreed to the FPDR option. Alert patients would verbally agree and a family facilitator (FF) offered the FPDR option to family members if they were present. A specially trained social worker prepared the family for FPDR and guided them through the process. To provide the FPDR option, special training and hospital policy were developed at the study site. The hospital policy and procedures for the FPDR option followed national clinical practice guidelines (AACN, 2016; ENA, 2012).

Within 72 hr after admission to SICU, trauma patients' families participating in the FPDR option were asked to participate. This time period was selected because of uncertain patient outcome and availability of family members (Leske et al., 2012). Family members who did not participate in the FPDR option already existed in clinical practice. This was due to not being present in the hospital at the time of the resuscitation. Within 72 hr after admission to SICU, trauma patients' families who did receive the FPDR option were also asked to participate. Ongoing monitoring of sample selection occurred to ensure diversity of family member participation. Only members of the research team obtained study data (Leske et al., 2012). This study was approved by the hospital and medical school's institutional review board for the protection of human subjects. Written, informed consent was obtained from all participants.

Actions were taken to maintain integrity of the study protocol, including structured training for the FF, monitoring of FPDR fidelity, standardized instrumentation, monthly team meetings, and training for data collectors. A member of the research team observed at random the FPDR to ensure procedural fidelity and compliance with the hospital policy. In addition, the dose of the FPDR was recorded as to the length of the resuscitation, length of time of family presence, and what procedures were done to the patient.

Data were collected in the privacy of a nearby SICU conference or private waiting room. It took about 25 min for participants to complete all self-report instruments. There was no difficulty in recruiting family members during this sensitive time frame, and the majority of family members agreed to participate (Leske, 2000,2003; Leske et al., 2012; Leske & Brasel, 2010; Pasquale et al., 2010).

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Instruments

All instruments were chosen for theoretical congruence, ease of administration, sound psychometric properties, reading level below eighth grade, suitability for diverse family constellations with varied social characteristics, and minimal response burden. Total scores were used in this study.

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Demographic Information

Family demographics (including age, gender, race/ethnicity, relationship to patient, education, occupation, employment status, income, prior ICU experience, and health conditions) were obtained from participants in both groups.

Patient demographics were collected from the hospital record and included age, gender, ethnicity, occupation, mechanism and type of injury, mode of transportation to hospital, Glasgow Coma Scale score at admission, and Injury Severity Score.

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Family Strengths
Resources

Family resources were measured by the family strengths subscale of the Family Inventory of Resources for Management (FIRM; McCubbin, Comeau, & Harkins, 1996). This 20-item self-report subscale included items that reflected family resources. Subjects indicated on a 4-point scale from 0 (not at all) to 3 (very much so) what family strength resources they believe they had available to them. Total FIRM scores range from 0 to 60, with higher scores indicating increased resources. Reliability and validity are well described (Leske, 2000,2003; Leske & Brasel, 2010; Leske & Jiricka, 1998; McCubbin et al., 1996). Alpha reliability was .90 in this study.

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Coping

Coping was measured by the Family Crisis-Oriented Personal Evaluation Scale (F-COPES; McCubbin, Olson, & Larson, 1996). This 30-item self-report tool required family members to indicate the extent of agreement or disagreement on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). Total F-COPES scores range from 30 to 150, with higher scores representing an increase in coping strategies. Reliability and validity are well established (Leske, 2000,2003; Leske & Brasel, 2010; Leske & Jiricka, 1998; McCubbin et al., 1988). Alpha reliability was .82 in this study.

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Communication

Communication was measured by the Family Problem-Solving Communication Index (McCubbin et al., 1988). The 10-item measure was designed to assess the specific communication style that families use to manage and solve problems. The index was a self-report tool scored on a 0 (false) to 3 (true) scale. Total scores range from 0 to 30, with higher scores indicating greater problem-solving communication. Reliability and validity are well established (McCubbin et al., 1988; McCubbin et al., 1996). Alpha reliability was .90 in this study.

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Family Outcomes
State Anxiety

State anxiety was measured by the S-Anxiety portion of the State Trait Anxiety Inventory (STAI) Form Y (Spielberger, 1977). This 20-item self-report scale evaluated qualities such as current feelings of apprehension, tension, nervousness, and worry. The responses to each statement were scored on a Likert-type scale, ranging from 1 (not at all) to 4 (very much so). Total S-Anxiety scores range from 20 to 80, with higher scores represented an increase in anxiety. Reliability and validity are well documented (Moser, 2007; Pochard et al., 2005; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983; Young et al., 2005). Alpha reliability was .93 in this study.

