jurnal kritis

8/19/2019 jurnal kritis

1/13

Intensive and Critical Care Nursing (2015) 31, 51—63

 Available online at www.sciencedirect.com

ScienceDirect 

 j ournal homepage : www.elsevier .com/ iccn

Families’ experiences of their interactionswith staff  in an Australian intensive careunit (ICU): A qualitative study

Pauline Wonga,∗, Pranee Liamputtongb,Susan Kochc, Helen Rawsond

a La Trobe University, Faculty of Health Sciences, School of Nursing & Midwifery, Melbourne, Victoria 3086,

 Australiab La Trobe University, Faculty of Health Sciences, School of Public Health & Human Biosciences, Melbourne,

Victoria 3086,  Australiac RDNS Institute, Royal District Nursing Service, St Kilda, Victoria 3182, Australiad Deakin University, Faculty of Health, School of Nursing & Midwifery, Melbourne, Victoria 3125,  Australia

Accepted 16 June 2014

KEYWORDSCritical care;Critical care nursing;Family care;Professional-familyrelations;Qualitative studies;Nursing

SummaryObjective: Nursing is characterised as a profession that provides holistic, person-centred care.Due to the condition of the critically ill, a family-centred care model is more applicable in thiscontext. Furthermore, families are at risk of emotional and psychological distress, as a result ofthe admission of their relative to intensive care. The families’ experiences of their interactionsin intensive care have the potential to enhance or minimise this risk. This paper presents asubset of findings from a broader study exploring families of critically ill patients’ experiencesof their interactions with staff, their environment, the patient and other families, when theirrelative is admitted to an Australian intensive care unit. By developing an understanding of theirexperience, nurses are able to implement interventions to minimise the families’ distress, whileproviding more holistic, person- and family-centred care.Research design: The study was a qualitative enquiry that adopted the grounded theoryapproach for data collection and analysis. In-depth interviews with family members occurredbetween 2009 and 2011, allowing the thoughts on interactions experienced by those fami-

lies, to be explored. Data were analysed thematically. Twelve family members of 11 patientsparticipated in this study.Setting: This study was undertaken in a mixed intensive care unit of a large metropolitanhospital in Australia.

∗ Corresponding author: Tel.: +61 3 9479 6734.E-mail address: p.wong@latrobe.edu.au (P. Wong).

http://dx.doi.org/10.1016/j.iccn.2014.06.0050964-3397/© 2014 Elsevier Ltd. All rights reserved.

http://localhost/var/www/apps/conversion/tmp/scratch_3/dx.doi.org/10.1016/j.iccn.2014.06.005http://localhost/var/www/apps/conversion/tmp/scratch_3/dx.doi.org/10.1016/j.iccn.2014.06.005http://localhost/var/www/apps/conversion/tmp/scratch_3/dx.doi.org/10.1016/j.iccn.2014.06.005http://localhost/var/www/apps/conversion/tmp/scratch_3/dx.doi.org/10.1016/j.iccn.2014.06.005http://www.sciencedirect.com/science/journal/09643397http://www.elsevier.com/iccnmailto:p.wong@latrobe.edu.auhttp://localhost/var/www/apps/conversion/tmp/scratch_3/dx.doi.org/10.1016/j.iccn.2014.06.005http://localhost/var/www/apps/conversion/tmp/scratch_3/dx.doi.org/10.1016/j.iccn.2014.06.005mailto:p.wong@latrobe.edu.auhttp://crossmark.crossref.org/dialog/?doi=10.1016/j.iccn.2014.06.005&domain=pdfhttp://www.elsevier.com/iccnhttp://www.sciencedirect.com/science/journal/09643397http://localhost/var/www/apps/conversion/tmp/scratch_3/dx.doi.org/10.1016/j.iccn.2014.06.005

8/19/2019 jurnal kritis

2/13

52 P. Wong et al.

Findings: Interactions experienced by families of the critically ill primarily revolved aroundseeking information and becoming informed. Further examination of the interviews suggestedthat staff interacted in supportive ways due to their communication and interpersonal skills.However, families also experienced unsupportive interactions as a result of poor communication.Conclusion: Facilitating communication and interacting in supportive ways should help alleviatethe anxiety and distress experienced by families of the critically ill in the intensive care unit.© 2014 Elsevier Ltd. All rights reserved.

Implications for Clinical Practice

• Families need to be assessed for their specific informational needs and the most appropriate time to give this informa-tion. Families that are also healthcare professionals may have different informational needs, due to their background,and this should be a consideration when assessing their needs.

• To communicate with families in supportive ways, ICU staff should use nontechnical terms and language that familiescan understand. In recognition of the significant role nurses play in ensuring effective communication with families,nurses should be present during all family meetings when possible.

• It must be recognised that there is often a need for tactful communication, when delivering bad news; and forbalancing the requirement to be realistic while maintaining cultural sensitivity and hope, as well as considering the

individual differences in the family members’ ability to take in information.• Poor communication or providing inconsistent information may cause further distress and anxiety for families in

intensive care. Staffing allocation should aim to provide continuity of care to minimise the risk of families receivinginconsistent or conflicting information.

• Staff should remain vigilant to families’ nonverbal cues, which may indicate a need for further information, clarifi-cation or reassurance.

Introduction

The importance of close family and friends to the Intensivecare Unit (ICU) patient’s recovery and outcomes is welldocumented. Families of the critically ill provide a sourceof social support for the patient, through the provision of aclose and familiar caring relationship (Hupcey, 2001; Olsenet al., 2009). Critically ill patients are often unresponsiveand unable to contribute to decision-making about theirhealth care or develop therapeutic relationships with staff.Consequently, families serve as a valuable resource forpatient care as staff come to know the patient betterthrough the family (Engström and Söderberg, 2007). Fam-ilies may not only influence the ability of staff to interactmore effectively with the patient, but are able to clarify thepatients’ preferences for care and treatment and decisionmaking about care issues may be facilitated (Davidson,

2009).The unexpected admission of a family member to ICU ina life-threatening condition can cause overwhelming stressand anxiety for families (Jones et al., 2004). Moreover, thepsychological and emotional well being of families is at riskas a result of this potentially traumatic experience. Familymembers have been found to experience high levels of acutepost-traumatic stress disorder (PTSD) symptoms, three tosix months following death or discharge of a family memberfrom the ICU, placing them at risk for the development of thecondition (Azoulay et al., 2005; Jones et al., 2004). At thevery least, families may experience changes in their sleep-ing and eating behaviours, their daily activities and family

functioning while their family member is in ICU (Van Hornand Tesh, 2000).

It has been suggested that the level of anxiety and dis-tress experienced by families may be influenced by the

interactions they experience while visiting their familymember in ICU, including the interpersonal relationshipsdeveloped with healthcare staff and the process by whichinformation is communicated (Auerbach et al., 2005;Davidson et al., 2012). Critical care nurses play a crucial rolein helping families manage their anxiety and their ability tocope with the stress of the situation and therefore, facilitatethe supportive role families provide for the patient.

