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Comfort and religious-spiritual coping of intensive care patients’ relatives
Intensive & Critical Care Nursing xxx (xxxx) xxx
Contents lists available at ScienceDirect
Intensive & Critical Care Nursing journal homepage: www.elsevier.com/iccn
Research article
Comfort and religious-spiritual coping of intensive care patients’ relatives Silmara Meneguin a,⇑, Camila Fernandes Pollo a,b, Cariston Rodrigo Benichel a,b, Larissa Kazitani Cunha a, Hélio Amante Miot a a b
Botucatu Medical School, Paulista State University – Unesp, São Paulo, SP, Brazil Paulista State University – Unesp, São Paulo, SP, Brazil
a r t i c l e
i n f o
Article history: Received 13 May 2019 Revised 7 January 2020 Accepted 10 January 2020 Available online xxxx Keyword: Spirituality Family Intensive Care Units Nursing
a b s t r a c t Objectives: To identify the level of comfort and religious-spiritual coping of family members of intensive care unit patients and to analyse the sociodemographic/clinical variables that influence this association. Methods: Cross-sectional study on the adult and paediatric intensive care units of two public hospitals in the state of São Paulo, between January and September 2016. Participants were divided into two groups: adult (n = 96) and paediatric (n = 70). We used the religious-spiritual coping brief (RSC-Brief) and the comfort scale for relatives of people in critical states of health (ECONF). Results: Comfort was low in both groups and the family members used limited strategies in the RSC-Brief. The multiple linear regression analysis indicated that the variable length of hospitalization (b = 0.69; p < 0.01) influenced comfort and was also associated with the RSC-Brief (b = -0.18; p < 0.01). Conclusion: Family members’ comfort was low in both groups. It increased with the hospitalisation time of the patients’ relative and tended to decrease with the severity of the disease. Ó 2020 Elsevier Ltd. All rights reserved.
Implications for clinical practice In view of the lack of studies involving family members’ comfort and religious-spirtual coping, factors that influence comfort and coping can guide nursing proposals focused on the family members. Length of hospitalisation is a important variable that influences comfort and religious-spiritual coping. It is necessary to have more concern for family members of intensive care unit patients. The comfort and religious-spiritual coping perceptions are highly individual.
Introduction The Intensive Care Unit (ICU) stands out in the hospital context because of its advanced equipment and technology necessary to care for critical care patients (Edeer et al., 2019). Nevertheless, this care model ends up imposing restrictive measures, which not only do not permit patient care in all of its forms, but also ignore the family members’ needs as individuals and care ⇑ Corresponding author at: Departamento de Enfermagem da FMB-Unesp, Distrito de Rubião Jr s/n, 18618-000 Botucatu, SP, Brazil. E-mail address: [email protected] (S. Meneguin).
subjects. In addition, the family members also need to be considered as individuals exposed to stress situations, who need actions to promote their comfort, as they suffer together with their relative (Twohig et al., 2015; Al-Mutair et al., 2014). Although the term comfort often appears in the nursing literature, few studies have sought to examine it. Comfort is a holistic, subjective and multidimensional concept, with influence from the physical, environmental, social and psychospiritual contexts, which changes in time and space (Kolcaba, 1994). It results from the individual’s interactions with the self, the surrounding people and situations faced in the disease and health care process (Freitas et al., 2012).
https://doi.org/10.1016/j.iccn.2020.102805 0964-3397/Ó 2020 Elsevier Ltd. All rights reserved.
Please cite this article as: S. Meneguin, C. F. Pollo, C. R. Benichel et al., Comfort and religious-spiritual coping of intensive care patients’ relatives, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2020.102805
2
S. Meneguin et al. / Intensive & Critical Care Nursing xxx (xxxx) xxx
In these circumstances, family members often turn to religion and spirituality as a source of comfort and support, mainly in chronic or end-of-life situations (Wall et al., 2007). Religion and spirituality are often adopted as constructs to cope with the stress the ICU hospitalisation of a patient causes. Although distinct, they are closely intermingled. Spirituality is considered to be a person’s essence, a search for meaning and purpose in life; while religiosity is the expression of spirituality itself through rituals, dogmas and doctrines (De Paula et al., 2009; Valcanti et al., 2012). In this context, religious-spiritual coping (RSC) refers to the use of faith, religion or spirituality in coping with stressful situations or crisis moments across the lifetime. Therefore, its study should be broad and based on a functional view of religion and the role it plays in coping (Harris et al., 2013). Although the religious coping concept comes with a positive connotation, it can be both positive and negative; the same is true for its strategies. The positive connotation groups measures that benefit the individual; while the negative connotation is related to measures that entail harmful consequences for the individual, such as questioning his existence, delegating problem solving to god, defining the stress condition as a punishment from God, among others (Mesquita et al., 2013). The relation between the comfort of ICU patients’ relatives and religiosity has not been well explored yet in the literature. Research has merely looked at the influence of religion as a coping strategy by the relatives of ICU patients (Schleder et al., 2013; Dreffs, et al., 2013). The hypothesis of the study is that the perception of comfort and RSC is influenced by the religiosity-spirituality and sociodemographic variables of the family members of patients hospitalised in intensive care units, as well as by the profile of the patients. In light of the above, this study aimed to identify the level of comfort and religious-spiritual coping of family members of intensive care unit patients and to analyse the sociodemographic/clinical variables that influence this association.