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State Stress

The Acute Stress Disorder (ASD) Scale measured state stress (Bryant, Moulds, & Guthrie, 2000). The 19-item ASD Scale measured distress that an individual family member could experience in the acute phase of a traumatic experience. The responses to each statement were scored on a Likert-type scale, ranging from 1 (not at all) to 5 (very much). Total ASD scores range from 19 to 95, with higher scores reflecting greater stress. Evidence for reliability and validity has been reported (Bryant, Moulds, & Guthrie, 2000; McAdam & Puntillo, 2009). Alpha reliability was .93 in this study.

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Well-being

Family well-being was measured by the Family Member Well-being Index (FWBI; McCubbin & Patterson, 1982). This inventory measured the degree to which a family member was adapted in terms of general concerns about health. The responses to each statement were scored on a Likert-type scale, ranging from 0 (not concerned at all) to 10 (very concerned). Total FWBI scores range from 8 to 80, with higher scores reflecting increased adaptation. Reliability and validity are well documented (Leske, 2003; Leske & Jiricka, 1998; McCubbin et al., 1996). Alpha reliability was .84 in this study.

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Satisfaction

Family satisfaction was measured by the Family Satisfaction in the Intensive Care Unit scale (Heyland & Tranmer, 2001). The responses to each statement were scored on a Likert-type scale, ranging from 1 (not applicable) to 6 (excellent). Items were scored so that higher values indicated higher satisfaction. Reliability and validity are documented (Heyland & Tranmer, 2001; Wall et al., 2007). Alpha reliability was .89 in this study.

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Data Analysis

Quantitative data were analyzed with SPSS for windows software (Statistical Package for the Social Sciences version 22 (IBM, 2013). Descriptive statistics were initially computed for all variables to ensure data quality. Any missing data at the item level were handled by multiple imputation methods. Family member and patient demographic characteristics were checked to identify any significant differences between families that participated in FPDR and those families that do not participate.

The primary aim was to examine the effects of the FPDR option on family outcomes of anxiety, stress, well-being, and satisfaction up to 72 hr posttrauma and compare those outcomes in families that participated in FPDR with those families that do not participate. Analysis of covariance (ANCOVA) was used with the measures of family strengths (coping, resources, and communication) serving as covariates. In addition, a single propensity score was created and used as another factor to account for any residual differences between the group of families that participated in FPDR and those families that do not participate. The propensity scores were divided into quintiles to produce a 2 × 5 factorial design. To test the main effects of FPDR on family outcomes, a 2-way ANCOVA was computed with FPDR as the first factor, the propensity score (divided into five levels) as the second factor, and the three family strength measures as explicit covariates.

The secondary aim was to examine any moderating effects of family strengths (coping, resources, and communication) on family outcomes of anxiety, stress, well-being, and satisfaction and compare any moderating effects in families that participate in FPDR with those families that do not participate. The same propensity score was used for measures of family and patient demographics. Analysis of covariance was used with FPDR as the first factor and family strengths measures as covariates.

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RESULTS

No significant differences were found between groups on any demographic variables. See Figure 2 for a flow diagram of study participants. Family members (n = 140) ranged in age from 20 to 84 years (M = 45.74, SD = 15.03, Mdn = 47). The majority were female (n = 112, 80%) and related to the patient as spouse (n = 46, 33%). Family member education ranged from 8 to 20 years (M = 13.46, SD = 2.20, Mdn = 13). The patient sample ranged in age from 18 to 93 years (M = 43.27, SD = 20.82, Mdn = 42). The majority were male (n = 99, 71%) and critically injured from MVC (n = 110, 79%). A secondary diagnosis of traumatic brain injury was recorded in 37% of the patient sample (n = 52). In addition, 31% (n = 44) arrived to the hospital via Flight for Life air transport (see Table 1).

Results of the primary aim indicated that participating in the FPDR option significantly reduced family reports of anxiety (t = −2.43, p = .04) and stress (t = −2.86, p = .005) and fostered family reports of well-being (t = 3.46, p = .001). The effects of participating in the FPDR option were not significant for satisfaction with critical care (t = −0.28, p = .78). The results of the secondary aim indicated that family resources moderated stress in the FPDR group (t = 2.59, p = .01; see Table 2).

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DISCUSSION

The FPDR option remains controversial and not the usual practice in most trauma centers. One of the reasons for the underutilization of FPDR has been the lack of sophisticated research on the effects of FPDR on family outcomes. This study addresses these concerns by using (a) theoretical guidance, (b) comparative design with adequate sample size, and (c) responses from various and diverse family members after trauma injury. Results contribute to the growing body of research that FPDR has beneficial effects for family members, at least during the initial critical care experience.