Background

Family needs in ICU

The needs of families in ICU have been the focus of family-

related research in this context since the late 1970s. Muchof the research centred on the importance of families’needs, as identified in Molter’s seminal study (Molter, 1979)and the subsequently developed Critical Care Family NeedsInventory (CCFNI). Now universally accepted, we know thatfamilies of critically ill patients require honest, accurate andup-to-date information; they want to be close to the patient;they want to be notified of any changes in the patient’scondition and they want to be assured that the patient isbeing well cared for (Burr, 1998; Davidson, 2009; Lam andBeaulieu, 2004; Leske, 1986; Molter, 1979; Obringer et al.,2012). Further studies have compared families’ needs withhealthcare professionals’ perceptions of their needs and

8/19/2019 jurnal kritis

3/13

8/19/2019 jurnal kritis

4/13

54 P. Wong et al.

In this study, we sought to explore the families’ interactionsmore broadly and within an Australian ICU context, signif-icantly adding to the body of knowledge around this topic.This paper focuses on the findings limited to one major areawithin the broader study that highlight the families’ expe-riences of their interactions specifically with physicians andnurses in ICU.

Family-centred care: theoretical framework

The theoretical framework upon which this study is basedis family-centred care (FCC). In response to family needsresearch conducted over the preceding three decades,FCC has emerged as an approach to delivering care topatients and their families that many organisations includein their unit policies and guidelines. Yet, although it iswidely practised in the neonatal ICU setting in Australia,its implementation is yet to be fully realised in the adultICU context. A FCC model considers the patient’s familyto be the unit around which care delivery should be orga-nised. However, more than simply a model of care delivery,

it is considered a philosophical approach based on the prin-cipal that patients are part of a larger whole (Hennemanand Cardin, 2002). A collaborative team approach, wherebymembers support and value the FCC philosophy, is essen-tial in its implementation (Damboise and Cardin, 2003).Patient- and family-centred care is defined by the Insti-tute for Patient- and Family-Centred Care as ‘‘an approachto the planning, delivery, and evaluation of health carethat is grounded in mutually beneficial partnerships amonghealth care providers, patients, and families’’ (Institutefor Patient- and Family-Centered Care, 2010b, para 1).Among the key concepts central to this framework are col-laboration; respect and dignity; information sharing andparticipation. The institute recognises the significant con-

tribution families provide in promoting the health and wellbeing of their family members of all ages (Institute forPatient- and Family-Centered Care, 2010a).

Method

Design

The main study on which this paper is based used thegrounded theory method. The resulting grounded theorydeveloped in this study will be presented in its entiretyin a follow up paper (Wong, 2014). Grounded theory is aqualitative methodology that is used to build or develop a

theory (Charmaz, 2006; Creswell, 2013). The intention ofa grounded theory research design is to provide a generaltheoretical explanation for a process or action, of which theparticipants have been a part. Thus, the theory is considered‘grounded’ in the data because it is ‘shaped by the views’of participants in the study (Creswell, 2013). Grounded the-ory methods are a set of systematic procedures used tocollect and analyse data to develop theories that are gen-erated from the data, and they may be especially usefulto explain practice or provide the foundation for furtherresearch (Charmaz, 2006; Creswell, 2013).

In this study, qualitative inquiries are essential becausewe sought to hear families’ stories about their experiences

when they interact in ICU. It is through an understandingof the individual’s experiences from their perspective thatclinicians can tailor practice to be more family-centred.

Qualitative research is commonly defined as a form ofinquiry that explores the way people experience and inter-pret the world in which they live. By understanding aperson’s view of the world and how this influences the waythey act, we can come to know more about human behaviour

(Liamputtong, 2013; Munhall, 2007).

Setting and sample

This study was conducted in an ICU at a major metropoli-tan hospital in Australia. It is one of the largest ICUs inthe country and admits over 2000 critically ill patients peryear with various life-threatening conditions. The ICU is acombined general unit with various sub-specialties includingtrauma and cardiothoracic surgery. There is an open vis-iting policy, although families are sometimes discouragedfrom visiting during medical rounds and nursing handover.However there is some flexibility dependent on the patientsituation. Generally, visitors are limited to two at the bed-side at any one time, and again this varies dependent on thepatient context. A ‘one spokesperson’ policy is supported inICU, whereby one family member is nominated as the liai-son between medical and nursing staff and the rest of thefamily. Generally, medical and nursing staff will communi-cate information about the patient’s progress and conditionto the spokesperson, who will then update the wider familymembers.

Participants who had a family member admitted to ICU noearlier than 48—72 hours following admission were invitedto participate. A family member was defined as anyonerelated to the patient by blood, marriage, adoption or a

non-traditional family relationship that was considered thepatient’s support system, or anyone who considered them-selves a part of the family. Inclusion criteria were familiesof patients admitted unexpectedly (e.g. due to road traumaor cardiac arrest), as opposed to a planned, elective admis-sion; any family member over the age of 18 years old andEnglish speaking. Families of patients admitted unexpect-edly to ICU are not given information about what to expector how to prepare for what could potentially go wrong. Wewere interested in exploring the impact of this situation onthe families’ experiences of their interactions. Exclusioncriteria were family members who were particularly dis-tressed, as deemed by the Social Worker, that approachingthem about the study may cause further emotional distress.

Families of patients at end-of-life or classified as brain deadwere also excluded from the study.

Based on the grounded theory approach we used theoret-ical sampling by selecting participants and collecting data onthe basis of its contribution to the conceptual and theoret-ical development of our analysis (Charmaz, 2006; Creswell,2013). A theoretical sampling strategy directed us to acton developing codes and categories by posing questions infurther interviews that tested propositions and themes toelaborate meaning and ‘‘discover variation within them’’(Charmaz, 2006, p. 108). Therefore, an iterative processof data collection, analysing then theoretically samplingto guide further data collection occurred (Charmaz, 2006).

8/19/2019 jurnal kritis

5/13

Families’ experiences of their interactions with staff in an Australian ICU 55

This process occurred over a period of approximately 12months.

Participants were recruited via the registered nurse (RN)caring for the patient, following an initial assessment ofthe family member’s emotional state by the social worker.The purpose of this initial assessment was to ensure thefamily member was not too overly distressed before beingapproached to participate in the study. The nurse unit man-

agers in ICU expressed concern about the RNs making anassessment of family member’s emotional state as they weredeemed as not having the relevant experience in this area.Consequently, ethics requirements for this study stipulatedthat the social worker must determine the families’ emo-tional suitability prior to being approached for participationin this study. Social workers are commonly a part of the mul-tidisciplinary team in ICUs throughout Australia. The primaryrole of the social worker in ICU is focused on crisis interven-tion, psychosocial assessment, support and counselling aswell as providing practical assistance (Hartman-Shea et al.,2011). This is similar in the Australian ICU context. Partici-pants were then approached by the RN who briefly explainedthe study. If the family member was interested in participat-ing, their contact details were forwarded to the researchers.The family were then contacted and a follow up meetingorganised, during which further details of the study wereclarified, questions answered and written consent sought.