A relative was defined as the person indicated as the closest to the patient, with or without blood bonds, who lived with them and maintained a close relationship.
Methods
Initially, all variables were analyzed descriptively. To compare the means of the RSC-Brief and Comfort scores between groups, Student’s t-test was used. The reliability of the questionnaires ECONF was tested by Cronbach´s alpha, and considered adequate if greater than 0.7. The variation in the RSC-Brief and comfort scores was assessed in view of the clinical and demographic variables by means of a generalised linear model. Spearman’s t-test was applied to explore the correlation among the variables. The analyses were developed in IBM SPSS, version 22. Significance was set at 5%.
Study design An exploratory, cross-sectional and comparative study with a quantitative approach was undertaken. Participants and setting The study was developed for the general adult and paediatric ICU of two public hospitals in the state of São Paulo, offering 16 beds adults and 15 beds paediatrics for clinical and surgical patients. Both ICUs have restricted visiting hours. The sample included consecutive family members who visited the ICU between January and September 2016. The inclusion criteria were: family members of both genders; aged 18 years or over; with a relative hospitalised in the ICU in the period between 72 hours and seven days; availability and in self-referred emotional conditions to answer the questionnaire and agreeing to participate in the research. Relatives who did not fully complete the data collection instrument were excluded. The participants were divided in two groups: Group I: family members of patients attended at the Adult ICU; Group II: family members of patients attended at the Paediatric ICU. The participants’ separation into two groups was due to the intense suffering caused by a child’s hospitalisation in a paediatric ICU, in view of the possibility of a definitive loss. In addition, the family’s power over and autonomy regarding the child are reduced, leading to feelings of suffering (Côa and Pettengill, 2011).
Data collection Sociodemographic/clinical data of the patients were obtained by consulting the medical records and the family members during the interview. In order to assess the comfort level authors used the Comfort scale for relatives of people in critical states of health (ECONF), which consists of 46 items, distributed in three dimensions: Safety, Support and Interaction between the relative and the patient. The answers vary on a 0 to 5 Likert scale. The score is divided as follows: <4.19 little comfort, 4.20–4.59 medium comfort and superior to 4.6 high comfort (Freitas, 2011). The RSC scale is a North American 92-item tool, originally denominated RCOPE (Pargament et al., 2000), whose brief version was validated for the Brazilian culture (Panzini and Bandeira, 2005). The RSC-Brief contains 49 items, divided in two main dimensions: Positive RSC (transformation of one’s self and/or one’s life; actions in search of spiritual help; supply of help to the other; positive position towards God; actions in search of the institutional other; personal search for spiritual knowledge; distancing through God, religion and/or spiritualities) and Negative RSC (negative reassessment of God; negative position towards God; negative reassessment of the meaning; dissatisfaction with institutional other). The answers range from 1 to 5 points on a Likert scale, as followed: from 1.0 to 1.5 none or negligible, 1.51 to 2.50 low; 2.51 to 3.50 average, 3.51 to 4.50 high and 4.51 to 5.0 very high (Panzini and Bandeira, 2005). The questionnaires were completed in a private room near the ICU, individually. If impossible, an appointment was made at each relative’s personal convenience. Statistical analysis
Ethical approval The data were obtained after the Institution’s Research Ethics Committee had approved the project under number 96950 and after the participants had signed a free and informed consent form with the information about the research. Results Based on the recruitment criteria, 170 family members were approached, four of whom declined to participate in the study. Thus, the sample consisted of 166 participants, being 96 in group I and 70 in group II (Table 1). In both groups there was a greater percentage of female participants, active catholics and those who had a partner. Most family members in the group II were direct relatives 50 (71,5%), lived with the patient 50 (71.4) and had no previous experience with a family member’s ICU hospitalisation (67.1%).
