FAMILY NURSING
Family-Focused Medical-Surgical Nursing
INTRODUCTION
Hospitalization is a stressful experience for patients and their families as well. Once considered the domain of only community health, mental health, or maternal-child nursing, family nursing is now recognized as an important part of care by most nurses in Medical-surgical settings. Providing care to the entire family unit, as well as caring for patients in the context of their families, is crucial regardless of the setting for nursing care delivery.
The purpose of this chapter is to describe the evolution of family nursing in medical-surgical settings and to describe issues for nurses to consider as they plan care for families. Included are a review of the stressors that families often face during hospitalization and a discussion of the impact of patient hospitalization on families. This chapter examines caring for families before illness, during acute and chronic illness, and at end of life and reviews broad categories of family nursing interventions to use during any of the phases of illness. A discussion of the application of theoretical models to family medical-surgical nursing highlights the connection between theory and practice. The chapter closes with a discussion of the implications of developments in family nursing on medical-surgical practice, education, research, and health care policy.
IMPACT OF PATIENT HOSPITALIZATION
FOR ILLNESS OR INJURY ON FAMILIES
Illness and trauma requiring admission to a hospital and/or a critical care unit is stressful for families (Lange, 2001). Not only are hospital environments foreign, but also nurses and doctors are strangers who speak another language. To add to the stress, families are often separated from their ill member soon after entering the hospital doors and are asked to go to a small, sometimes crowded, waiting room. There, they wait endlessly for someone to give them information as they deal with emotions such as fear, anger, and guilt. Some families are better prepared to deal with these stressors than others are. Researchers have found that, among 51 family members of patients who had motor vehicle accidents or gunshot wounds, increases in prior stressors, strains, and transitions were negatively related to family adaptation outcomes and that family hardiness, resources, coping, and problem-solving communication were positively related to family adaptation outcomes (Leske & Jiricka, 1998).
Illness or injury requiring hospitalization of a loved one has been termed a nonnormative stressor event for families; that is, it is unexpected and unpredictable. Experiencing such an event may help some families grow but may cause conflicts in others. In the case of illness or injury, home routines are disrupted and some family members may need to assume responsibilities they have never had before. In addition, parents may struggle with how much to tell their children, or children may fear that they are going to lose a parent.
COMMON THEORETICAL PERSPECTIVES: ASSESSING
IMPACT OF ILLNESS ON FAMILIES
Chapter describes several theoretical frameworks for nursing of families. Models from the social science genre of theories—structural-functional theory, family systems theory, family stress theory, and family resilience theory—may be more helpful to medicalsurgical nurses because they are concise and easy to use and do not depend on long-term relationships with families. In medical-surgical settings, the short hospital stays involved, the sometimes overwhelming needs of patients, and the many other demands ourses’ time influence their abilities to plan and deliver care to families. For the family, the first priority is to help them cope with the immediacy of the hospitalization. Thus, theories must help nurses assess and provide care for families within a short period of time. Personal philosophy, hospital unit philosophy, the nature of the nurse’s clinical practice, and patient and family needs will influence the selection of the appropriate model to guide clinical practice.
Therapeutic Quadrangle
In addition to the social science theories, assessment of each component of the therapeutic quadrangle may also provide insight into the impact of the illness or injury on the family and aid in the determination of associated family care needs. The therapeutic quadrangle contains four parts: the illness, the family, the health care team, and the patient (Rolland, 1988). Caring for families in medical-surgical settings requires analyzing each of these components and designing and implementing tailor-made plans for family care accordingly.
CHARACTERISTICS OF ILLNESS
Illness is the first element of the therapeutic quadrangle. There is a great deal of variability associated with illness, and this variability is characterized by differences in the onset, course, outcome, and degree of incapacitation of the illness (Rolland, 1988). Strokes and myocardial infarctions have sudden onsets; arthritis and emphysema have gradual onsets. The type of onset may explain the amount and speed of family readjustment needed. The course of the disease may be progressive, constant, or relapsing. Cancers, rheumatoid arthritis, and emphysema are progressive; a spinal cord injury is constant; and multiple sclerosis and asthma are relapsing. Relapsing illnesses require a different kind of family adaptability from that needed with a progressive or constant course (Rolland, 1988).