Twelve family members of 11 patients admitted to ICUparticipated. Average length of stay (LOS) in ICU, for thepatients of the families interviewed, was 19 days, with arange of 5—38 days. The high average LOS may be explainedby the nature of the ICU in which the study was performed.The ICU is considered a level three tertiary referral unitand provides comprehensive critical care including complexmulti-system life support. A level three ICU is classified asthe highest of three levels by the Australian Institute of

Health and Welfare and therefore manages patients that areamong the most severely critically injured in the country(Australian Institute of Health and Welfare, 2013).

Background information about the participants, such astheir age and relationship to the patient is presented inTable 1.

Data collection and analysis

In-depth interviews were used to collect informationbetween 2009 and 2011. Interviews were conducted on thehospital site, external to ICU. A location independent of theICU was necessary to make it clear to participants that there

was no connection between the care of their family mem-ber in ICU and the study. Interviews occurred on site at thehospital as most families spent the majority of their time inhospital. At the time of interview, four patients had beentransferred out of ICU to the wards, with the remainingpatients still in ICU. Each interview was audio recorded andtranscribed verbatim and lasted between 30 and 88 minutes.An interview schedule was used as a guide for the interviewwith initial questions being developed from a review of theliterature, however participants were encouraged to discussin depth, any aspect of their experience interacting in ICU.The interview guide varied at each interview to reflect theneed to explore themes and concepts that arose from the

Table 1 Participants’ background information.

Participanta Age Gender Relationshipto patient

Days in ICUat time ofinterview

Eileen 66 F Mother 15Kay 57 F Wife 21

Rita 58 F Wife 14Sharon 32 F Wife 12Michael 44 M Father 24Jenny 43 F Mother 25Margaret 61 F Wife 15Terry 43 M Husband 7Linda 44 F Mother 38Carol 54 F Mother 7Cheryl 52 F Daughter 5George 54 M Father 13

a The actual participant’s names have been substituted withpseudonyms to maintain their anonymity.

analysis of previous interviews in line with the nature oftheoretical sampling.

Ethics approval to conduct this study was granted bythe University Human Ethics Committee and the hospital’sresearch ethics committee. Written consent was also soughtfrom participants. Anonymity was assured by de-identifyingparticipants with the use of pseudonyms when transcribingthe recorded interviews.

Data were analysed using thematic analysis based on theprinciples of the grounded theory method of data analysis(Liamputtong, 2013). Grounded theory research is often sit-uated within a symbolic interactionism framework, which isconcerned with the subjective meanings that people have

for their actions and environments. This framework is basedon the premise that individuals construct their perceptionsand meanings as a result of their interaction with others(Liamputtong, 2013). In our broader study, we examinedhow families interacted with healthcare staff, their envi-ronment, the patient and other families. The partial dataanalysis presented in this paper relates to the interactionsbetween families and healthcare staff only. Data analy-sis occurred by reading and re-reading each transcript andmaking sense of what the participants said about theirexperiences. According to Charmaz (2006), initial codingin grounded theory involves naming segments of data andconstructing codes to represent what is seen in the dataand define meanings within it. Our initial coding produced

multiple codes and concepts that represented differentexperiences of families as they interacted in ICU. Focusedcoding follows initial coding during which decisions are madeabout categorising larger amounts of data. This involves syn-thesising the most significant or frequent earlier codes intocategories and themes that make most analytical sense.These processes are not linear but iterative as focusedcoding produces new insights and prompts the researcherto return to earlier data or follow up leads by returningto the field to collect further data (Charmaz, 2006). Ourthemes were revised and refined as analysis progressed andas new insights emerged from checking the themes againstthe codes and the overall data (Liamputtong, 2013). NVivo

8/19/2019 jurnal kritis

6/13

56 P. Wong et al.

version 8 software was used to store and manage the data.While computer-assisted qualitative data analysis softwarewas useful for organising the large volumes of data, theauthors still had to interpret the data using analytical think-ing processes to analyse and formulate the themes andcategories (Liamputtong, 2013).

Table 2 offers an outline of how each theme was devel-oped during the analysis, with verbatim examples that

represent each theme. In presenting verbatim examplesfrom the participants, we used a fictitious name to preservetheir anonymity.

Trustworthiness

Methodological rigour in this study was maintained by sev-eral strategies. Firstly, memos, as part of an audit trail,were used to document decision-making processes and howconclusions were reached, during data analysis. Secondly,clarification and further explanations from participantswere sought during the interviews or later in follow up phonecalls to ensure the families’ perspectives were represented

accurately. Thirdly, the authors independently reviewed thesame transcripts developing their own codes and discuss-ions of the similarities and differences ensued. This formof peer review was used to seek alternative explanationsto the principal researcher’s propositions, avoiding bias andany attempts to ‘force’ interpretations unsubstantiated bythe data (Holloway and Wheeler, 2003).

Findings

Families’ interactions and experiences with staff werefocused around communication. Communication experi-enced by families revealed four themes — obtaining

information, language of communication, supportive com-munication and unsupportive communication. Specifically,participants discussed who kept them informed, howinformation was delivered, the appropriateness of commu-nication and what communication they found supportive andunsupportive.

Obtaining information

Families were constantly receiving or seeking informationabout their critically ill family member from all health-care professionals, such as physicians and nurses. However,ICU nurses most commonly facilitated communication and

kept families informed by passing on important informationfrom physicians, and other sources, to families. If familieshad missed meeting with the physicians, they would askthe nurses to communicate what the physicians had saidabout their family member’s progress and condition. Sharonremarked:

I’m talking to the nurses and they say ‘‘Well the doctorcame by and said . . ..’’ and so . . . I don’t feel the need togo looking for a doctor to ask . . . cause I feel I’ve got allthe information already.

Some families found it easier to communicate withthe nurses because they were at the bedside ‘around the

clock’ and therefore, were a more accessible source ofinformation. However, families also felt more ‘at ease’communicating with nurses as they were more friendly,approachable and clarified information using simplified lan-guage families could understand, as Michael’s experienceillustrates:

Yeah it might have been a bit technical for me . . . justthe finer points I think was what I needed . . . a bit ofclarification . . . and I got that off the nurse.

The nurses kept the families informed by channellingimportant information from the physicians to the families.They were able to facilitate this communication becausethey were most accessible, approachable and used languagefamilies could understand.

The information families wanted about their family mem-ber’s treatment or progress was often framed by a context oftime. Some could only cope by focusing on the current situ-ation. Others wanted detailed information about the futureplan well before discharge was discussed. Terry expressedhis frustration when he was unable to be informed aboutfuture services for his wife in the following statement:

One of the things I found frustrating is I’ve asked aboutthe occupational therapy and rehab . . . where she’s goingto go.