Please cite this article as: S. Meneguin, C. F. Pollo, C. R. Benichel et al., Comfort and religious-spiritual coping of intensive care patients’ relatives, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2020.102805
S. Meneguin et al. / Intensive & Critical Care Nursing xxx (xxxx) xxx Table 1 Sociodemographic characterisation of relatives according to the groups 2016. Variable
Group
Age (years) Mean (±SD) Gender Male Female Marital status With partner No partner Education Complete/incomplete primary education Complete high school Complete higher education Religion Catholic Non Catholic Employment situation Employed Unemployed Degree kinship Direct Indirect Previous hospitalization of relative at ICU Yes No Lives with the patient Yes No Income Average Min-Max
I N (%)
II N (%)
46.60 (±16.05)
33.58 (±10.8)
38 (39.6) 58 (60.4)
16 (22.9) 54 (77.1)
80 (83.3) 16 (16.7)
55 (78.6) 15 (21.4)
38 (39.5 46 (48.0) 12 (12.5)
39 (55.7) 27 (38.5) 4 (5.8)
49 (51.0) 47 (49.0)
37 (52.9) 33 (47.1)
60 (45.8) 36
38 (44.3) 32
36 (37.5) 60 (62.5)
50 (71.5) 20 (28.5)
41 (42.7) 55 (57.3)
31 (44.3) 39 (55.7)
47 (48.9) 49 (51.1)
50 (71.4) 20 (28.6)
2191.8 500–9200
1393.3 0–4000
In both groups the patients, whose relatives took part in the study, were medical (non-surgical patients), (85.4% group I; 70% group II) tended to have low disease severity (55.2% group I; 47.2% group II) and the ICU stay ranged from two to eight days. The diagnosis leading the ICU admission was a respiratory system disease. In Table 2, the data on the family members’ level of comfort and coping are displayed. As observed, in both groups, low comfort stood out (score <4.1) and the support dimension was the most compromised. A statistically significant difference was observed between the safety and support dimensions and the general comfort score in the comparison between the groups. Concerning the
Table 2 Distribution of mean, median comfort and brief religious-spiritual coping score of ICU patients’ family members, according to groups 2016. Comfort (ECONF) Group
Safety Interaction relative and patient Support General
p-value*
I Mean (±SD)
II Mean (±SD)
4.3 4.1 3.6 4.0
3.8 4.3 2.5 3.4
(±0.61) (±1.06) (±0.90) (±0.70)
(±69) (±0.63) (±1.35) (±0.77)
<0.0001 0.0732 <0.0001 <0.0001
RSC-Brief Factors Positive Negative Total
RSC-Brief, the total score demonstrated the low use of this coping strategy among the participants in both groups. The participants’ use of the positive factor scored in the average range and surpassed the negative factor, which scored low. Next, multiple linear regression analysis was applied, using the comfort score and the RSC-Brief as response variables and sex, partner, religion, income, education, severity and length of hospitalisation as explanatory variables (Table 3). Only the length of hospitalisation was statistically significant for RSC-Brief and Comfort. Patient severity showed a trend for comfort only (p = 0.068).
Discussion
N: number; Min-Max: minimum-maximum; SD: standard deviation.
Dimensions
3
3.0 (±0.62) 1.3 (±0.26) 2.2 (±0.32)
2.9 (±0.65) 1.4 (±0.22) 2.1 (±0.36)
0.1726 0.1721 0.0740
*Student’s t-test. SD: Standard Deviation; RSC-Brief: religious-spiritual coping-brief inventory; ECONF: comfort scale for critical care patient relatives.
The family members are predominantly adults, female, with partner and Catholic. These data are in line with a study involving family members of patients hospitalised on an adult ICU of a public hospital that exclusively receives patients from the Unified Health System (Puggina et al., 2014). The wife’s presence with the patient is intended to respond to some needs this individual experiences, mainly related to safety and emotional support (Stickney et al., 2014). In this study, the participants’ general comfort score was considered low in both groups and the support domain obtained the lowest score. In a qualitative study, involving 14 relatives of critical patients, it was verified that comfort meant being respected, accepted, valued, heard and understood by the team. This research also showed that the family members expected the team to perceive the family’s suffering and the possibilities to minimise it (Freitas et al., 2012). Thus, the welcome that the family members receive may have affected the assessment of the support domain and, consequently, the comfort score. In a study that assessed the perceived satisfaction of professionals and family members of ICU patients, it was shown that 67% of the families did not know the nurses’ name and that 70% of the professionals perceived that the information they passed to the families upon admission was not fully understood (Martos-Casado et al., 2014). In another recent study, developed at a public hospital, it was evidenced that the relatives’ feeling towards the ICU hospitalisation is marked by abandonment and that they perceive little availability or welcoming of the family (Maestri et al., 2012). In the present study, on average, the relatives experienced seven days of ICU hospitalisation with restricted visits. The practice of limiting ICU visits is scientifically unfounded and rests on the premise that the relatives’ presence at the bedside could interfere in the unit routines (Montes Bueno et al., 2016). This is also the most feasible for some severe patients. This fact should be considered in the discussion of our results, as it may have influenced the perceived comfort, although the latter is a multidimensional construct. In order to meet the second specific objective of this study, the multiple linear regression analysis of the comfort score was performed with some explanatory variables Comfort was positively associated with the patients’ length of ICU hospitalisation and presented a negative trend with patient severity. When a patient is hospitalised on an ICU, the relatives’ main and often unrealistic idea is of severity associated with death. Over time, however, they always expect the recovery and discharge, which can contribute to increase the perceived comfort. Regarding the evaluation of CRE-Brief, the indices demonstrate a low utilisation of this coping strategy by study participants. Nevertheless, positive coping was more used than the negative type. Based on this fact, we consider that the beneficial effect is linked to an expression of spirituality, safety in the relationship with god and a spiritual connection.