Moreover, the likelihood of death resulting from an illness also affects the family. Metastatic cancer and AIDS are progressive and usually fatal, whereas hypertension and arthritis are not likely to end in death if treated properly. Illness outcome influences the degree to which the family experiences anticipatory grief (Rolland, 1988). Thus, the expectation of future loss can alter family perceptions and problem-solving abilities. “The tendency to see the family member as practically ‘in the coffin’ can set in motion maladaptive responses that divest the ill member of important responsibilities” (Rolland, 1988). The degree of illness incapacitation also determines the specific adjustments required of a family. Incapacitation can result from impairment of cognition (e.g., Alzheimer’s disease), sensation (e.g., blindness), movement (e.g., stroke with paralysis), or energy production (e.g., cardiovascular and pulmonary diseases). Illness incapacitation can also result from social stigma (e.g., AIDS).
The complexity, frequency, and efficiency of treatment; the amount of home care and hospital-based care required; and the frequency and intensity of symptoms vary widely across illnesses and have important implications for family adaptation (Rolland, 1988).
FAMILY
The family is the second element in the therapeutic quadrangle. The following factors influence the family’s relationships with the other elements in the therapeutic quadrangle: family flexibility, the amount of time the family has had to prepare for the illness event, the family’s previous experience with illness or injury, the availability of resources to deal with the event, problem-solving ability, coping skills to assist the family in managing the illness or injury, the amount of family disruption or number of family changes caused by the event, family cohesion, structure, cultural background, and family perceptions. All of these characteristics vary dramatically from family to family, and all affect the extent and manner by which each family can handle illness of a family member.
There are a number of family tasks to consider in relation to illness (Moos, 1984). These illness-related tasks include (1) learning to deal with pain, incapacitation, or other illness-related symptoms of their ill member; (2) learning caregiving procedures; and (3) establishing workable relationships with the health care team.
Measuring Patients’ Perceptions of Patient-Centered Care: A Systematic Review of Tools for Family Medicine.
Health Care Team
The third element in the therapeutic quadrangle is the health care team. Health team members vary in the priority they assign to family care, in their sensitivity to family needs, and in their knowledge and ability to assess and intervene with families. Several strategies may be used by nurses to foster positive relationships with families as shown in the following box. Strategies that inhibit relationships with families include depersonalizing the family, maintaining an efficient attitude, and displaying lack of trust in the family (Hupcey, 1998).
Fostering Positive Relationships with Families
Patient
The final element in the therapeutic quadrangle is the patient. The identity of the sick person (e.g., mother, father, grandmother, spouse, sister) and the way the patient handles illness affect family adjustment. The point in the individual’s life span at which the illness occurs also influences the family’s adjustment. Often illness in the prime of life is unexpected, whereas illness in old age may be anticipated. In general, the more emotionally significant the sick family member, the more disruptive the illness will be. For example, if the ill person is the one everyone in the family depended on or turned to when they needed advice or other types of help, it is more likely that the loss of their contributions to the family will be acutely missed.
FAMILY MEDICAL-SURGICAL NURSING AT VARIOUS PHASES OF ILLNESS
Medical-surgical nurses may care for families before illness, during periods of acute illness and chronic illness, and at the end of life.
Health Promotion
Caring for families before illness has two aims. The first is to help all family members develop healthy lifestyles. The second is to prevent a hospitalization from affecting the family’s health. Studies have shown that families play a key role in determining the healthpromoting behaviors of their members (Franks, Pienta, & Wray, 2002; Denham, 2003) and that family support is important in changing both health attitudes and behaviors (Bovbjerg et al., 1995). Nurses play a critical role in facilitating health promotion within the family (Loveland-Cherry & Bomar, 2004). Before illness develops, nurses caring for patients at high risk for familial diseases such as heart disease, stroke, or cancer can suggest to the whole family ways to lower the risk of developing these diseases. Not only can this be done in the same amount of time that it takes to teach the patient alone, but also the family benefits as a whole and, at the same time, can help the patient make necessary changes in lifestyle.
The Human Genome Project
A second aim of family nursing during the health promotion period is to prevent a stress-filled hospitalization from negatively affecting the family’s health. When under stress, healthy family members are at risk of numerous physical, mental, emotional, social, and financial problems of their own (Bengston, Karlsson, Wahrborg, Hjalmarson, & Herlitz, 1996; Holicky, 1996; Lenz & Perkins, 2000; Stolarik, Lindsay, Sherrard, & Woodend, 2000; Swoboda & Lipsett, 2002).