Further analysis revealed several explanations for expe-riences such as Terry’s. According to the families, staffsometimes believed the families did not need to be con-cerned with specific issues at that point in time; otherfamilies suggested staff were only concerned about theday-to-day care in ICU and perceived that staff were notconcerned about what happened ‘down the track’:

You know the ones you’re dealing with are just totally

absorbed in the current. . .

in the moment care sort ofthing . . . it’s not their issue about what happens downthe track I guess after ICU. (Kay)

In the process of obtaining information, families useda variety of strategies including asking staff questions, aswell as less direct methods, such as ‘eavesdropping’ on theward round, ‘picking up cues’ and piecing together bits ofinformation.

Obtaining information was important to families. Theyobtained information from healthcare professionals eitherdirectly or indirectly and most often it was the ICU nurseswho were the communication channels between otherhealthcare professionals and families. Families varied in

their need for information about the future. For some fam-ilies, information about what to expect in the future wasimportant, however for others, the current situation was allthey could cope with.

The Language of communication

Families, who received bad news, appreciated the wayhealthcare professionals communicated the informationopenly and honestly. They used the term ‘‘sugar-coating’’to describe how they did not want staff to ‘disguise’ badnews and make it sound better than it actually was in orderto avoid upsetting them. Families felt that by receiving

8/19/2019 jurnal kritis

7/13

Families’ experiences of their interactions with staff in an Australian ICU 57

Table 2 Outline of thematic analysis.

Theme Category Codes Example quotes

Obtaininginformation

Nurses ascommunicationchannels

AccessiblePersonableClarifying

The nursing staff would  pretty much keep us up to date

with everything . . . The doctors would come in and see

[patient] . . . if  they had missed us we knew that we

could speak to the nursing staff and  . . . they were

 pretty  good as  far as telling us what the doctors had said. (Linda)

The way they’ve tried to explain things to me about

what’s happening to her, the way they’ve explained 

things to me that the doctors have told them have been

. . . you know, things that they’ve said  in that way have

been good and there’s not so many  grey areas. (Terry)Strategies forbecominginformed

Asking questionsBeing resourcefulPutting the piecestogether

If we ever  had a question or something you just  go up

and ask them, if they were on their rounds we would 

certainly ask. (Linda)

I thought of  figure I’d  like to be in hand over  and  find 

out what they’re saying in there compared to what

things I’m trying to . . . cues I’m trying to  pick up  from

what’s happening (Kay)

Temporality ofbeing informed

Focused on thepresentNeedinginformation aboutthe future

They’re very  careful not to say more than what they’relooking after . . . and when you ask . . .’’ what about

after, how’s she going to  go?’’ The answer  . . . was ‘‘Oh I

don’t know about then, they move on’’ . . . he’s ready to

look after the next badly broken person (Eileen)

The most disappointing would be having to say the

 follow up now, what’s  going to happen. As I said I don’t

know, I have no idea what happens from here. (Cheryl)

I’m concentrating on now. I  just . . . think I’d have a

nervous breakdown if  I tried to look too  far ahead.

(Sharon)

Language of

communication

Being open andhonest

Building trustDelivering bad

newsNot sugar coating

They were honest . . . didn’t ‘‘sugar coat’’ anything . . .

you know they’re not  going to say he’s  got a scratch on

his leg when he’s as bad as what he was so they . . .

 prepared us  for it. (Michael)

 And the nurses. . . they’d been doing the dressings and 

. . . said  ‘‘look, you know, I’ll be honest it does look

 gunky’’ she said  . . . (Jenny)

Using Layman’sTerms

Making thecomplex simpleSpeaking ourlanguage

They  just had a way about . . . talking and explaining

things in our terms too, not all in technical terms

because when you’re in shock you don’t want to hear 

‘we’ve  put him on these drugs’ and things like that.

(Jenny)

I think it was very much like a layman’s terms really . . .

he communicated to me, and  . . . I don’t regard myself a

medico or an extremely intelligent person and yet

everything he was saying I could understand him clearly 

(Terry)

Supportivecommunication

ReassuranceConsistent themesOK to leaveKeeping usup-to-date

They  just reassured us that we could  go home . . .  just

being reassured that we can ring twenty-four seven . . .

and speak to someone if we’re concerned about

anything. (Jenny)

She confirmed that the interaction with the male nurse

who sat her down and explained things well, told her 

that ‘no questions were silly questions’ that this was . . .

reassuring for her. (Carol)

8/19/2019 jurnal kritis

8/13

58 P. Wong et al.

Table 2 (Continued )

Theme Category Codes Example quotes

Responding tononverbal cues

Anticipating ourinformation needsComfortingBody language

He said ‘are you alright’; I must have looked like a lost

soul. (Carol)

Spotting if we are having a bad day without even us

having to utter a word. (Jenny)

Unsupportivecommunication

Poorcommunication

InconsistentthemesAbrupt

What we were told at the bed was different to whatwas actually happening. (Cheryl)

I was sort of told it’s  going to be one-on-one and on a

number of occasions it wasn’t one-on-one. (Terry)

Keeping a distanceBeing fobbed offFeeling excludedBeing in the way

I ask a lot of questions . . . there has been some where

they  just  give . . . a  generic answer that they want . . .

not to ‘‘fob you off’’, but  just to say  ‘‘You know this is

why we’re doing it’’ and not  go into the detail maybe

that some of the other nurses do. (Michael)

[Physician] totally ignored me, totally ignored me and I,

um, apologised to him straight away and he  just

ignored me,  just continued talking on to the rest of 

them. (Cheryl)

 A couple of days later he [nurse] came . . . sort of 

keeping a wide berth . . . didn’t sort of  . . . after being

sort of almost pally when we were initially there to

standoffish. (Kay)

information honestly and upfront, not only enabled themto prepare for the future, but it established trusting rela-tionships with them. This is illustrated by Sharon:

You could tell they were telling you the truth . . . theyweren’t sugar-coating it for you . . . they were telling youeverything, so you felt you could trust them, becausethey weren’t keeping stuff from you.

Some healthcare professionals delivered bad news byusing well-chosen words and an appropriate tone in theirvoice that considered the families’ fragile emotional con-dition, but others did this poorly. Linda described onephysician she labelled the ‘bad news doctor’ because of theway he delivered this type of information but contrasted thiswith another physician who delivered bad news with a morehumanistic approach:

He said . . . ‘‘she’s in a bit of a hole, we need to get her outof this’’ . . . He didn’t have a great deal to say to us, hethought about everything he said very carefully . . . he’sjust one of those people that I could go through life and

I’ll never forget what he has to say and the way he saysit.

When receiving bad news, although families wanted staffto be open and honest, it was still important for them todeliver the information in a caring and compassionate man-ner that considered their vulnerable and emotional state.