Please cite this article as: S. Meneguin, C. F. Pollo, C. R. Benichel et al., Comfort and religious-spiritual coping of intensive care patients’ relatives, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2020.102805
4
S. Meneguin et al. / Intensive & Critical Care Nursing xxx (xxxx) xxx
Table 3 Generalized linear model for comfort and needs/stressors measures of family members who participated in the study 2016. ECONF
RSC-Brief
Explanatory Variables
Coef. b
Standard error
p-value
Coef. b
Standard error
p-value
Gender (ref. male) Partner (ref. with partner) Religion (ref. Catholics) Income (ref. up to 1700.00) Education (ref. secondary level) Severity (ref. stable) Length hospitalisation (ref. in days) RSC-Brief (ref. comfort) Comfort (ref. RSC-Brief)
0.08 0.12 0.05 0.08 0.64 0.29 0.69 0.24 –
0.12 0.12 0.12 0.12 0.23 0.16 0.13 0.16 –
0.54 0.36 0.68 0.50 0.18 0.07 <0.01 0.14 –
0.09 0.09 0.08 0.03 0.12 0.07 0.18 – 0.53
0.55 0.08 0.06 0.064 0.11 0.06 0.06 – 0.35
0.09 0.26 0.17 0.68 0.253 0.22 <0.01 – 0.13
Ref.: reference framework; Coef b: Beta coefficient; ECONF: comfort scale for critical care patient relatives; RSC-Brief: religious-spiritual coping- brief inventory.
Although, in this specific situation of having a family member hospitalised on the ICU, religion/spirituality can benefit the family member and contribute to coping with a critical situation, that was not demonstrated in our study, going against the findings of other studies on the theme (Valcanti et al., 2012; Schleder et al., 2013). The negative association between the RSC-Brief and the length of hospitalization is also interesting. It can be inferred that, as the length of the ICU hospitalisation increases, people develop adaptive mechanisms to cope with the situation.
Limitations The limits of the study results initially refer to the sample size of group II. This fact can be due to the regional characteristics of the paediatric ICU where the research was carried out, to the small number of beds at those ICUs and the limited patient turnover. Moreover, the application of the questionnaire at a single moment may not be enough to picture the extent of the interferences and difficulties the family member experiences in this period.
Conclusion These study results indicate the low comfort of ICU patients’ family members in both groups. When associated with the sociodemographic and clinical variables, the comfort increased with the relative’s length of hospitalisation and tends to drop with the patient’s severity. Despite the low use of RSC during the hospitalisation process of a family member, the use of positive coping prevailed. The RSCBrief dropped as the length of the hospitalisation of the family member/patient at the ICU increased. In view of the lack of studies involving family members’ comfort and RSC-Brief, we believe that these results can guide nursing proposals focused on the family members, in line the associations found among variables length of hospitalisation and patient severity.
Funding sources São Paulo Research Foundation, Fapesp, Brazil – Process number 2014/21102-9.
Conflicts of interest None.
Ethical approval The data were obtained after the Institution’s Research Ethics Committee had approved the project under number 96950. References Al-Mutair, A.S., Plummer, V., Clerehan, R., O’Brien, A., 2014. Needs and experiences of intensive care patients’ families: a Saudi qualitative study. Nurse Crit. Care 9, 135–144. Edeer, A.D., Bilik, Ö., Kankaya, E.A., 2019. Thoracic and cardiovascular surgery patients: intensive care unit experiences. Nurse Crit. Care. https://doi.org/ 10.1111/nicc.12484. Côa, T.F., Pettengill, M.A.M., 2011. The vulnerability experienced by the family of children hospitalized in a pediatric intensive care unit. Rev. Esc. Enferm. USP 45, 825–832. De Paula, E.S., Nascimento, L.C., Rocha, S.M.M., 2009. Religion and spirituality: the experience of families of children with chronic renal failure. Rev. Bras Enferm. 62, 100–106. Dreffs, F.M.L., Stumm, E.M.F., Winkelmann, E.R., et al., 2013. Coping mechanisms used by family of patients in intensive care. Rev. Ciênc Saúd. 6, 52–58. Freitas, K.S., (2011). Construção e validação da escala de conforto para familiares de pessoas em estado crítico de saúde (ECONF). 198f. Tese (Doutorado) - Escola de Enfermagem. Universidade Federal da Bahia, Salvador, Brasil. Freitas, K.S., Menezes, I.G., Mussi, F.C., 2012. Comfort from the perspective of families of people hospitalized in the intensive care unit. Texto Contexto Enferm. 