The nursing leadership of our ICU and Coronary Care Unit (CCU) realized that the time had come to conduct a true nursing research study. Nursing staff in the units readily supported and participated in multidisciplinary research and were ready to engage in their own research project. Shortly thereafter an opportunity presented itself.

An opportunity

Our leadership team joined a voluntary collaborative on Improving Quality of Care and Communication in Intensive Care Units, sponsored by the New Jersey Hospital Association (NJHA). This work led to the creation of an ICU Patient and Family Communication Bundle (a bundle consists of a group of best practices that when applied together result in significant improvements in patient outcomes) to promote delivery of high-quality end-of-life (EOL) care in the ICU.

The idea for the unit’s first nursing research project evolved from development of the bundle. We considered that the assessment of quality EOL care was an essential step in planning evidence-based interventions for future improvements of the bundle. We also anticipated that study results and subsequent improvements in care would increase staff expertise and enhance staff satisfaction through their participation in culture change and by helping patients and families navigate through some of the most difficult moments in their lives.

This group of critical care staff nurses became novice researchers and went forward energetically with the project titled “The Effect of a Multidisciplinary Education Program on Documentation Compliance of an ICU Patient/Family Communication Bundle Related to End-of-life Care.”

Forging forward

We were fortunate to have a culture of supportive administrators, physicians, research coordinators, and statisticians in place to help push the project forward. The study was a chart review using a three-group comparative design to test the effectiveness of a comprehensive education program. This design was perfect for a first project, and participation by staff in the study was greater than anticipated. Our group became busy with first steps—writing up the proposal for submission to the Institutional Review Board (IRB) and obtaining National Institutes of Health (NIH) human subjects approval and certification for the nurses who would review the charts.

Our research mentor assisted from the onset, since no one on the unit had any research experience other than in the classroom. She served as a constant support, providing needed encouragement when the project faced barriers, most of which were time constraints.

Events at the hospital often took priority over the research study and the group faced delays in accomplishing goals in data collection. The ICU moved to a newly constructed building and the staff was involved in every aspect of the project from design of the unit to planning the safe move of every ICU patient from the old unit to the new. Next, the hospital implemented an electronic health record. Again it was necessary to involve everyone in the education and safe roll out of the new documentation system. Despite these major projects and delays, the group took every opportunity to push data collection forward.

Unexpected benefits

On our way to completing the study, we found unexpected benefits in the form of projects based on ideas stemming from information and discussion about components of the communication bundle and the study’s educational intervention.

Revision of brochures. Both the ICU and CCU revised their Guidelines for Visitors brochure and created a separate ICU Patient/Family Communication brochure as a result of the study in progress and the associated collaboration with the NJHA. The communication brochure discussed the different ways information would be relayed to patients and families as well as definitions of key terms families might hear in a meeting discussing the plan of care for their loved ones. These projects correlated with the bundle component related to patients and families being oriented to the unit and given an information brochure.

Memory box. The next result was that one staff nurse championed an idea from a neurocritical care unit at Riverside Methodist Hospital in Columbus, Ohio, which had developed a memory box project. The memory box fit into two key areas identified by the ICU collaborative and were also part of the education intervention for the research project related to the objectives of:

• effective communication to achieve patient and family driven care and
• to provide emotional and spiritual support for family as well as staff.

The box is about the size of a shoebox and has an imprinted design. It’s lined with matching tissue paper to cushion the contents, which include a scented sachet for under the patient’s pillow and a scented candle for the family to take home with them.

The box also contains a purse string bag for a lock of hair if the family desires and, depending on cultural and spiritual considerations, either the well-known “Footprints” story on parchment paper or a nondenominational inspirational quote. The patient’s handprint is traced onto the paper. Each nurse decides individually which components of the box are appropriate to use.

Before giving the box to the family, the nurse removes a sympathy card, which is then sent 5 days after the patient dies with signatures from the staff who were involved with the patient’s care.

We thought it important and significant to give a gift that holds memories of a peaceful and dignified death. In addition to the goal of the ICU Research project, the memory box serves a secondary goal, the cultivation of caring nurses who enhance outcomes. The box has now become a caring tradition integrated into the unit’s culture.

Patient safety checklist. Another unpredicted positive result of the collaborative and the nursing study came in the form of the Critical Care Daily Patient Safety Checklist. This effort recognized the importance of having a process in place that not only fosters excellence in patient care, but also contributes to the creation of a healthy work environment.

The Critical Care Patient Safety Checklist is limited to 5 topics. Our unit-based council, along with our physician leadership, selected the topics. The communication bundle specified the healthcare proxy/spokesperson be identified and that a family meeting be planned within an early admission timeframe; having “communication” on the checklist ensure this component of the bundle was met. Other topics include central line assessment, antibiotics, restraint review, and consultation with physical/occupational therapy.

Research has shown that daily goal checklists improve patient outcomes and decrease length of stay and mortality rates. The use of a “prompter” (one of our ICU nurses) fosters effective communication in interdisciplinary rounds and ensures that the needs of the patient and family are foremost.

As part of the education regarding the checklist, Deputy Safety Nurse Badges were distributed as a visible sign that nurses are empowered to speak up and initiate crucial conversations. This reinforced their nurse advocate role and accountability, to self and others.

Communication in patient’s electronic record. Last, work began to integrate the ICU Patient and Family Communication bundle into the electronic health record. Additionally, a note category, similar to a progress note called Patient/Family Communication was created. Physicians, nurses, and other disciplines use the note to record vital information pertaining specifically to communication with families. The note can take the form of a family meeting template or simply a general note. The purpose of this note is to simplify the ease by which information specifically pertaining to family meetings and/or other pertinent family information can be found.

Multiple positive outcomes

In retrospect, these unforeseen positive outcomes seem to dwarf the actual results of the study, even though they were positive as well. The education intervention was effective. Evidence from the study suggests that patients’ wishes for care are being communicated through family meetings and regular updates. Clear documentation of goals of care continues as an essential component of ICU/CCU care on the Critical Care Daily Patient Safety Checklist.

Overall, the results noted have implications for improved care for future patients and families in the ICU as well as benefits to those providing that care. Our research project, with its focus on issues such as communication, end of life, and nursing advocacy, helped to promote quality of care in a number of areas. Despite the idea that a nurse-driven research study may seem daunting, our experience demonstrates it can be rewarding in many ways from improvements in patient care to empowerment of nurses.

Janette McFetridge is associate clinical director for the ICU/CCU at Cooper University Health System in Camden, New Jersey.

Selected references
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Yeager S, Doust C, Epting S, et al. Embrace hope: an end-of-life intervention to support neurological critical care patients and their families. Crit Care Nurse. 2010;30(1):47-58.