The language of communication was also represented bythe way staff phrased the information provided. Simplifyinginformation, by rephrasing it in ‘non-technical’ or lay terms,so that families could understand the complex medical lan-guage used by healthcare professionals, was important forfacilitating communication with families. This was particu-larly helpful when families were in a state of shock early

in the admission and potentially unable to process much ofwhat they were told. It also helped families feel confident inthe care and treatment their family member was receiving,as stated by Terry:

I think it was very much like . . . layman’s terms . . . so I feltconfident with what he said . . . and it installed confidencein [wife’s] care.

In order for families to fully understand the informationthey are given, it needs to be provided in a language thefamilies comprehend and of which they can make sense.

Supportive communication

Families experienced interactions around communicationwith staff that were considered supportive, while otherswere described as unsupportive. Reassurance and res-ponding to nonverbal cues represented communicationstrategies that families experienced as supportive whilethey were in ICU.

Families were determined, early in the admission, not toleave the hospital so they could remain close to their familymember. Some families received reassurance and felt com-forted in the knowledge that they could go home and contactthe ICU at any time to get information about their familymember. Families were also reassured by being informedconstantly about the family member’s progress, treatmentand care. For example, a physician put Kay’s mind at ease:

One doctor . . . might have been the second day . . . I didn’tknow how severe his injuries were and the big picture sortof thing . . . whether he was going to die from it or whetherhe was ever going to come out of the coma . . . but I thinkone of the senior intensive care doctors probably picked

8/19/2019 jurnal kritis

9/13

Families’ experiences of their interactions with staff in an Australian ICU 59

up on that and said ‘‘Well he’s not going to die from this’’.So that was reassuring.

When information received from different healthcareprofessionals was a consistent theme, they felt reassuredeven if the news was not always positive, as highlighted byTerry’s comment:

No one’s really given me much of a deviation of what

the doctors have told me. . .

but it’s been reassuring andthere’s a consistent theme . . . and it’s helped me . . .

Families felt reassured, not only by constantly receivinginformation about their family member, but also when theinformation given was consistent between various staff.

Supportive communication is also represented by staffthat responded to families’ nonverbal cues that indicatedthey were confused, anxious or worried while in ICU. The vig-ilance with which staff perceived their distress, by observingtheir body language or facial expressions, prompted them toclarify information, provide reassurance or further investi-gate why families may have been upset. In the followingstatement, Jenny described the immediate response of the

ICU nurse to her concern, when she misinterpreted data onthe monitor:

At one stage I looked at it and it said ‘49’ . . . and straightaway the nurse could see me looking . . . worried and shesaid ‘‘it’s not his temp’’ . . . I said ‘‘oh phew!’’

Linda described how the receptionist staff responded toher nonverbal cues of distress and then followed up by askingthe ICU nurses to investigate further:

I’m sitting there having a cry. And they [receptionists]must have . . . rung [the] ICU nurse and said ‘‘can you findout what’s wrong with [Linda] because she’s obviously notherself today’’.

Families described the way staff were receptive to theirfeelings of anxiety or distress, without them needing to sayanything. The ability of staff to subsequently respond totheir concerns was supportive for these families.

Unsupportive communication

In contrast to supportive communication, families expe-rienced poor communication such as staff speakingabruptly, rudely or providing inconsistent information.These examples are represented by the theme Unsupportivecommunication.

Poor communication was represented by staff who spoke

to them in an abrupt and rude manner. Cheryl experiencedthe following interaction with a physician:

I said to him I had a couple of concerns about mum beingoperated on this early just for an eye socket, and he said‘‘and who are you, what experience do you have’’. Hewas really rude and, um, it was hard, I nearly burst intotears over it actually . . . it was like a knife stabbing intoyou, it was . . . and from then on I probably was a bitreluctant to ask too many questions.

When families received inconsistent information, suchas that experienced by Michael in the following excerpt, itoften led to further anxiety and distress for families:

The ICU doctor . . . said ‘‘look he’s got a couple a badbugs in his system . . . we’re pretty sure that the leg is notcreating the bugs’’ . . . and he walked out and wouldn’thave been a minute later the burns guys come in and said‘‘ah look we think his legs creating all these bugs and . . .we might have to amputate above the knee’’.

The manner in which staff spoke to families and the con-sistency of the information were important in terms of beingsupported or unsupported. Speaking abruptly or rudely anddelivering inconsistent information, did not support familiesduring their time in ICU.

In summary, families’ interactions with physicians andnurses in ICU revolved around communication. More specif-ically, families were constantly obtaining information fromthe healthcare staff, and most often from the ICU nurses.The context of time around which the information wasframed, was important for families. Direct and indirectmethods, such as ‘eavesdropping’ were used by families toobtain information they required. Of equal importance toobtaining information from staff, was the language health-care staff used to communicate that information. Families

appreciated staff that used ‘lay’ terms and nontechni-cal language that was easier for them to comprehend.It was also important that staff were honest and upfrontwhen communicating, especially bad news. Families expe-rienced both supportive and unsupportive communication.When staff communicated in ways that provided them withreassurance or when they were astute to families’ nonver-bal cues, the communication was considered supportive.Poor communication, during which staff spoke rudely orreprimanded families and inconsistent information, was con-sidered unsupportive.

Discussion

The findings from this study are supported by current andprevious literature in this area. The following discussion willlink the findings to the current literature and the implica-tions for clinical practice.

The results of this study are similar to previous workin this area, specifically the important need families havefor obtaining information. Molter’s (1979) seminal workdetermined one of the most important needs of criticallyill patients’ family members is information about thepatient’s prognosis and condition. Previous studies havesubstantiated the families’ desire for information and thisfinding is now universally accepted (Ågård and Harder,2007; Fry and Warren, 2007; Lee et al., 2000; Plakas et al.,

2009). However, further to those studies that identify whatfamilies need, the findings of our study frame the provisionof information around a context of time and highlight theimportance of assessing each family for their particularinformational needs and determining the most appropriatetime to provide such information. For example, there wasconcern from some families that the nursing staff wereunable, or unwilling, to provide specific information aboutwhat happened in the future after ICU because their focuswas on the day to day care in ICU. Interestingly, two partic-ipants whose expectations about future information afterICU were not met, were both nurses. It raises the question asto whether family members with a healthcare professional

8/19/2019 jurnal kritis

10/13

60 P. Wong et al.

background differ from lay families with regard to theirexpectations and experiences of their interactions. Thereis some evidence that healthcare professionals who arealso family members of patients in ICU, experience specificchallenges related to their interactions with ICU staff andtheir expectations of care (Crunden, 2010; Dockerty andDockerty, 2006; Salmond, 2011). Salmond (2011) exploredthe experience of being a nurse with a relative in ICU.

As a consequence of having medical knowledge, nursefamily members expected more detailed information suchas assessment findings and planned care. They were awareof expected care standards and judged staff competenceand the quality of care based on this knowledge (Salmond,2011). Likewise, it is possible that the nurse family membersin our study had higher than usual expectations about theinformation they should receive and therefore were morelikely to experience unmet informational needs.