Anxiety scores significantly were lower in the FPDR group. However, scores for both groups remain above the national norms (Spielberger et al., 1983). Family member high anxiety is consistently reported in other research (Anderson et al., 2009; Bailey, Sabbagh, Loiselle, Boileau, & McVey, 2010; Fumis et al., 2012; McAdam et al., 2012; Wolters et al., 2015). A recent systematic review reported that anxiety was better in family members who were offered FPDR (Oczkowski et al., 2015). Symptoms of stress can be severe in family members of critical care patients (Anderson et al., 2009; Auerbach et al., 2005; McAdam & Puntillo, 2009). However, effects of participating in the FPDR option on reducing family stress depends on increased family resources during this time frame. Decreased family well-being has been reported by family members during critical care, especially when they ignore their own health concerns (Johansson, Hildingh, Wenneberg, Fridlund, & Ahlström, 2006). In this study, family well-being scores were significantly higher in the FPDR group and above the national norms (McCubbin et al., 1996).

The use of a designated FF was important is this study. This procedure follows prior research that the FF is separate from the resuscitation team (Porter et al., 2014; Sak-Dankosky, Andruszkiewicz, Sherwood, & Kvist, 2014; Terzi & Aggelidou, 2008). This may be difficult in some practice settings but is essential to assess family dynamics, level of distress, and level of understanding of the situation. Training and support for the FF are instrumental in the implementation of an FPDR protocol.

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LIMITATIONS

The major limitation to this study was the inability to randomize the FPDR option. Family presence during resuscitation was offered only when the trauma team agreed and family were available. The data were cross-sectional, so the impact of the FPDR option on family outcomes over time remains to be examined in further research. In addition, self-report measures have inherent limitations. The timing of outcome measures collected within 72 hr of traumatic injury may underestimate the anxiety, stress, well-being, and satisfaction of family members. Recall bias may be of concern due to the stress of trauma. The data were collected in one site; thus, generalizability to other setting cannot be assumed.

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CONCLUSION

The vital role of the family in the health and recovery of the critically injured patient is well recognized (Davidson et al., 2007; Leske, 2003; Leske & Brasel, 2010). Yet, during critical care, when family involvement is urgently needed, family members report that their helping behaviors are negatively impeded by high anxiety and stress (Davidson et al., 2007; Duran et al., 2007; Holzhauser et al., 2006; Paparrigopoulos et al., 2006; Terzi & Aggelidou, 2008), leading to inadequate family participation in patient rehabilitation, prolonged patient recovery, and increased health care costs. The results of this study suggest that participating in the FPDR option may help the family be better equipped to help the patient during the initial critical care period.

Critical injury interferes with family structure and function and challenges the family's established patterns of behavior (Auerbach et al., 2005; Pochard et al., 2005; Rodriguez, 2005). If the traumatic event is not handled optimally, the result may be prolonged physiologic and psychological instability of family members (Anderson et al., 2009; Rodriguez, 2005). At the time of the highest level of stress, which is the initial phase of critical injury, the least amount of attention may be given to the family (Azoulay et al., 2001).

Family presence during resuscitation remains consistent with the core principles of a partnership that recognizes the integral role of the family in the recovery of the patient. Recognizing the importance of the family on patient recovery after trauma, HCPs in EDs ought to continue to offer the option of FPDR. Incorporating a family-centered approach such as FPDR in the delivery of critical care may promote more positive family outcomes (Oczkowski et al., 2015).

The study setting had a formal FPDR policy for several years. Policy development for FPDR does not seem to be universal but is important for patient-/family-centered care progression. Patient-/family-centered care may benefit from a formal policy in each institution to standardize FPDR practice. However, the phenomenon of FPDR may be too complex to capture fully its effects on families via statistical inquiry alone. Exploring the nature and meaning of FPDR and its aftermath from the perspective of families may provide formative information for the development and application of effective FPDR. In addition, a qualitative exploration of patients' appraisals of family involvement in their care following trauma may provide another vital viewpoint in comprehending the capacity and utility of FPDR.

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KEY POINTS

* Participation in FPDR has beneficial effects for family members of trauma patients.

* Participation in FPDR reduces family anxiety and stress during the first 72 hr after trauma.

* Participation in FPDR fosters family well-being during the first 72 hr after trauma.

* Assessment of family resources is important for designing family interventions after trauma.

* Long-term effects of participation in FPDR remain to be determined for family members of trauma patients.

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Acknowledgments

Appreciation is expressed to the health care team and family members for the participation in this study. All authors were members of the research team: Dr. Leske conceived and designed the project; Dr. Brasel participated in designing the project and implementing the study; Dr. Feetham participated in designing the work and interpreting the results; and Ms. McAndrew participated in collecting the data. All authors made important changes to the manuscript content and approved the final version.

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Critical care; Family presence; Resuscitation; Trauma

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