21, 896–904. Harris, G.M., Allen, R.S., Dunn, L., Parmelee, P., 2013. ‘‘Trouble won’t last always”: religious coping and meaning in the stress process. Qual. Health Res. 23, 773– 781. Kolcaba, K.Y., 1994. A theory of holistic comfort for nursing. J. Adv. Nurs. 19, 1178– 1184. Maestri, E., Nascimento, E.R.P., Bertoncello, K.C.G., et al., 2012. Evaluation of the welcoming strategies in the intensive care unit. Rev. Esc. Enferm. USP 46, 75– 81. Martos-Casado, G., Aragón-López, A., Gutiérrez-Ramos, N., 2014. Satisfaction of relatives of the patients admitted to an intensive care unit: perceptions of relatives and professionals. Enferm. Intensiva 25, 164–172. Mesquita, A.C., Chaves, E.C.L., Avelino, C.C.V., et al., 2013. The use ofreligious/ spiritual coping among patients with cancer undergoing chemotherapy treatment. Rev. Latino-Am Enfermagem. 21, 539–545. Montes Bueno, M.T., Quiroga, A., Rodríguez, S., Sola, A., 2016. Family access to neonatal intensive care units in Latin America: A reality to improve. An Pediatr. 85 (2), 95–101. Panzini, R., Bandeira, D.R., 2005. Spiritual/religious coping scale (SRCOPE Scale): elaboration and construct validation. Psicol. Estud. 10, 507–516. Pargament, K.I., Koenig, H.G., Perez, L.M., 2000. The many methods of religious coping: development and initial validation of the RCOPE. J Clin Psychol. 56 (4), 519–543. Puggina, A.C., Ienne, A., Carbonari, K.F.B.S.F., et al., 2014. Perceptionof communication, satisfaction and importance of family needs in the intensive care unit. Esc. Anna Nery 18, 277–283. Schleder, L.P., Parejo, L.S., Puggina, A.C., Silva, M.J.P., 2013. Spirituality of relatives of patients hospitalized in intensive care unit. Acta Paul Enferm. 26, 71–78. Stickney, C.A., Ziniel, S.I., Brett, M.S., et al., 2014. Family participation during intensive care unit rounds: attitudes and experiences of parents and healthcare providers in a tertiary pediatric intensive care unit. J. Pediatr. 164, 402–406. Twohig, B., Manasia, A., Bassily-Marcus, A., et al., 2015. Family experience survey in the surgical intensive care unit. Appl. Nurs. Res. 28, 281–284. Valcanti, C.C., Chaves, E.C.L., Mesquita, A.C., et al., 2012. Religious/spiritual coping in people with chronic kidney disease undergoing hemodialysis. Rev. Esc. Enferm. USP 46, 838–845. Wall, R.J., Engelberg, R.A., Gries, C.J., et al., 2007. Spiritual care of families in the intensive care unit. Crit. Care Med. 35, 1084–1090.
Please cite this article as: S. Meneguin, C. F. Pollo, C. R. Benichel et al., Comfort and religious-spiritual coping of intensive care patients’ relatives, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2020.102805
Contents lists available at ScienceDirect
Intensive & Critical Care Nursing journal homepage: www.elsevier.com/iccn
Research article
Comfort and religious-spiritual coping of intensive care patients’ relatives Silmara Meneguin a,⇑, Camila Fernandes Pollo a,b, Cariston Rodrigo Benichel a,b, Larissa Kazitani Cunha a, Hélio Amante Miot a a b
Botucatu Medical School, Paulista State University – Unesp, São Paulo, SP, Brazil Paulista State University – Unesp, São Paulo, SP, Brazil
a r t i c l e
i n f o
Article history: Received 13 May 2019 Revised 7 January 2020 Accepted 10 January 2020 Available online xxxx Keyword: Spirituality Family Intensive Care Units Nursing
a b s t r a c t Objectives: To identify the level of comfort and religious-spiritual coping of family members of intensive care unit patients and to analyse the sociodemographic/clinical variables that influence this association. Methods: Cross-sectional study on the adult and paediatric intensive care units of two public hospitals in the state of São Paulo, between January and September 2016. Participants were divided into two groups: adult (n = 96) and paediatric (n = 70). We used the religious-spiritual coping brief (RSC-Brief) and the comfort scale for relatives of people in critical states of health (ECONF). Results: Comfort was low in both groups and the family members used limited strategies in the RSC-Brief. The multiple linear regression analysis indicated that the variable length of hospitalization (b = 0.69; p < 0.01) influenced comfort and was also associated with the RSC-Brief (b = -0.18; p < 0.01). Conclusion: Family members’ comfort was low in both groups. It increased with the hospitalisation time of the patients’ relative and tended to decrease with the severity of the disease. Ó 2020 Elsevier Ltd. All rights reserved.
Implications for clinical practice In view of the lack of studies involving family members’ comfort and religious-spirtual coping, factors that influence comfort and coping can guide nursing proposals focused on the family members. Length of hospitalisation is a important variable that influences comfort and religious-spiritual coping. It is necessary to have more concern for family members of intensive care unit patients. The comfort and religious-spiritual coping perceptions are highly individual.
