Families and Healthcare: What Do You Think?

netglow, ASN, RN · Feb 26, 2011

I think she was telling you that once you start explaining the detail of monitors and ranges, the family might just start to call and question you every time there is a change. This, if it gets out of control will make it a freaking nightmare for all nurses all shifts to work with the patient and the family. Often times, this starts a downhill free fall where the family begins to demand you treat or not treat off of how they analyze the information they now see - they become instant "intensivists". As soon as you kindly disagree and explain why/why not, they often become totally insulted. Why, you ask? Well, because they now subconsciously believe they have medical knowledge. All the stress and worry they have kind of starts this mini psychotic dream for them. Trust me, it can be a total nightmare for all staff if this happens.

merlee · Feb 26, 2011

I think that your preceptor is trying to teach you some things, just as you are trying to teach the family.

Sometimes too much info is overwhelming. For all of you!

When you have a large group to deal with, make sure that ONE person is the liason for thw whole group. When you tell that person anything, have her say it back to you in mainly her own words, so you are certain she underrands.

Best wishes!

nurse2033, MSN, RN · Feb 26, 2011

I think it is wrong for the preceptor to tell you you are giving too much information. She could have framed that statement differently. What she probably meant is just to be more general. She is right, you are not orienting the family to work there. You should give information appropriate to their abilities, which you assess as you go. They don't need to know the action and doses of all the pressors that are being used, just that we are supporting blood pressure with medications, for example. If they are highly educated or have medical knowledge that might be different. She is right also that you don't want the family micro-questioning care and every action that you and subsequent nurses make. I wouldn't take this too hard, this is a very complex and difficult job and this is only one aspect of it. Good luck.

Ruby Vee, BSN · Feb 26, 2011

the family, who are not very educated and not as capable as most to do and to have access to research, visit frequently. i inform them that they can ask questions if they have any and they almost immediately begin asking me questions such as "what are these numbers on this machine (talking about the ventilator) and why are those numbers different from these numbers (talking about the vital signs being consistently read in comparison to the numbers on the ventilator)?" i explain to them how the ventilator works, why the numbers are different on the two machines, and why the patient needs these machines during his stay in the icu in as elementary terms as possible. the family also begins to ask about how his vital signs have been doing, if these numbers are good, and if any significant changes have happened over the patient's stay. i explain to them exactly what each vital sign was, how they are read, what the normal ranges for each are, how some of the medications are helping these vital signs stay wnl, and why we need to reinterpret them so frequently. as i was explaining this, my preceptor interjects by saying that she needed to show me something in another area, pulled me to the side, and proceeded to reprimand me for giving the family too much information. she told me that with all of this information the family might make judgments about our care or begin to think that we were attempting to make the patient dnr (which i really didn't understand). she proceeded to tell me to keep it simple and to not disclose so much information about this patient's care.

i'm interested in what you're not saying about the family -- do they not have education and access to research because they're poor? (the public library is free). or because they're not very bright?

i think that if the latter is the case, you did indeed give them too much information -- not because they're not entitled to information, and not because they might "make judgements" but because they probably don't have the background to understand everything you've told them. and now you've created a situation where a family is going to sit and stare at the monitors and ventilator and react to the numbers. every nurse who follows you will be treated to "dreamsdocometrue said that number should be a 99 and it's a 94. is that bad? how come you're not doing something about it?" or "yesterday that number was 16 and today it's 14. is that good?"

families, for the most part, don't need to know all the "numbers" and the normal ranges. what they're most interested in (or should be, anyway) is how well mom is doing. i would have told them that "we're monitoring her vital signs and her breathing, and today she's doing just a little bit better. we're having to use less of the blood pressure medication to keep her blood pressure where we want it, and she's doing more of the work of breathing on her own. our plan for today is to get rid of some of the extra fluid she has that's making her so puffy -- we'll give her a medication to make make her pass more of the fluid out in urine. and we plan to improve her breathing muscles by letteing her do more of the work for a few hours, and then we'll let her rest for awhile. those numbers let me monitor how much of the work she's doing, and i'll be able to tell when she starts to tire out so we can let her rest." or whatever your plan for the day might be.

i'd rather have a family looking at the big picture -- is mom getting better or not? and is her breathing improving or not? -- than focusing on numbers that they don't understand and pestering whoever is taking care of mom to explain each change in the numbers.

besides, looking at the numbers can make you crazy. i make sure i don't look when the patient is my family member! or at least not to stare at them, transfixed, when i should be looking into mom's eyes and reassuring her that i love her.

loriangel14, RN · Feb 26, 2011

I think what you did was awesome and the preceptor was wrong for wanting you to keep the family in the dark. It would be less confusing and less scary for the family if they understood a little of what they were seeing. I do agree with the posters that suggested not going into too much detail and overwhelming the family but I think attempting to educate is better than not sharing any information. Good job.

Altra, BSN, RN · Feb 26, 2011

Excellent post above from Ruby Vee.

Consider your own nursing education and your developing clinical judgement: it didn't happen overnight, did it? It is equally unrealistic to expect families without a background in health care to instantly grasp the pathophysiology of whatever has landed their loved one in the ICU. And that has little to do with their intelligence level.

Acute and critical care are complex. Any given parameter - a vital sign, or any value on any monitor - often has limited value in and of itself. It is considered with all other available data in the big picture assessment of the patient, relative to prior history and relative to the goals of the patient's individualized treatment.