The significance of assessing families for their specificinformational requirements and then determining the mostappropriate time to provide such information is aligned withthe philosophy of a FCC theoretical framework. Inherentwithin a FCC model is the provision of timely informationby healthcare professionals that enable families to effec-tively contribute to decision-making. This is supported byHenneman and Cardin (2002), who suggest that to imple-ment FCC in ICU, nurses play several important roles inrelation to meeting the families’ need for information, oneof which is to assess the family’s needs and ensure they areaddressed appropriately.

Findings from this study support the assertion that fam-ilies prefer to seek information from nurses because theywere often easier to approach and friendlier. Additionally,during the process of obtaining information, ICU nurses wereoften the communication channel between the family andother healthcare professionals such as the physicians. Sev-

eral studies have reported the important role of both nursesand physicians in communicating various types of informa-tion, however, they acknowledge the important role of thenurse as the immediate source of information and in com-municating information (Maxwell et al., 2007; Söderstromet al., 2003). Gutierrez (2012) explored the communicationof prognostic information by physicians and nurses to fam-ilies in ICU and found that nurses have a significant role toplay in this type of communication. The ICU nurses often‘filled the gaps’ or interpreted the physician’s explanationsensuring they understood what the physicians had told themand the implications of the information. Auerbach et al.(2005) studied interpersonal perceptions of healthcare staffand found nurses were viewed as ‘‘more friendly and less

hostile’’ (p. 208) than physicians at admission and discharge.The authors suggested the reason for this was that ‘‘bedsidenurses are in continual contact with patients’ families andare the families’ primary source of information and supportuntil the patient’s discharge from ICU’’ (p. 208). While it istrue that families are in contact with nurses more often, it isdifficult to support a link between the nurses’ approachableand friendly demeanour and their physical accessibility.

Findings from this study suggest the way staff deliver badnews to families is important and families want the truthabout their family member despite the serious nature oftheir condition. Information delivered in an open and hon-est way and with a caring and empathetic approach help

families become informed and reduce anxiety. However, itmust be recognised that there is often a need for tactfulcommunication, when delivering bad news; and for bal-ancing the requirement to be realistic while maintainingcultural sensitivity and hope, as well as considering the indi-vidual differences in the family members’ ability to take ininformation.

Despite the overwhelming need for families in this study

to receive open and honest information, there are sev-eral reports in the literature that raise important questionsaround this issue and how bad news is communicated byhealthcare professionals. Engström and Söderberg (2007)reported that although ICU nurses understand the impor-tance of being honest about the gravity of the situation,they find it difficult to do this while still maintaining hopefor families. The importance of communicating effectivelywith family members in the ICU, especially during end-oflife care is well recognised (Nelson et al., 2006; Shannonet al., 2011). Jurkovich et al. (2000) investigated familiesof trauma patients who died in ICU or Emergency Depart-ments, and found that the most important characteristic inthe communication process of giving bad news, along withprovision of clear information, was the attitude of the per-son delivering the information. This was found to be moreimportant than the person’s level of knowledge or whetherthey could respond to questions.

Furthermore, recent attention has been focused on com-munication with patients and families from a non-Englishspeaking background (NESB), with at least one study sug-gesting they may be at increased risk of receiving lessinformation and emotional support from healthcare pro-fessionals due to language and cultural barriers (Thorntonet al., 2009). Similarly, Lee et al. (2000) highlighted acultural concern related to Chinese families, who tradi-tionally avoid saying ‘bad’ things or speaking negatively

about the patient for fear of causing ‘bad luck’ and howthis may impact on the need to be honest with families.Thornton et al. (2009) suggest further research is required toidentify ways of improving communication and support forfamilies from NESB. Respect and dignity for the patients’and families’ values, beliefs and cultural background, isa core concept underpinning the FCC theoretical frame-work. Healthcare professionals must listen and respect thefamilies’ perspectives and choices when planning and imple-menting care for their relatives (Institute for Patient- andFamily-Centered Care, 2010b). Language and cultural bar-riers may challenge the staff’s ability to practice a FCCphilosophy in this context.

In direct contrast to supportive communication expe-

rienced by families when healthcare staff providedreassurance and consistent information, families in ourstudy also found communication unsupportive when therewas inconsistency of information among healthcare profes-sionals. Ågård and Harder (2007) found that ‘knowing’ aboutthe patient’s condition and progress, provided reassuranceand was essential in helping families adapt and cope withthe uncertainty of their situation. However, inconsistent orconflicting information causes unnecessary confusion anddistress, therefore strategies to minimise or prevent familiesfrom receiving inconsistent messages need to be considered.Nelson et al. (2005) investigated the informational needs ofpatients and families of chronic, critically ill patients and

8/19/2019 jurnal kritis

11/13

Families’ experiences of their interactions with staff in an Australian ICU 61

found families experienced confusion and further anxietyas a result of receiving conflicting messages from differentphysicians and nurses. Staff rostering in ICU that promotescontinuity of care from both physicians and nurses wouldhelp resolve this problem. In clinical practice guidelines,based on a systematic review of the literature, Davidson(2007) recommend that nurses and physicians allocated toeach patient should be as consistent as possible and the

number of healthcare professionals who provide informa-tion be minimised, in order to reduce the confusion andfrustration of families who interact with multiple health-care professionals. Ongoing interdisciplinary communicationabout the patient’s progress and planned treatment andcare is necessary to ensure consistent messages are beingdelivered by all healthcare professionals (Davidson et al.,2007).

Families in this study felt that staff were generallyalert to nonverbal cues and were then able to respond toconfusion or distress. In order for healthcare staff to sup-port families who experience distress and anxiety whilethey are visiting ICU, it is important that expressionsof concern, confusion or misunderstanding are identifiedby staff so these can be addressed in a timely man-ner and before they escalate. Ågård and Harder (2007)found that in the process of constantly seeking informa-tion, families form their own personal cues about thepatient and their environment. Sometimes these personalcues are inaccurate representations of the actual situ-ation but these misinterpretations may never come tothe nurses’ attention. Davidson (2009) suggests that fami-lies who have misconceptions about the ICU environment,or patient related events, may benefit from the nursesquestioning the family more to expose underlying con-cerns or misunderstandings, therefore avoiding unnecessaryanguish.

Limitations

The findings from this study will add to the knowledge baseof families’ experiences of their interactions with staff inICU. Although not detracting from the study and its find-ings, we do acknowledge some limitations. The majority ofparticipants were white Anglo-Saxon. In 2010—2011, only2% of trauma patients admitted to this ICU were from aNESB. Hence, the data presented in this paper representthe voices of white Anglo-Saxon participants more thanthose from ethnic minorities. Future research should aimto replicate the study and include a greater proportion

from non-English speaking backgrounds. This would allowus to apply conclusions to clinical practice and be con-fident that the perspectives of these groups have beenrepresented. Another limitation of this research is the factthat it is only a single study and therefore we need tobe cautious about inferring conclusions based on this onestudy. Furthermore, this study was confined to unexpectedadmissions and so the findings might not reflect the expe-riences of families of electively admitted patients. Finally,as identified previously, families of patients at end-of-lifeor who were particularly distressed were excluded fromthe study, and this could be considered a limitation of thisstudy.

