Scientific knowledge has expanded over the years leading to the rapid occurrence of change in the delivery of health care (Williams & Rice, 1977) . Initially, recovery room and private duty nurses were charged with providing round-the-clock individualized care to critically ill patients. Presently, this care has been widely replaced by intensive care units (ICUs). As such, individuals in unstable states or with life-threatening conditions are now able to be provided with constant care and observation by highly skilled nurses in a particular area (Williams & Rice, 1977) . Such specialized care has expanded exponentially since it was first introduced in Baltimore, Maryland in 1958 (Grauer, 2008). Several scholars have elucidated the financial and psychosocial impact of ICU hospitalization on not only the patients but also their families. However, it is not yet clear how best social work interventions can be employed to help meet the needs of a family whose member is ICU hospitalized.
Families of ICU patients have a range of stressors and concerns stemming from their experiences in the unit, which is a hindrance to their wellness. Some of the needs of the families include support, assurance, and most importantly, the need for information concerning the progress of the patient. Nevertheless, these family needs are often not recognized and thus remain unmet (Kotkamp-Mothes et al., 2005). Even in situations where the needs of the families are known to the ICU personnel, healthcare providers seldom address them as in most cases, health care professionals are more inclined towards addressing the medical needs of their patients and are less focused on the welfare of their patients’ families. Social workers have the requisite training to work alongside patients’ families to address any of their psychosocial needs. Accordingly, this aims to explore how social work intervention with the families of critically ill patients in the ICU may help in recognizing and thus meeting the psychosocial needs of these families.
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Literature Review
According to Scott, Thomson, and Shepherd (2019), admission of patients to the ICU is often unforeseen and most patients are usually in unstable conditions. Many patients in these units cannot communicate with medical professionals or take part in deliberations regarding their treatment given their physical status, sedation, or delirium (Scott, Thomson, & Shepherd, 2019; Mitchell, Chaboyer, Burmeister, & Foster, 2009). For these reasons, Al-Mutair et al. (2013) assert that healthcare professionals are compelled to approach family members to speak for their hospitalized kin and progressively expand the support and care provided to patients to cover their families as well. Paul and Finney (2015) reiterate the importance of involving the families of the critically ill in the ICU stage of care as it enhances the provision of person-centered care. In their view, however, family members who know and understand the patient best are often not included in the care team.
Scott, Thomson, and Shepherd (2019) posit that whether premeditated or unpremeditated, admission to the ICU means that patients’ families may suddenly be faced with decision-making and doubt about the condition affecting their relatives and its prognosis. Bijttebeir et al. (2001) and Delva et al. (2002) suggest that such family members are often overawed by feelings of worry and anxiety due to the fear of losing their relatives, preoccupations about the future, and deterioration of the family structure. All these concerns are further compounded by the tense technological environment in the ICU. Reportedly, about half of the patients' relatives experience anxiety and emotional stress for close to two years following the discharged of their loved ones from the hospital (Scott, Thomson, & Shepherd, 2019). Accordingly, ICU care should incorporate the perception of patients’ families of whether their needs are met or not as well as their contentment with the care process and patient outcomes. Importantly, Flaatten (2012) emphasizes the need for evaluating the interventions geared towards improving the psychosocial status and well-being of families whose members are in the ICU.
Cagle and Bunting (2018) estimate that about five million people receive ICU care every year. They highlight the highly invasive and burdensome ICU interventions such as mechanical respiration and intubation which in most cases trigger a constellation of symptoms among family members. These symptoms have been shown to include anticipatory grief, interpersonal conflict, high-intensity emotions, and a reduced capacity to process intricate information. According to Cagle and Bunting (2018), these symptoms are collectively referred to as family ICU syndrome. Further, they suggest that the ICU social worker is appropriately placed to support and provide interventions to families during this challenging time. Findings from a systematic review by Haryman-Shea et al. (2011) point to counseling and psychosocial support as the primary role of social workers in ICU settings. Other commonly identified roles included psychosocial assessment, crisis prevention, end-of-life care, facilitating communication between the family and health care workers, and practical assistance (Hartman-Shea, Hahn, Fritz Kraus, Cordts, & Sevransky, 2011).
Rose and Shelton (2006) opine that the high costs and at times the invasive processes associated with the ICU may not seem beneficial to the families of patients admitted in these units who inspire little hope for recovery. From their perspective, the clarification of the medical goals for ICU patients to the patients themselves and their families is typically facilitated by dealing with psychosocial factors. Rose and Shelton (2006) further echo the views of previously mentioned authors by asserting that intensive care social workers are uniquely placed to address and assess many of the multifaceted psychosocial challenges and can provide clarity on possible misperceptions and enhancing patients between patients or their families and members of the medical team. Such interventions may enhance the quality of life for the critically ill and their families and minimize the possibility of decision-making wrangles from occuring (Rose & Shelton, 2006).