Unfortunately, health care providers do not get reimbursed for providing care to family members. Consequently, the health of family members often receives little time and attention. Only a few researchers have designed studies to determine how the health-related activities and health of significant others are altered by patients’ hospitalizations (Hathaway, Boswell, Stanford, Schneider, & Moncrief, 1987; Wicks, Milstead, Hathaway, & Cetingok, 1998; Leung, Chien, & Mackenzie, 2000; O’Farrell, Murray, & Hotz, 2000). Findings suggest that family members do not have a lot of concern about their personal and physical needs, that self-rated health does not improve during the illness experience, and that health practices and health deteriorate over the course of the illness.
Despite short hospital stays, there are several ways that nurses can systematically structure care to promote family health. During hospitalization of a family member, nurses can facilitate family health promotion by including families in assessments at the same time the patient admission assessment is conducted; by determining the effects of patient hospitalization on the family and providing an opportunity to discuss potential coping strategies; and by intervening to address family needs such as by contacting the hospital chaplain or by arranging a family conference with the health care team.
Acute Illness
The acute phase of illness refers to the period immediately following the onset of an acute illness event, such as an acute myocardial infarction, a stroke, or coronary artery bypass surgery. Families with members who are acutely or critically ill are often seen in ICUs, cardiac care units, or emergency rooms under conditions in which they are greatly stressed because a member of their family is experiencing a life-threatening illness or injury.
Family members experience an emotional burden a result of their relative’s stay in ICU. This burden often results in anxiety and depression. One study reported that more than two-thirds of family members visiting patients in the ICU suffer from symptoms of anxiety and depression (Pochard et al., 2001). Communication among family members may become distorted because the fear, anger, and guilt that members experience may be too intense for them to handle. In some families, conflicts may be blocked or submerged during the initial period of a critical illness, but as time goes on and the family resources become depleted, conflict between members may become more obvious (McClowery, 1992, p. 561).
There are five tasks that families must accomplish during the crisis phase of illness: (1) creating a meaning for the illness event that preserves a sense of mastery over their lives, (2) grieving for the loss of the family identity before illness, (3) moving toward a position of accepting permanent change while maintaining a sense of continuity between the past and the future, (4) pulling together to undergo short-term crisis reorganization, and (5) developing family flexibility about future goals (Rolland, 1988).
Understanding the work of families during the crisis phase of illness should serve to remind nurses to maintain open and caring relationships with them, as well as cautiourses to respond in a positive and sympathetic way to potential manifestations of erratic or angry family behavior.
Nurses around the world have investigated the needs of families facing acute or life-threatening illness (Molter, 1979; Leske, 1986; McLennan, Anderson, & Pain, 1996; Wagner, 1996; Lindsay et al., 1997; Kosco & Warren, 2000; Leung, Chien, & Mackenzie, 2000; Lee & Lau, 2003). The following needs were found to be most important:
• To have questions answered honestly
• To know the facts about what is wrong with the patient
• To be informed about the patient’s progress, outcome, and chance for recovery
• To be called at home about changes in the patient’s condition
• To receive understandable explanations
• To receive information once a day
• To have hope
• To believe that hospital personnel care about the patient
• To have reassurance that the patient is receiving the best possible care
• To see the patient frequently
In general, families’ needs in a critical care unit or during the acute illness period are similar, regardless of their age, gender, relationship to the patient, and patient diagnosis (Leske, 1991). A nurse supports the family by showing compassion, concern, and sensitivity to all family needs (Leske, 1992; Wesson, 1997).
Family Needs in Acute Care
Families who receive attentive nursing care will be able to provide better comfort to their ill relative, foster improvements in care, and augment the assessment skills of health care providers. Leske’s five family need categories can be used to direct nursing interventions, which should begin on initial contact with family members (Titler, Bombei, & Schutte, 1995).
Providing assurance entails establishing a calm and relaxed atmosphere that will support a trusting and empathetic relationship (Leske, 1992). Enhancement of proximity means allowing family members to be near the patient by exercising flexible family visitation policies.
Information and Family Needs Studied
The need for information about the patient has been shown to be the number one identified need of families of critically ill patients, regardless of diagnosis or length of stay (Jastremski & Harvery, 1998). A study initiated to determine the level of satisfaction of family members with the care that they and their critically ill relative received found completeness of information to be associated with overall satisfaction (Heyland et al., 2002). Families require informatioot only upon admission and discharge but also throughout the course of the patient’s stay in the hospital.