Introduction The Intensive Care Unit (ICU) stands out in the hospital context because of its advanced equipment and technology necessary to care for critical care patients (Edeer et al., 2019). Nevertheless, this care model ends up imposing restrictive measures, which not only do not permit patient care in all of its forms, but also ignore the family members’ needs as individuals and care ⇑ Corresponding author at: Departamento de Enfermagem da FMB-Unesp, Distrito de Rubião Jr s/n, 18618-000 Botucatu, SP, Brazil. E-mail address: [email protected] (S. Meneguin).
subjects. In addition, the family members also need to be considered as individuals exposed to stress situations, who need actions to promote their comfort, as they suffer together with their relative (Twohig et al., 2015; Al-Mutair et al., 2014). Although the term comfort often appears in the nursing literature, few studies have sought to examine it. Comfort is a holistic, subjective and multidimensional concept, with influence from the physical, environmental, social and psychospiritual contexts, which changes in time and space (Kolcaba, 1994). It results from the individual’s interactions with the self, the surrounding people and situations faced in the disease and health care process (Freitas et al., 2012).
https://doi.org/10.1016/j.iccn.2020.102805 0964-3397/Ó 2020 Elsevier Ltd. All rights reserved.
Please cite this article as: S. Meneguin, C. F. Pollo, C. R. Benichel et al., Comfort and religious-spiritual coping of intensive care patients’ relatives, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2020.102805
2
S. Meneguin et al. / Intensive & Critical Care Nursing xxx (xxxx) xxx
In these circumstances, family members often turn to religion and spirituality as a source of comfort and support, mainly in chronic or end-of-life situations (Wall et al., 2007). Religion and spirituality are often adopted as constructs to cope with the stress the ICU hospitalisation of a patient causes. Although distinct, they are closely intermingled. Spirituality is considered to be a person’s essence, a search for meaning and purpose in life; while religiosity is the expression of spirituality itself through rituals, dogmas and doctrines (De Paula et al., 2009; Valcanti et al., 2012). In this context, religious-spiritual coping (RSC) refers to the use of faith, religion or spirituality in coping with stressful situations or crisis moments across the lifetime. Therefore, its study should be broad and based on a functional view of religion and the role it plays in coping (Harris et al., 2013). Although the religious coping concept comes with a positive connotation, it can be both positive and negative; the same is true for its strategies. The positive connotation groups measures that benefit the individual; while the negative connotation is related to measures that entail harmful consequences for the individual, such as questioning his existence, delegating problem solving to god, defining the stress condition as a punishment from God, among others (Mesquita et al., 2013). The relation between the comfort of ICU patients’ relatives and religiosity has not been well explored yet in the literature. Research has merely looked at the influence of religion as a coping strategy by the relatives of ICU patients (Schleder et al., 2013; Dreffs, et al., 2013). The hypothesis of the study is that the perception of comfort and RSC is influenced by the religiosity-spirituality and sociodemographic variables of the family members of patients hospitalised in intensive care units, as well as by the profile of the patients. In light of the above, this study aimed to identify the level of comfort and religious-spiritual coping of family members of intensive care unit patients and to analyse the sociodemographic/clinical variables that influence this association.
A relative was defined as the person indicated as the closest to the patient, with or without blood bonds, who lived with them and maintained a close relationship.
Methods
Initially, all variables were analyzed descriptively. To compare the means of the RSC-Brief and Comfort scores between groups, Student’s t-test was used. The reliability of the questionnaires ECONF was tested by Cronbach´s alpha, and considered adequate if greater than 0.7. The variation in the RSC-Brief and comfort scores was assessed in view of the clinical and demographic variables by means of a generalised linear model. Spearman’s t-test was applied to explore the correlation among the variables. The analyses were developed in IBM SPSS, version 22. Significance was set at 5%.
Study design An exploratory, cross-sectional and comparative study with a quantitative approach was undertaken. Participants and setting The study was developed for the general adult and paediatric ICU of two public hospitals in the state of São Paulo, offering 16 beds adults and 15 beds paediatrics for clinical and surgical patients. Both ICUs have restricted visiting hours. The sample included consecutive family members who visited the ICU between January and September 2016. The inclusion criteria were: family members of both genders; aged 18 years or over; with a relative hospitalised in the ICU in the period between 72 hours and seven days; availability and in self-referred emotional conditions to answer the questionnaire and agreeing to participate in the research. Relatives who did not fully complete the data collection instrument were excluded. The participants were divided in two groups: Group I: family members of patients attended at the Adult ICU; Group II: family members of patients attended at the Paediatric ICU. The participants’ separation into two groups was due to the intense suffering caused by a child’s hospitalisation in a paediatric ICU, in view of the possibility of a definitive loss. In addition, the family’s power over and autonomy regarding the child are reduced, leading to feelings of suffering (Côa and Pettengill, 2011).
