Families are not prepared for traumatic injuries of loved ones. Emergency nurses have the important role of caring for patients and families in this time of crisis. Family needs in the critical care setting have been explored using the Critical Care Family Needs Inventory (CCFNI), however little is known about family needs in the emergency department.
This study sought to determine the needs of family members accompanying injured patients into the emergency department, and if these needs were met.
A quantitative, descriptive, study was conducted in a level 1 trauma facility in Johannesburg, South Africa. The population included families of patients admitted to the emergency department, sampling 100 participants. The instrument, based on the CCFNI, was validated in a pilot study in Melbourne, Australia and re-evaluated using the Cronbach Alpha validity test to ensure internal consistency.
Five themes were explored: ‘meaning’, ‘proximity’, ‘communication’, ‘comfort’ and ‘support’ and data were analysed using descriptive statistics. Responses to open-ended questions were analysed using content analysis. Permission from the Human Research Ethics Committee was granted and participants were ensured confidentiality and the option for counselling if required.
Themes ranked highly important were ‘meaning’ and ‘communication’. Satisfaction was highest for ‘meaning’. Low satisfaction levels for ‘communication’ were found. Issues regarding prolonged time spent in the emergency department and discrimination were raised.
These findings have a negative impact on the family’s satisfaction with care and it is recommended that the nurse’s role in family care be further explored and emphasised.
Traumatic injuries have been described by the World Health Organization as a global health problem. They account for 5.8 million deaths per year, a devastation that surpasses that of other global epidemics such as malaria, tuberculosis and HIV (WHO
In South Africa, traumatic injuries fall within the top 10 leading causes of death nationwide (Norman
Death and disability are not the only consequences of traumatic injuries. The emotional turmoil which is thrust upon a family in the event of sudden traumatic injury to a loved one can be debilitating and families are dependent on the health professionals in the emergency department not only to give acute care to their loved one but also to walk them through the process of dealing with the current crisis (WHO
The speciality field of critical care nursing has added knowledge and literature to the concept of family centred care (Linnarson, Bubini & Perseius
The theme proximity takes into account the family’s access to their injured loved one, while comfort refers to the emotional and physical comfort offered by the staff and facilities available in the hospital. Support does not only refer to support offered by staff but also whether staff recognise and allow for the family to make use of their own social support structures. Communication does not only refer to transfer of information but encompasses the way in which information is shared, how regularly information is given and the how interactive the process of communication is. Meaning enables families to cope with the crisis at hand by ensuring that communication is honest while still offering hope (Linnarson, Bubini & Perseius
The emergency department setting is fast paced and unpredictable in nature (Cardona
The needs of families in the critical care setting have been studied using the Critical Care Family Needs Inventory (CCFNI). However, few studies have been conducted in the trauma and emergency setting and it cannot be assumed that the needs of families are the same in both environments (Linnarsson, Bubini & Perseius
A quantitative, descriptive, design study was conducted in a level 1 trauma care facility in a public tertiary academic hospital in Johannesburg, South Africa, where an average of 952 patients is seen per month as recorded in the hospital’s monthly statistics. This emergency department specialises in the acute care of patients with traumatic injuries.
The population comprised families of patients brought into the emergency department who were literate in English, over the age of 18, cognitively intact to participate in the study and were present in the hospital at the time of being approached to participate in the study. If at any time the researcher encountered a family with signs of emotional distress, the family was given the option to be referred to an advanced psychiatric nurse (who had given her assent), for further counselling. Family members included any next of kin or spokesperson elected by the family or patient. Participants were approached in the waiting area of the hospital either while waiting for files to be compiled or after having seen their injured relative. Families who appeared overly distressed were excluded from the study.
Permission from the Human Research Ethics Committee, from the relevant academic institution and all relevant authorities was sought and granted (Ethical Clearance certificate M130133). Participants were given a letter of information and the posting of an anonymous completed questionnaire into a sealed box was taken to imply consent.
A power analysis was completed with the
An instrument was formulated to determine the needs of families accompanying patients into the emergency department (Redley
The original instrument was tested during a pilot study in Melbourne, Australia. An inter-rater agreement level of 90% was determined to ensure relevance of the items and to ensure reliability and was later tested in a pilot study conducted in an emergency department in Melbourne (Redley
Results Cronbach alpha test.
Variable | Theme | Alpha value |
---|---|---|
Meaning | 0.7457 | |
Proximity | 0.7686 | |
Communication | 0.6483 | |
Comfort | 0.7246 | |
Support | 0.6811 | |
Meaning | 0.9262 | |
Proximity | 0.8502 | |
Communication | 0.903 | |
Comfort | 0.8515 | |
Support | 0.8812 |
CCFNI, Critical Care Family Needs Inventory.
Within the domain ‘communication’, three items were found to weaken the Alpha value, and within ‘support’ four items were reviewed. The difference in Alpha values upon removal of these items was miniscule. The items were relevant to the domain and therefore included.