So while it is natural for families to ask about equipment and specific numbers on the monitors -- and I always answer direct questions directly, BTW -- I would strongly caution you to be mindful of the amount of detail you are providing and whether or not it is likely to really increase a family's comfort with their understanding of the big picture -- which is whether or not the patient is getting better.

Consider those things and then ask yourself the questions you raised in your post:

Did I go too far?

Did I give too much information to the family?

Does the family deserve to know this information?

Isn't it our jobs as nurses to be patient advocates and give the family as much information and teaching as possible to help them understand that we are doing all we can to help their loved one? And if so, why was my preceptor so adamant about me giving the family too much information?

Did the details of numbers on the monitors, drug dosages, etc. increase the family's real understanding? Did it increase their comfort level or further raise their stress level? And did you ask your preceptor for further explanation?

Is my preceptor feeling guilty about something and therefore not comfortable with disclosing information about this patient's care?

Probably unlikely ... but did you ask him/her?

Is this teaching and education within our scope of practice?

Lots of things are within our scope of practice -- it doesn't mean that they are necessary, or are the best course of action.

Was I wrong to inform the family of and keep the family informed of the patient's situation?

What specific verbiage is likely to best meet the goal of truly *informing* the family so that they have more meaningful information than before? And is *information* the same as *data*?

linearthinker, DNP, RN · Feb 26, 2011

I think you probably did go a little overboard. KISS principle applies. The most important thing to make family understand is that numbers themselves are meaningless most of the time. I always emphasized trends going the way we wanted them to, or not. Not to mention, I never had time to provide abridged pathophysiology classes. And the truth is they probably misunderstand most of what they hear and only get more anxious than they already were.

2011NursingStudent · Feb 26, 2011

Many people really appreciate when nurses take the time to explain to them what's going on, and don't assume they "don't need to know". You should never change!!! When my son was in the hospital and nearly lost his fingers due to a vascular injury, there were nurses that came into the room and acted like he was a checklist, couldn't take the time of day to say anything but "We're working on it", "Don't worry", etc. and I continued to sob and worry.

Then there was a nurse who TOOK THE TIME to explain to me that what I was most concerned about - my sons losing fingers, was not as imminent as I had thought because a small amount of blood was still getting to the fingers through other smaller veins.

So please, whatever all the other nurses say about giving general answers and trying to do everything as quickly as possible - don't listen. You will be the kind of nurse families remember and talk about for years as having been the phenomenal nurse that took such good care of their loved one and provided them whatever peace of mind that you could afford to give them.

silentRN · Feb 26, 2011

I had a family walk in the room and look at the vital signs on the monitor and the vital signs were always fine...the problem wasn't with the rest of his body, but with his brain. The kid had no neuro function. One side of the family understood, but the other side thought he would recover because his 'vitals' were ok. They eventually decided to withdraw, but it's always good to explain things to the family. There were several times when I went over my neuro exam with the mother alone to show her the reality of it all.

porterwoman · Feb 27, 2011

Some ways you can redirect those questions about numbers & details:

-you can shift their focus to Mom the Person, not Mom the patient: "I know you're very worried about Mom and a lot of times families become really focused on numbers and values. Let us worry about those. Your job right now is to be here and be present with Mom."

-you can acknowledge their worry/fear/etc. and encourage them to voice their concerns: "This can be so overwhelming. Sometimes families focus on the numbers in order to have something to focus on and help keep this from being so scary."

-you can give general information, trends: "Since yesterday, we've come down on the amount of support Mom's getting from the breathing machine. Her blood pressure has been low overnight, so we've had to come up on the medicines keeping her blood pressure up. Overall, she's still very sick."

-And definitely assess their knowledge base first: "When's the last time you had an update? From what you know right now, what do you see is happening with Mom right now?"

Kind of like teaching little kids about sex--figure out exactly what it is they're really asking, give just enough information to answer it, reassure them, and keep all the technical stuff to yourself.

Good luck. Pt & family teaching in the ICU can be especially daunting.

2011NursingStudent · Feb 27, 2011

Some ways you can redirect those questions about numbers & details:
-you can shift their focus to Mom the Person, not Mom the patient: "I know you're very worried about Mom and a lot of times families become really focused on numbers and values. Let us worry about those. Your job right now is to be here and be present with Mom."
-you can acknowledge their worry/fear/etc. and encourage them to voice their concerns: "This can be so overwhelming. Sometimes families focus on the numbers in order to have something to focus on and help keep this from being so scary."
-you can give general information, trends: "Since yesterday, we've come down on the amount of support Mom's getting from the breathing machine. Her blood pressure has been low overnight, so we've had to come up on the medicines keeping her blood pressure up. Overall, she's still very sick."
-And definitely assess their knowledge base first: "When's the last time you had an update? From what you know right now, what do you see is happening with Mom right now?"
Kind of like teaching little kids about sex--figure out exactly what it is they're really asking, give just enough information to answer it, reassure them, and keep all the technical stuff to yourself.
Good luck. Pt & family teaching in the ICU can be especially daunting.

Granted, I have a greater interest in science and technology than most, but having someone talk to me like I was a child and tell me "my job is not to worry about the numbers" would cause me to be incredibly angry/frustrated. I guess it depends on the person - some people that would fly for, others its absolutely the wrong approach and the implication that technical/specific knowledge/information would be "too much" for a family member to handle would make me want to change hospitals.