Data collection Sociodemographic/clinical data of the patients were obtained by consulting the medical records and the family members during the interview. In order to assess the comfort level authors used the Comfort scale for relatives of people in critical states of health (ECONF), which consists of 46 items, distributed in three dimensions: Safety, Support and Interaction between the relative and the patient. The answers vary on a 0 to 5 Likert scale. The score is divided as follows: <4.19 little comfort, 4.20–4.59 medium comfort and superior to 4.6 high comfort (Freitas, 2011). The RSC scale is a North American 92-item tool, originally denominated RCOPE (Pargament et al., 2000), whose brief version was validated for the Brazilian culture (Panzini and Bandeira, 2005). The RSC-Brief contains 49 items, divided in two main dimensions: Positive RSC (transformation of one’s self and/or one’s life; actions in search of spiritual help; supply of help to the other; positive position towards God; actions in search of the institutional other; personal search for spiritual knowledge; distancing through God, religion and/or spiritualities) and Negative RSC (negative reassessment of God; negative position towards God; negative reassessment of the meaning; dissatisfaction with institutional other). The answers range from 1 to 5 points on a Likert scale, as followed: from 1.0 to 1.5 none or negligible, 1.51 to 2.50 low; 2.51 to 3.50 average, 3.51 to 4.50 high and 4.51 to 5.0 very high (Panzini and Bandeira, 2005). The questionnaires were completed in a private room near the ICU, individually. If impossible, an appointment was made at each relative’s personal convenience. Statistical analysis
Ethical approval The data were obtained after the Institution’s Research Ethics Committee had approved the project under number 96950 and after the participants had signed a free and informed consent form with the information about the research. Results Based on the recruitment criteria, 170 family members were approached, four of whom declined to participate in the study. Thus, the sample consisted of 166 participants, being 96 in group I and 70 in group II (Table 1). In both groups there was a greater percentage of female participants, active catholics and those who had a partner. Most family members in the group II were direct relatives 50 (71,5%), lived with the patient 50 (71.4) and had no previous experience with a family member’s ICU hospitalisation (67.1%).
Please cite this article as: S. Meneguin, C. F. Pollo, C. R. Benichel et al., Comfort and religious-spiritual coping of intensive care patients’ relatives, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2020.102805
S. Meneguin et al. / Intensive & Critical Care Nursing xxx (xxxx) xxx Table 1 Sociodemographic characterisation of relatives according to the groups 2016. Variable
Group
Age (years) Mean (±SD) Gender Male Female Marital status With partner No partner Education Complete/incomplete primary education Complete high school Complete higher education Religion Catholic Non Catholic Employment situation Employed Unemployed Degree kinship Direct Indirect Previous hospitalization of relative at ICU Yes No Lives with the patient Yes No Income Average Min-Max
I N (%)
II N (%)
46.60 (±16.05)
33.58 (±10.8)
38 (39.6) 58 (60.4)
16 (22.9) 54 (77.1)
80 (83.3) 16 (16.7)
55 (78.6) 15 (21.4)
38 (39.5 46 (48.0) 12 (12.5)
39 (55.7) 27 (38.5) 4 (5.8)
49 (51.0) 47 (49.0)
37 (52.9) 33 (47.1)
60 (45.8) 36
38 (44.3) 32
36 (37.5) 60 (62.5)
50 (71.5) 20 (28.5)
41 (42.7) 55 (57.3)
31 (44.3) 39 (55.7)
47 (48.9) 49 (51.1)
50 (71.4) 20 (28.6)
2191.8 500–9200
1393.3 0–4000
In both groups the patients, whose relatives took part in the study, were medical (non-surgical patients), (85.4% group I; 70% group II) tended to have low disease severity (55.2% group I; 47.2% group II) and the ICU stay ranged from two to eight days. The diagnosis leading the ICU admission was a respiratory system disease. In Table 2, the data on the family members’ level of comfort and coping are displayed. As observed, in both groups, low comfort stood out (score <4.1) and the support dimension was the most compromised. A statistically significant difference was observed between the safety and support dimensions and the general comfort score in the comparison between the groups. Concerning the
Table 2 Distribution of mean, median comfort and brief religious-spiritual coping score of ICU patients’ family members, according to groups 2016. Comfort (ECONF) Group
Safety Interaction relative and patient Support General
p-value*
I Mean (±SD)
II Mean (±SD)
4.3 4.1 3.6 4.0
3.8 4.3 2.5 3.4
(±0.61) (±1.06) (±0.90) (±0.70)
(±69) (±0.63) (±1.35) (±0.77)
<0.0001 0.0732 <0.0001 <0.0001
RSC-Brief Factors Positive Negative Total
RSC-Brief, the total score demonstrated the low use of this coping strategy among the participants in both groups. The participants’ use of the positive factor scored in the average range and surpassed the negative factor, which scored low. Next, multiple linear regression analysis was applied, using the comfort score and the RSC-Brief as response variables and sex, partner, religion, income, education, severity and length of hospitalisation as explanatory variables (Table 3). Only the length of hospitalisation was statistically significant for RSC-Brief and Comfort. Patient severity showed a trend for comfort only (p = 0.068).
Discussion
N: number; Min-Max: minimum-maximum; SD: standard deviation.
Dimensions
3
3.0 (±0.62) 1.3 (±0.26) 2.2 (±0.32)
2.9 (±0.65) 1.4 (±0.22) 2.1 (±0.36)
0.1726 0.1721 0.0740
*Student’s t-test. SD: Standard Deviation; RSC-Brief: religious-spiritual coping-brief inventory; ECONF: comfort scale for critical care patient relatives.