Conclusion

When nurses are working in the busy and highly technologicalICU environment, their priority is to maintain the critically illpatient’s physiological stability. At times the families’ needfor emotional and psychological support become secondary,attended to if, and when, time permits. Families, however,play an important role in providing the patient with psy-

chosocial support, and are also at risk of emotional distressif they are not well supported. FCC is currently recognisedas a philosophical approach to care delivery that consid-ers the patient and families perspectives, values and beliefswhen planning, delivering and evaluating care (Institute forPatient- and Family-Centered Care, 2010b). It is a modelthat can be implemented in ICU to ensure families’ emo-tional, psychosocial and other needs are met. The findingsfrom this study can be used towards operationalising a FCCframework in ICU. Facilitating communication by interactingin supportive ways through reassurance and being responsiveto families’ cues — while promoting strategies that minimiseunsupportive communication — may help alleviate the anxi-

ety and distress experienced by families of the critically ill.Hence we recommend the clinical implications for practiceas presented in the ‘Clinical Implications’ as necessary forproviding improved family-centre care.

Funding

The authors have no sources of funding to declare.

Conflict of interest

The authors have no conflict of interest to declare.

Acknowledgements

We would like to acknowledge the families who contributedto this research and to whom we are extremely grateful.

References

Ågård AS, Harder I. Relatives’ experiences in intensive care: find-ing a place in a world of uncertainty. Intensive Crit Care Nurs2007;23:170—7.

Auerbach SM, Kiesler DJ, Wartella J, Rausch S, Ward KR, Ivatury R.Optimism, satisfaction with needs met, interpersonal percep-tions of the healthcare team, and emotional distress in patients’family members during critical care hopsitalization. Am J CritCare 2005;14:202—10.

Australian Institute of Health and Welfare. Metadata Online Reg-istry. Canberra, ACT: Australian Government; 2013, Availableat http://meteor.aihw.gov.au/content/index.phtml/itemId/327234 (29.10.13).

Azoulay E, Pochard F, Kentish-Barnes N, Chevret S, Aboab J, AdrieC, et al. Risk of post-traumatic stress symptoms in family mem-bers of intensive care unit patients. Am J Respir Crit Care Med2005;171:987—94.

Blom H, Gustavsson C, Sundler AJ. Participation and support inintensive care as experienced by close relatives of patients — aphenomenological study. Intensive Crit Care Nurs 2013;29:1—8.

Bloomer MJ, Tiruvoipati R, Tsiripillis M, Botha JA. End of lifemanagement of adult patients in an Australian metropolitan

http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://meteor.aihw.gov.au/content/index.phtml/itemId/327234http://meteor.aihw.gov.au/content/index.phtml/itemId/327234http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0030http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0030http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0030http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0030http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0030http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0030http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0030http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0030http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0030http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0030http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0030http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0030http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0030http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0025http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0020http://meteor.aihw.gov.au/content/index.phtml/itemId/327234http://meteor.aihw.gov.au/content/index.phtml/itemId/327234http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0010http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0005

8/19/2019 jurnal kritis

12/13

62 P. Wong et al.

intensive care unit: a retrospective observational study. Aust CritCare 2010;23:13—9.

Bond AE, Draeger CRL, Mandleco B, Donnelly M. Needs of fam-ily members of patients with severe traumatic brain injury.Implications for evidence-based practice. Crit Care Nurse2003;23:63—72.

Buckley P, Andrews T. Intensive care nurses’ knowledge of criticalcare family needs. Intensive Crit Care Nurs 2011;27:263—72.

Burr G. Contextualizing critical care family needs through tri-

angulation: an Australian study. Intensive Crit Care Nurs1998;14:161—9.

Chaboyer W, Kendall E, Kendall M, Foster M. Transfer out of intensivecare: a qualitative exploration of patient and family percep-tions. Aust Crit Care 2005;18:138—45.

Chaboyer W, Thalib L, Alcorn K, Foster M. The effect of an ICUliaison nurse on patients and family’s anxiety prior to trans-fer to the ward: an intervention study. Intensive Crit Care Nurs2007;23:362—9.

Charmaz K. Constructing grounded theory: a practical guide throughqualitative analysis. Thousand Oaks: Sage Publications; 2006.

Chesla CA. Reconciling technologic and family care in critical carenursing. J Nurs Scholarsh 1996;28:199—203.

Chesla CA, Stannard D. Breakdown in the nursing care of families inthe ICU. Am J Crit Care 1997;6:64—71.

Coulter MA. The needs of family members of patients in intensivecare units. Intensive Care Nurs 1989;5:4—10.

Creswell JW. Qualitative inquiry and research design: choosingamong five approaches. 3rd ed. Thousand Oaks, CA: Sage Publi-cations Inc.; 2013.

Crunden E. A reflection from the other side of the bed — an accountof what it is like to be a patient and a relative in an intensivecare unit. Intensive Crit Care Nurs 2010;26:18—23.

Cypress BS. The intensive care unit: experiences of patients,families, and their nurses. DCCN — Dimens Crit Care Nurs2010;29:94—101.

Damboise C, Cardin S. Family-centered critical care: how one unitimplemented a plan. Am J Nurs 2003;103, 56AA-EE.

Davidson JE. Presence of family liaison might build case for familypresence. Am J Crit Care 2007;16:333—4.

Davidson JE. Family-centered care: meeting the needs of patients’families and helping families adapt to critical illness. Crit CareNurs 2009;29:28—35.

Davidson JE, Powers K, Hedayat KM, Tieszen M, Kon AA, ShepardE, et al. Clinical practice guidelines for support of the familyin the patient-centered intensive care unit: American Collegeof Critical Care Medicine Task Force 2004—2005. Crit Care Med2007;35:605—22.

Davidson JE, Jones C, Bienvenu OJ. Family response to criti-cal illness: postintensive care syndrome-family. Crit Care Med2012;40:618—24.

Dockerty JD, Dockerty JL. When health professionals become NICUparents. Neonatal Netw — J Neonatal Nurs 2006;25:295—6.

Eggenberger SK, NelmsTP. Being family: the family experience whenan adult member is hospitalized with a critical illness. J Clin Nurs2007;16:1618—28.

Engström Å, Söderberg S. Close relatives in intensive care from theperspective of critical care nurses. J Clin Nurs 2007;16:1651—9.

Fry S, Warren NA. Perceived needs of critical care family members:a phenomenological discourse. Crit Care Nurs Q 2007;30:181—8.