Methodology
The current study is a qualitative study designed to determine the significance of social work interventions on families with critically ill, ICU hospitalized relatives. The sample of participants was obtained from six hospitals of Dakshina Kannada District of Karnataka, India with more than fifty beds. The clinical resource coordinators and social workers of the ICUs of the respective hospitals helped to recruit participant families. Face-to-face semi-structured interviews were used to ask participants open-ended questions about their perceptions of social work interventions to assist them during the stay of their relatives in the ICU. One hundred participants were interviewed (sixty females and forty males). The analysis of the collected data focused on the shared perceptions of the interviewed family members and less on individual responses on an issue. A reputable service was used to transcribe the interviews and an inductive approach used by the researcher to identify common patterns in the data using thematic codes as suggested by Bowen (2005).
Results and Discussions
Table 1 : The Relationship between the Intervention of Social Workers and the Level of Trauma
| Was the Intervention helpful in reducing you trauma? | Yes | Not Sure | No |
| 70 | 10 | 20 |
Graph 1: Impact of Social Workers in Alleviating Trauma
Table 2: Impact of Person’s View of the Traumatic Occurrence, Support System, and Coping Mechanism on Dealing with Trauma
| Trauma Alleviation Approach | Mean Score for Each Aspect out of 10 |
| View of Traumatic Occurrence | 4 |
| Support System | 7 |
| Coping Mechanism | 9 |
Graph 2: Impact of Individual Aspects on Dealing with Trauma
A majority of the interviewed participants felt that treatment interventions in meeting acute medical needs seemed highly mechanical and impersonal. Relatives of ICU patients felt that their loved ones were occasionally dehumanized and subjected to an absolute lack of privacy. A significant portion of the interviewed family members also felt that they were disturbed by the sight of their loved ones in an impersonal and strange environment. The experience of seeing a relative in a coma was shown to be emotionally overwhelming to observers and many of the participants expressed feelings of fear and guilt for the present conditions of their relatives in the ICU. Significant distress was particularly noted from families whose members have been asked to take part in life-or-death decisions. Interventions by social workers based on the crisis model were also shown to have the potential to adequately assist affected families by reducing the trauma often associated with ICU hospitalization.
From the study, it was shown that individual variations in responding to traumatizing experiences depend on the person’s view of the traumatic occurrence, the presence of a support system, and the mechanisms to cope with the event. Assessment and interventions by social workers in these three fronts were shown to be critical to helping families endure the stress undergone during the ICU hospitalization of their loved ones. One of the social work interventions that were found to have a significant impact on improving family experiences in the ICU was the enhancement and promotion of communication lines between the relatives of the patients and the unit personnel. Most participants felt that the reinterpretation or simplification of the medical team's professional discussion about the condition of the patient was helpful. A significant number of them also asserted the periodic relay of information about the status of the patient to the waiting family creates a strong supportive linkage.
From the study, it was also shown that mobilizing support from community resources is often essential. A particular practical concern that was noted among families with ICU hospitalized members and which social workers were deemed key to addressing was the housing problems. Some families indicated that they did not reside within the proximity of the hospital. Accordingly, they felt that social workers could assist them in planning for the use of short-term housing facilities within the hospital’s locale. It was also noted that referrals were frequently needed for immediate as well as continuing or longstanding financial assistance. It was observed that many of the affected families were not adequately prepared for the medical emergencies that befell them and as such, financial constraints added enormously to their feelings of anxiety. Social work intervention in sourcing for financial assistance was thus considered critical to easing the stress endured by the families of ICU hospitalized patients. Importantly, participants expressed their desire to have a core of social workers to stay with families and provide much-needed emotional support, preferably on a twenty-four-hour basis.
Conclusion
It is often overwhelming for family members to see their relatives being cared for in the impersonal, mechanical, and hectic environment that typifies the ICU. Social work interventions have been proven to have the potential to lessen the stress faced by the families of ICU hospitalized patients. As advocates of the patients' families, social workers may provide the required interventions at such times of crisis. Their assessment of, and assistance with the perception of the family of the prevailing circumstances, available situational supports, and coping mechanisms are critical to the efforts of the ICU team in managing and caring for patients. By enhancing communication between family members and the medical team, mobilizing community resources, providing emotional support, social work interventions may significantly lessen the trauma associated with ICU stays and substantially improve the operation of families in the crisis period.
References
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