Descriptive statistical analysis was used to explore the collected data. Data were captured on a Microsoft Excel spread sheet and then cleaned and coded. The data were then imported to STATA version 12.0 statistical software for analysis and organised into the five major categories which the instrument addresses. Using a Likert scale, scores were allocated to the items within the categories to determine values. Content analysis was used for analysis of responses to the open-ended questions. Responses to the open-ended questions were recorded and analysed. Analysis of responses included identifying existing and recurring concepts and grouping these concepts into categories. Eight categories were identified: communication, proximity, time taken to be attended to, friendliness or caring gestures, professionalism, treatment of the patient, equality and physical needs of family members.
In total, 50 questionnaires for CCFNI-1 and 50 questionnaires for CCFNI-2 were received between May and June 2013. Participants who answered the first questionnaire (CCFNI-1), consisted of 53% (
Participants who completed the second questionnaire (CCFNI-2) comprised 61% (
Needs statements within the instrument were assigned to one of the five themes; scores were allocated by assigning values to the Likert scale, with 1 indicating the lowest score and 4 being the highest. Means for each statement individually as well as for each theme were calculated and analysed accordingly. Results from CCFNI-1 reported on what families ranked as being most important while the results of CCFNI-2 reported on their level satisfaction with the services for meeting their needs (see
Overview of results for themes of CCFNI-1 (level of importance).
Overview of results for themes of CCFNI-2 (level of satisfaction of needs met).
The theme ranked with the highest mean score for identified needs was ‘meaning’ and the lowest was ‘support’ (see
Top 10 ranked needs statements CCFNI-1 (level of importance).
Ranking | Question | Statement | Total score | Mean score | Mode | Theme |
---|---|---|---|---|---|---|
1 | 17 | To be assured that the best care possible has been given to your relative | 197 | 3.86 | 4 | Meaning |
2 | 30 | To feel hospital staff care about your relative | 188 | 3.84 | 4 | Meaning |
3 | 15 | To have questions about the condition of your relative answered honestly | 195 | 3.82 | 4 | Meaning |
4 | 12 | To talk to a nurse | 191 | 3.82 | 4 | Communication |
5 | 6 | To have explanations given in understandable terms | 193 | 3.78 | 4 | Communication |
6 | 7 | To be kept updated frequently | 193 | 3.78 | 4 | Communication |
7 | 14 | To know about the expected outcome of your relative | 188 | 3.76 | 4 | Meaning |
8 | 35 | To feel like there is hope | 192 | 3.76 | 4 | Meaning |
9 | 11 | To talk to a doctor | 192 | 3.76 | 4 | Communication |
10 | 28 | To feel accepted by hospital staff | 188 | 3.76 | 4 | Comfort |
CCFNI, Critical Care Family Needs Inventory.
The top 10 ranking statements were analysed according to mean scores, 5 of the top 10 ranking statements belonged to the theme ‘meaning’, while 4 belonged to the ‘communication’ theme and 1 belonged to the ‘comfort’ theme.
The theme with the highest mean score was found to be ‘meaning’. The lowest scoring theme was ‘support’ (see
Top 10 ranked needs statements CCFNI-2 (level of satisfaction).
Ranking | Question | Statement | Total score | Mean score | Mode | Theme |
---|---|---|---|---|---|---|
1 | 35 | To feel like there is hope | 153 | 3.40 | 4 | Meaning |
2 | 39 | To have toilet facilities nearby | 147 | 3.34 | 4 | Comfort |
3 | 30 | To feel hospital staff care about your relative | -153 | 3.33 | 4 | Meaning |
4 | 17 | To be assured that the best care possible has been given to your relative | 149 | 3.24 | 4 | Meaning |
5 | 31 | To be assured of the comfort of your relative | 135 | 3.21 | 4 | Comfort |
6 | 19 | To see your relative as soon as possible | 143 | 3.18 | 4 | Proximity |
7 | 28 | To feel accepted by hospital staff | 134 | 3.12 | 4 | Comfort |
8 | 1 | Have a doctor or nurse meet you on arrival at the hospital | 151 | 3.08 | 3 & 4 | Support |
9 | 29 | To be treated as an individual | 129 | 3.07 | 4 | Meaning |
10 | 27 | To have time alone with your relative | 135 | 3.07 | 4 | Proximity |
CCFNI, Critical Care Family Needs Inventory.
The highest ranking needs statement with regards to satisfaction of needs met was 35. ‘To feel like there is hope’. Needs statements ranked in the top 10 were derived from the themes meaning’, ‘comfort’, proximity’ and ‘support’. No needs statements from the theme ‘communication’ were included in the top 10 ranked items.