Gutierrez KM. Prognostic communication of critical care nurses andphysicians at end of life. Dimens Crit Care Nurs 2012;31:170—82.

Halcomb E, Daly J, Jackson D, Davidson P. An insight into Australiannurses’ experience of withdrawing/witholding of treatment inthe ICU. Intensive Crit Care Nurs 2004;20:214—22.

Hartman-Shea K, Hahn AP, Fritz Kraus J, Cordts G, Sevransky J.The role of the social worker in the adult critical care unit:a systematic review of the literature. Soc Work Health Care2011;50:143—57.

Henneman EA, Cardin S. Family-centered critical care: a practicalapproach to making it happen. Crit Care Nurs 2002;22:12—9.

Holloway I, Wheeler S. Qualitative research in nursing. 2nd ed.Oxford: Blackwell Science Ltd.; 2003.

Hughes F, Bryan K, Robbins I. Relatives’ experiences of critical care.Nurs Crit Care 2005;10:23—30.

Hupcey JE. Establishing the nurse-family relationship in the inten-sive care unit. West J Nurs Res 1998;20:180—94.

Hupcey JE. Looking out for the patient and ourselves — the pro-

cess of family integration into the ICU. J Clin Nurs 1999;8:253—62.

Hupcey JE. The meaning of social support for the critically illpatient. Intensive Crit Care Nurs 2001;17:206—12.

Institute for Patient- and Family-Centered Care. Fre-quently asked questions: What are the core concepts ofpatient- and family-centered care? Bethesda: Institute forPatient- and Family-Centered Care; 2010a, Available athttp://www.ipfcc.org/faq.html(24.06.13).

Institute for Patient- and Family-Centered Care. Frequently askedquestions: What is patient- and family-centered health care?Bethesda: Institute for Patient- and Family-Centered Care;2010b, Available at http://www.ipfcc.org/faq.html(23.06.13).

Jamerson PA, Scheibmeir M, Bott MJ, Crighton F, Hinton RH, CobbAK. The experiences of families with a relative in the intensivecare unit. Heart Lung 1996;25:467—74.

Jones C, Skirrow P, Griffiths RD, Humphris G, Ingleby S, Eddleston J,et al. Post-traumatic stress disorder-related symptoms in rela-tives of patients following intensive care. Intensive Care Med2004;30:456—60.

Jurkovich GJ, Pierce B, Pananen L, Rivara FP. Giving bad news: thefamily perspective. J Trauma 2000;48:865—70.

Khalaila R. Patients’ family satisfaction with needs met at the med-ical intensive care unit. J Adv Nurs 2012;69:1172—82.

Kinrade T, Jackson AC, Tomnay JE. The psychosocial needs offamilies during critical illness: comparison of nurses’ and fam-ily members’ perspectives. Aust J Adv Nurs (Online) 2009;27:82—8.

Lam P, Beaulieu M. Experiences of families in the neurological ICU:a bedside phenomenon. J Neurosci Nurs 2004;36:142—55.

Lee IY, Mackenzie AE, Chien WT. Needs of families with a relative ina critical care unit in Hong Kong. J Clin Nurs 2000;9:46—54.

Leske JS. Needs of relatives of critically ill patients: a follow-up.Heart Lung 1986;15:189—93.

Liamputtong P. Qualitative Research Methods. 4th ed. Melbourne:Oxford University Press; 2013.

Maxwell KE, Stuenkel D, Saylor C. Needs of family members of criti-cally ill patients: a comparison of nurse and family perceptions.Heart Lung 2007;36:367—76.

Mitchell ML, Chaboyer W. Family Centred Care — a way to con-nect patients, families and nurses in critical care: a qualitativestudy using telephone interviews. Intensive Crit Care Nurs2010;26:154—60.

Mitchell ML, Chaboyer W, Burmeister E, Foster M. Positive effects ofa nursing intervention on family-centered care in adult criticalcare. Am J Crit Care 2009;18:543—52.

Mitchell ML, Courtney M. Reducing family members’ anxiety anduncertainty in illness around transfer from intensive care: anintervention study. Intensive Crit Care Nurs 2004;20:223—31.

Molter NC. Needs of relatives of critically ill patients: a descriptivestudy. Heart Lung 1979;8:332—9.

Munhall PL. Nursing research: a qualitative perspective. Sudbury,MA: Jones and Bartlett Publishers; 2007.

Nelson JE, Angus DC, Weissfeld L, Puntillo K, Danis M, Deal D, et al.End-of-life care for the critically ill: a national intensive careunit survey. Crit Care Med 2006;34:2547—53.

Nelson JE, Kinjo K, Meier DE, Ahmad K, Morrison RS. When criti-cal illness becomes chronic: informational needs of patients andfamilies. J Crit Care 2005;20:79—89.

http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0030http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0030http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0030http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0035http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0035http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0035http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0035http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0035http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0040http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0040http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0040http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0045http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0045http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0045http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0045http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0050http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0050http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0050http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0050http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0055http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0055http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0055http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0055http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0055http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0060http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0060http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0065http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0065http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0065http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0070http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0070http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0070http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0075http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0075http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0075http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0080http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0080http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0080http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0085http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0085http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0085http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0085http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0085http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0090http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0090http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0090http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0090http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0090http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0095http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0095http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0100http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0100http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0100http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0105http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0105http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0105http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0105http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0110http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0110http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0110http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0110http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0110http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0110http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0115http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0115http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0115http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0115http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0120http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0120http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0120http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0120http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0125http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0125http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0125http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0125http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0130http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0130http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0130http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0130http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0135http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0135http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0135http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0140http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0140http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0140http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0145http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0145http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0145http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0145http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0150http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0150http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0150http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0150http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0155http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0155http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0155http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0160http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0160http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0165http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0165http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0165http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0170http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0170http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0170http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0175http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0175http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0175http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0175http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0175http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0180http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0180http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0180http://www.ipfcc.org/faq.htmlhttp://www.ipfcc.org/faq.htmlhttp://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0195http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0195http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0195http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0200http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0200http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0200http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0200http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0205http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0205http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0205http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0210http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0210http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0210http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0210http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0215http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0215http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0215http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0215http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0215http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0220http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0220http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0220http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0225http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0225http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0225http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0230http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0230http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0230http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0235http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0235http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0240http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0240http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0240http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0240http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0260http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0260http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0260http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0265http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0265http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0270http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0270http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0270http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0275http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0270http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0270http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0270http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0270http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0270http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0270http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0270http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0270http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0270http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0270http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0270http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0270http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0270http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0270http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0270http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0270http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0270http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0270http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0265http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0265http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0265http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0265http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0265http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0265http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0265http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0265http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0265http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0265http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0265http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0265http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0265http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0260http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0260http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0260http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0260http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0260http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0260http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0260http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0260http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0260http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0260http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0260http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0260http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0260http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0260http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0260http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0260http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0255http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0250http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0964-3397(14)00062-7/sbref0245http://refhub.elsevier.com/S0