There are several ways to provide family information: educational orientation programs, classes that provide social support and information about illness management and recovery, informational packets, or unit tours. Learning the balance between too little and too much information and how to deliver it is an important skill for acute care nurses to learn (Goodell & Hanson, 1999). Additionally, nurses should consider the nature of the information to be conveyed to the family when deciding the best way to provide the information. In a study of 390 families of patients who died in an ICU, researchers found that the majority of the respondents (82.6 percent) expressed no criticism of the patient’s hospital stay, 17 percent felt the information received concerning diagnosis was insufficient or unclear, and 30 percent expressed dissatisfaction regarding the information received on the cause of death (particularly among family members who were informed of the death by telephone and not in person) (Malacrida et al., 1998). A face-to-face meeting may best convey information about patient progress or prognosis, and perhaps information about self-management activities or visiting hours can be best addressed in a classroom setting or in a booklet.
Investigators have tested the effectiveness of interventions to meet informatioeeds. For example, Medland and Ferrans (1998) tested a structured communications program for family members to determine whether the program would increase family members’ satisfaction with care, meet their needs for information better, and decrease disruption for the ICU nursing staff caused by incoming calls from family members. The intervention consisted of three components: (1) a discussion with a nurse approximately 24 hours after admission of the patient, (2) an informational pamphlet given at the time of the discussion, and (3) a daily telephone call from the nurse who was caring for the patient that day. The number of incoming calls from family members was significantly lower in the experimental group than in the control group. In the experimental group, satisfaction with care increased significantly from before to after the test, as did the members’ perception of how well their informatioeeds were being met (Medland & Ferrans, 1998).
Another group of investigators examined the effects of a communication team intervention on length of stay and costs for patients near the end of life in the intensive care unit (Ahrens, Yancey, & Kollef, 2003). The communication team—a physician and a clinical nurse specialist—provided daily medical updates, shared medical advice regarding treatment, and provided other information to families as needed. Compared with the control group, patients in the communication intervention group had significantly shorter stays in both the intensive care unit and the hospital and had lower fixed and variable costs. The researchers suggested that the provision of clear and direct information led to early discussion of options and support. As a result, more families elected to withhold life-prolonging treatments, resulting in decreased lengths of stays and costs.
Other findings suggest videotapes, nurse-coached volunteers, visual pamphlets, or individual counseling sessions as useful ways to impart information (Appleyard et al., 2000; Lenz & Perkins, 2000; Petterson, 2000; Oermann, Webb, & Ashare, 2003). Increasing numbers of nurses are evaluating technological methods to provide information to families. Technologies that are being explored to enhance communication with families, and to meet their informatioeeds, include the Internet, pagers, e-mail, and telephone help lines (Carlsson, Strang, & Lindblad, 1996; Olson, 1997; Topp, Walsh, & Sanford, 1998; Brennan et al., 2001; Jones & Brennan, 2002; Artinian et al., 2003).
Before providing any information, however, it is important to use relevant cues to assess for illiteracy and modify methods of providing health information when appropriate (Artinian, Lange, Templin, Stallwood, & Hermann, 2003).
Culture and Expression of Family Needs
Family Need for Visitation during Hospitalization
Families of patients in hospitals, particularly in critical care units and emergency departments, spend a great deal of time waiting for news about their loved one. Waiting has been linked with dissatisfaction with health care services (Bruce, Bowman, & Brown, 1998). In a qualitative study designed to describe the experience of waiting, researchers found families were diligently watchful—not wanting to go far for fear of missing information (Bournes & Mitchell, 2002).
Families reported the experience of waiting as “distressful,” “horrible,” “brutal,” and “terrible.” Unfortunately, restrictive visiting policies exacerbate families’ feelings of distress. During the period of acute illness, families usually encounter restrictive hospital visiting policies. They may not be able to visit their loved one in the hospital when it is convenient for them or when their work schedule permits, and frequently, they must rearrange their plans and routines to fit the policies set by the hospital. Originally, hospital visiting periods were limited so that the patient could rest and recover. However, a sound scientific basis for restricting visiting hours does not exist (Slota, Shearn, Potersnak, & Haas, 2003). In fact, one study found that “restricting visits to short time periods and terminating visits prematurely contribute to adverse hemodynamic responses in critically ill patients” (Titler & Walsh, 1992, p. 625).