Categories emerging from the data included communication, proximity, time taken to be attended to, friendliness and gestures of caring, professionalism, treatment of the patient, equality and physical needs of the participants. Responses from both groups of participants were similar and categories were identical. Of all the categories, communication, time taken to be attended to and equality were met with the most dissatisfaction with mostly negative responses regarding these issues. Participants verbalised frustrations about poor communication and prolonged waiting times and references were made to discrimination based on nationality. Responses related to communication included:
Some participants however, remarked positively about the emergency department staff and described them as being friendly and professional:
Needs related to ‘meaning’ were ranked as most important. The need to derive meaning from the crisis situation that families find themselves in when a relative is injured has been highlighted as a means of developing an ability to cope with the anxiety and stress of the crisis (Redley, Beanland & Botti
The second most important theme ranked by families was ‘communication’, and unique to this study was the ranking of the need to talk to a nurse. Families ranked this as the most important communication need, above the need to talk to a doctor. In the ‘communication’ theme, families expressed the need to talk to a nurse, to be given explanations in understandable terms and to be kept updated frequently, as highly important needs. The anxiety of not knowing about the condition of an injured loved one can be reduced by ensuring good communication between the nurse and family (Linnarsson
The theme ranked as being the next most important need was that of ‘proximity’. Families desire to be able to see their injured relatives. The emergency department used for the purpose of this study made use of an open visiting policy with no fixed visiting times. However families were restricted to short visits at a time. Research has shown that units with open visiting policies derived a higher level of satisfaction of families with regard to proximity (Cook
Needs related to ‘comfort’ and ‘support’ were not ranked as being highly important. However, to feel accepted by hospital staff was included in the top 10 most important needs statements. Emotional comfort is a means of reassuring the families about their importance and identity (Redley
Data, emerging from responses to the open-ended questions, were largely supportive of the findings in the questionnaire. However, from the categories that emerged from the open-ended questions of both questionnaires, two were highlighted as being important for future research and for the needs of families accompanying injured relatives into the emergency department. Time spent in the emergency department was prolonged according to the responses of the study’s participants. This has a considerable influence on the level of satisfaction of care, as the longer an injured relative is kept in the emergency department; the more negative the experience becomes (Taylor & Benger
Families desire to be treated equally, regardless of race and nationality. This is of particular importance in a South African context, where history has shown issues of equality to be a source of conflict and current incidents indicate that xenophobia is on the rise (Landau
An encouraging finding of this study was the positive remarks about equality of care with regard to race. Families in this setting identified this as an important need, and were satisfied with the equality of care received based on race. This is an affirmation of the growth of post-apartheid South Africa. However it does not fully address the need for equality related to nationality. Nurses need to become aware of their own personal difficulties related to these issues, as well as the implications for patients and their families. Nurses’ own beliefs have been identified as a hindrance to embracing family-centred care (Saveman
These findings are not necessarily applicable to the total population of South Africa and cannot be generalised. A lower internal consistency score on two of the domains of the questionnaire also decreased the validity of the questionnaire. The questionnaire did not include demographics such as education, culture, nationality and preferred language which may have influenced the findings. By excluding people who could not communicate in English the sample was limited. The use of two separate cohorts for each questionnaire could limit the ability to generalise that the needs of both cohorts were the same. No interviews were conducted with health care providers. Consequently their experiences and perceptions remain unknown.
The findings of this study have important implications for the clinical practice of the emergency nurse. From its history, trauma and emergency nursing has had as its focus, the patient in the emergency room. This focus is evolving and needs to include the important aspect of caring for families of patients admitted into the emergency department. The role of the nurse in communication has been emphasised and needs to be realised in practice. Families have expressed their need for support and communication from the nurse, who in turn may offer more holistic nursing practice, taking into consideration the family in crisis. The burden of crime and traumatic injuries in South Africa is considerable and emergency nurses may become overwhelmed by the influx of patients. It is important that consideration for the needs of the family become a part of the emergency nurse’s role and responsibility.
Issues of discrimination based on race and nationality are of great concern in post-apartheid South Africa and the equality of patients should be reflected in the care of all professional nurses.
There is a need for the role of the emergency nurse with regard to family care to be further explored. Further research may define this role more practically and suggest methods of meeting the needs of family members while dealing with the stressors of multiple responsibilities within the emergency department. Research should include the perspectives, needs and experiences of the health care providers. Nursing education should embrace the move towards family centred care.
In conclusion, this study has highlighted the needs of families accompanying injured relatives into the emergency department. These needs were not the same as those identified in the critical care setting and therefore the unique role of the emergency nurse is yet to be defined. Identified issues of concern regarding the care of families include poor communication and discrimination based on nationality. This study provides a platform for the development of holistic trauma and emergency nursing in South Africa. Needs expressed by families should be considered in defining the roles and responsibilities of nurses in practice as well as in the education of nurses.
I would like to acknowledge Dr Gayle Langley, my supervisor, for support and guidance. Your input has been invaluable and is sincerely appreciated. All glory belongs to my Lord Jesus.
The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article.
M.L.B. was the primary researcher. The project was completed under the supervision of G.L.