Therapeutic Alliance between Family Members and Health Care Providers in the ICU
CCCF ePoster library. Kalocsai C. Oct 26, 2015; 117377; P51 Disclosure(s): The project was funded by AHSC AFP Innovation Fund.
Dr. Csilla Kalocsai
Dr. Csilla Kalocsai
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Abstract
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P51


Topic: Quality Assurance/Quality Improvement Project


Therapeutic Alliance between Family Members and Health Care Providers in the ICU



Csilla Kalocsai, L. Gotlib Conn, D. Piquette, S. Dev, P. Taylor, J. Downar, A. Amaral

Trauma, Emergency, and Critical Care Research Program, Sunnybrook Research Institute, Toronto, Canada | Trauma, Emergency, and Critical Care Research Program, Sunnybrook Research Institute, Toronto, Canada | Critical Care, Sunnybrook Health Sciences Centre, Toronto, Canada | Critical Care, Sunnybrook Health Sciences Centre, Toronto, Canada | Communications, Sunnybrook Health Sciences Centre, Toronto, Canada | Palliative Care and Critical Care, UHN, Toronto, Canada | Critical Care, Sunnybrook Health Sciences Centre, Toronto, Canada

Introduction:

A positive family-provider relationship in the ICU is crucial to improve family satisfaction and anxiety, provider stress and job satisfaction, and quality of care. Multiple studies, however, document “the epidemic of physician-family conflict,” and suggest that communication between families of critically ill patients and providers needs to change (Long et al. 2013).

Our study explores family-provider relationships in the ICU, and uses the concept of therapeutic alliance as an ideal relationship. Therapeutic alliance is a dynamic patient-provider relationship, which emerges when patients and providers collaborate in establishing mutual goals, allowing patients to partner in decision-making. This collaborative and empowering relationship is supported by communication and patient integration. Since patients lack the capacity for communication and decision-making in the ICU, we extend therapeutic alliance to the family-provider relationship.



Objectives:

1) To understand the main sources of and barriers to therapeutic alliance from the perspective of families;

2) To develop an intervention to increase therapeutic alliance;

3) To improve satisfaction, psychopathological symptoms and decision-making ability of families.

This presentation will focus on the first objective.



Methods:

Using a qualitative approach, we conducted 19 semi-structured interviews with family members of critically ill patients hospitalized in an academic hospital in Toronto between October 2014 and February 2015. Interviews were analyzed inductively and iteratively following an interpretivist paradigm. We turned to the four dimensions of the therapeutic alliance concept to provide an analytical framework for our findings: collaboration, or the establishment of mutual goals; empowerment, or partnering in decision-making; communication, or information-exchange and affective bonding; and integration, or the reduction of power differences between providers and families.



Results:

We identified 6 sources of and 11 barriers to therapeutic alliance in the ICU. One of the most important sources of therapeutic alliance is communication with nurses involving frequent information-exchange and compassion. Families acknowledge intensivists’ upfront information-sharing, clear messaging at decision-making, and occasional compassion, but their limited availability and use of medical terminology highlight important gaps in communication and reinforce power differences. Since families are surrounded by many unidentified clinical professionals, they also feel poorly integrated. Intensivists’ clear messaging is empowering, but families are often left with limited understanding of their decision-making role and criticize how decisions are requested on the phone. Although many appreciate goals of care discussions, others problematize physicians’ lack of attention to family concerns in more informal interactions.



Conclusion:

Many sources of therapeutic alliance usually appear in those communicative moments that have been studied in the literature and targeted in quality improvement projects, such as in family meetings about goals of care and treatment decisions. However, some of the major barriers occur in those communicative moments that have been understudied and less targeted in quality improvement projects, for example, in informal updates or decision-making calls. They also highlight how family involvement in care and decision-making must be clarified in order to create empowered and integrated families, and to transform the ICU into a family-centered culture.



References:

Long, AC. and Curtis, RJ (2013) The Epidemic of Physician –Family Conflict in the ICU and What We Should Do About It. Critical Care Medicine 42(2): 461-462.

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