Another study found that patient control of family visiting in a coronary care unit (CCU) had positive effects (Lazure & Baun, 1995). Results showed that, over time, perceived control of visits and rests between visits were greater, and heart rate and diastolic blood pressure were lower, for subjects who used a visitor control device. Thus, a combination of patient and family factors may influence the nature of family visits in a CCU.
Chronic Illness
Chronic illness imposes another set of concerns for families. A chronic illness refers to any physical or mental condition that requires long-term (more than 6 months) monitoring and/or management to control symptoms and to shape the course of the disease (Corbin, 2001). Many factors influence the effect of chronic illness on families: the type of illness, the stage of illness, the structure of the family, the role of the patient, the life-cycle stage of the patient, and the lifecycle stage of the family (Biegel, Sales, & Schulz, 1991; Young, 1995).
The entire family system is affected when chronic illness strikes. “Normal patterns of interaction are disrupted, and there are often reassignments in tasks and roles assumed by particular family members” (Biegel, Sales, & Schulz, 1991). The family must reorganize itself around the chronic illness or disability (Steinglass, 1992). Families may make changes related to work schedules, household tasks, or provision of family income or in interpersonal areas, such as solidarity and belonging, sexuality, and love (Leventhal, Leventhal, & Nguyen, 1985).
Families and patients face both social and psychological challenges during the course of chronic illness (Hanson, 1988; Biegel, Sales, & Schulz, 1991). These include the following:
• Preventing medical crises and managing them once they occur
• Controlling symptoms
• Carrying out prescribed regimens
• Preventing or living with the sense of isolation caused by lessened contact with others
• Adjusting to changes in the course of the disease
• Normalizing interactions with others and finding the necessary money to pay for treatments or to survive, despite partial or complete loss of employment
• Confronting attendant psychosocial, marital, and familial problems
Families in the chronic phase may have to deal with a member’s illness for a long time—an illness that may be constant, progressive, or episodic iature. A key family task is to maintaiormal life in the “abnormal” presence of this chronic illness and the resulting heightened uncertainty (Rolland, 1988).
Jennifer A. Jilks – Palliative diagnosis essential in US, in Canada: Patient Trajectory
As they manage their family member’s illness on a day-to-day basis, families become expert caregivers. Exacerbation of a chronic illness, when it leads to hospitalization, brings expert family caregivers in contact with the health care team. Researchers have analyzed relationships between the family and the health care team from the perspective of the family members and found that these relationships moved through three stages (Thorne & Robinson, 1988). These stages reflected shifts in family trust of health care professionals. Family members who had not had much experience with chronic illness described the first stage, naïve trusting. These family members trust that health care professionals have the same perspective about caring for their ill member that they did. Families believe that their involvement on a day-to-day basis as the primary health care providers will be acknowledged and respected and that professionals will be cooperative and collaborative. Family members naively trust that health care professionals will act in their ill member’s best interests. Over time, however, family members learn that their long experience is often disregarded, as is their involvement and expertise in illness management.
The second stage, the disenchantment phase, is characterized by dissatisfaction with care, frustration, and fear. Families find that it is difficult to be effectively involved in care because they have difficulty obtaining information. As trust diminishes, family relationships with health care professionals become adversarial, and families see their ill member as vulnerable and needing protection.
During the last stage, the guarded alliance phase, families renegotiate trust with health care professionals. They actively seek information and understand the differences in their perspective and that of health care professionals. Families are able to state clearly their own expectations and perceptions, an ability that leads to more satisfying care. Families and health care professionals develop a partnership in care. Nevertheless, families still experience the frustration of waiting, fear that they will not know the right questions to ask, and anger at the recognition that their own expertise is devalued.
Interventions for families experiencing chronic illness may focus on the family’s cognitive, affective, and behavioral levels of functioning (Boise, Heagerty, & Eskenazi, 1996; Wright & Leahey, 2000). Cognitive interventions include giving information about the chronic illness and its treatment, giving advice about potential family responses to the illness (e.g., need for respite, possible strain on family relationships), giving information about community resources, and helping with family decision making.
Affective interventions are designed to modify intense emotions, such as guilt or anger, which may block a family’s problem-solving efforts (Wright & Leahey, 2000). They include validating family members’ emotional responses and helping them understand that those responses are normal, discussing with families ways to reduce their isolation, referring families to an appropriate support group, helping families open channels of communication, and helping families identify and mobilize their strengths and resources. A family’s response of denial or lack of hope in the future has been identified as a major obstacle to successful patient adaptation. The hopeless family may be unable to make the necessary changes at home or learn the important aspects of the patient’s care. Nurses should devise hope-facilitating strategies.
Interventions targeted at behavioral functioning are designed to help family members interact more effectively (Wright & Leahey, 2000). This goal can be accomplished by assigning specific behavioral tasks to some or all family members (Leahey & Wright, 1987; Wright & Leahey, 2000). In a recent study of 40 family members of patients 65 years or older who had been hospitalized for more than 2 days, the investigator found that 95 percent of family members preferred to participate in care and daily care activities (Li, 2002). Families may need help to coordinate responsibilities for particular caregiving activities (Gilliss, Rose, Hallburg, & Martinson, 1989).They may also need caregiving training to feel comfortable with the tasks at hand.
End-of-Life Care
Sometimes nurses in medical-surgical settings encounter families who are coping with patients at the end of life. Knowledge about the process of dying can help nurses work effectively with families during this very difficult time. Family members have reported the experiences of a family member’s death as including a downward spiral of prognoses, difficult decisions, feelings of inadequacy, eventual loss despite the members’ best efforts, and perhaps no good-byes (Kirchhoff et al., 2002). The more the nurse knows about the family, the better, because the way a family deals with death is affected by cultural background, stage in the life cycle, values and beliefs, the nature of the illness, whether the loss is sudden or expected, the role played by the dying person in the family, and the emotional functioning of the family before the illness (Rosen, 1990; Leonard, Enzle, McTavish, Cumming, & Cumming, 1995). This knowledge of families will help nurses provide more-sensitive care as they move through the phases of end-of-life adaptation.
Phases of Adaptation
Families move through three phases of adaptation in response to the news that a family member has a fatal illness (Rosen, 1990). Various emotional responses may emerge during these phases, including disorganization, anxiety, emotional lability, or turning inward. The first phase is the preparatory phase. This phase begins when symptoms first appear and it continues through the initial diagnosis. During the preparatory phase, families experience fear and denial and may refuse to accept the prospect of death. Some family members decide to withhold all information from those whom they consider vulnerable, such as children or elderly parents (Rosen, 1990). During the period of initial symptoms, diagnosis, and treatment plan, the family may be highly disorganized and display emotional instability.
Once the family accepts the prospect of loss and begins to live with the reality of the fatal illness and the caretaking tasks of the illness, it moves into the middle phase. Families live the day-to-day challenge of dealing with physical symptoms, treatment, and care (Rosen, 1990). The family becomes less disorganized; indeed, it reorganizes to assume new roles. On the other hand, the tedium of daily care may tax the physical and financial resources of the family. If hospitalizations are lengthy or frequent, the logistics of visitation may create discord among family members (Rosen, 1990)—some members of the family may feel that others are visiting too little or too much—and unresolved family issues from the past may emerge. The final stage, acceptance, arrives when the family accepts the imminent death and concludes the process of saying farewell. Family emotions that surfaced during the first phase but subsided during the middle phase may resurface. Family members may draw together in anticipation of their loved one’s death (Rosen, 1990).
Nurses can help families with a dying relative by informing them that it is natural to pass through phases of adaptation and that they can expect to address complex issues in each phase of a fatal illness. Helping families accept their feelings and directing them to appropriate resources, such as a hospice, family support groups, social workers, and family conferences, may be useful.
Meeting Family Needs Before Death
Meeting family needs is also important. Needs of families of dying patients include the following:
1. To be with the dying person and to provide help to the dying person
2. To be informed of the dying person’s changing condition and to understand what is being done to the patient and why
3. To be assured of the patient’s comfort and to be comforted
4. To ventilate emotions and to be assured that their decisions were right
5. To find meaning in the dying of their loved one 6. To be fed, hydrated, and rested (Truog et al., 2001)
Although not always possible, a private room is most conducive to family emotional and physical intimacy. Usual restrictions on visitation should be relaxed as much as possible. Providing the family with an electronic pager or cellular phone may allow family members to take a break for a while without feeling out of contact (Truog et al., 2001). Attention to family well-being by providing tissues, blankets, coffee, and water is also important (Truog et al., 2001).
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