The family members are predominantly adults, female, with partner and Catholic. These data are in line with a study involving family members of patients hospitalised on an adult ICU of a public hospital that exclusively receives patients from the Unified Health System (Puggina et al., 2014). The wife’s presence with the patient is intended to respond to some needs this individual experiences, mainly related to safety and emotional support (Stickney et al., 2014). In this study, the participants’ general comfort score was considered low in both groups and the support domain obtained the lowest score. In a qualitative study, involving 14 relatives of critical patients, it was verified that comfort meant being respected, accepted, valued, heard and understood by the team. This research also showed that the family members expected the team to perceive the family’s suffering and the possibilities to minimise it (Freitas et al., 2012). Thus, the welcome that the family members receive may have affected the assessment of the support domain and, consequently, the comfort score. In a study that assessed the perceived satisfaction of professionals and family members of ICU patients, it was shown that 67% of the families did not know the nurses’ name and that 70% of the professionals perceived that the information they passed to the families upon admission was not fully understood (Martos-Casado et al., 2014). In another recent study, developed at a public hospital, it was evidenced that the relatives’ feeling towards the ICU hospitalisation is marked by abandonment and that they perceive little availability or welcoming of the family (Maestri et al., 2012). In the present study, on average, the relatives experienced seven days of ICU hospitalisation with restricted visits. The practice of limiting ICU visits is scientifically unfounded and rests on the premise that the relatives’ presence at the bedside could interfere in the unit routines (Montes Bueno et al., 2016). This is also the most feasible for some severe patients. This fact should be considered in the discussion of our results, as it may have influenced the perceived comfort, although the latter is a multidimensional construct. In order to meet the second specific objective of this study, the multiple linear regression analysis of the comfort score was performed with some explanatory variables Comfort was positively associated with the patients’ length of ICU hospitalisation and presented a negative trend with patient severity. When a patient is hospitalised on an ICU, the relatives’ main and often unrealistic idea is of severity associated with death. Over time, however, they always expect the recovery and discharge, which can contribute to increase the perceived comfort. Regarding the evaluation of CRE-Brief, the indices demonstrate a low utilisation of this coping strategy by study participants. Nevertheless, positive coping was more used than the negative type. Based on this fact, we consider that the beneficial effect is linked to an expression of spirituality, safety in the relationship with god and a spiritual connection.
Please cite this article as: S. Meneguin, C. F. Pollo, C. R. Benichel et al., Comfort and religious-spiritual coping of intensive care patients’ relatives, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2020.102805
4
S. Meneguin et al. / Intensive & Critical Care Nursing xxx (xxxx) xxx
Table 3 Generalized linear model for comfort and needs/stressors measures of family members who participated in the study 2016. ECONF
RSC-Brief
Explanatory Variables
Coef. b
Standard error
p-value
Coef. b
Standard error
p-value
Gender (ref. male) Partner (ref. with partner) Religion (ref. Catholics) Income (ref. up to 1700.00) Education (ref. secondary level) Severity (ref. stable) Length hospitalisation (ref. in days) RSC-Brief (ref. comfort) Comfort (ref. RSC-Brief)
0.08 0.12 0.05 0.08 0.64 0.29 0.69 0.24 –
0.12 0.12 0.12 0.12 0.23 0.16 0.13 0.16 –
0.54 0.36 0.68 0.50 0.18 0.07 <0.01 0.14 –
0.09 0.09 0.08 0.03 0.12 0.07 0.18 – 0.53
0.55 0.08 0.06 0.064 0.11 0.06 0.06 – 0.35
0.09 0.26 0.17 0.68 0.253 0.22 <0.01 – 0.13
Ref.: reference framework; Coef b: Beta coefficient; ECONF: comfort scale for critical care patient relatives; RSC-Brief: religious-spiritual coping- brief inventory.
Although, in this specific situation of having a family member hospitalised on the ICU, religion/spirituality can benefit the family member and contribute to coping with a critical situation, that was not demonstrated in our study, going against the findings of other studies on the theme (Valcanti et al., 2012; Schleder et al., 2013). The negative association between the RSC-Brief and the length of hospitalization is also interesting. It can be inferred that, as the length of the ICU hospitalisation increases, people develop adaptive mechanisms to cope with the situation.
Limitations The limits of the study results initially refer to the sample size of group II. This fact can be due to the regional characteristics of the paediatric ICU where the research was carried out, to the small number of beds at those ICUs and the limited patient turnover. Moreover, the application of the questionnaire at a single moment may not be enough to picture the extent of the interferences and difficulties the family member experiences in this period.
Conclusion These study results indicate the low comfort of ICU patients’ family members in both groups. When associated with the sociodemographic and clinical variables, the comfort increased with the relative’s length of hospitalisation and tends to drop with the patient’s severity. Despite the low use of RSC during the hospitalisation process of a family member, the use of positive coping prevailed. The RSCBrief dropped as the length of the hospitalisation of the family member/patient at the ICU increased. In view of the lack of studies involving family members’ comfort and RSC-Brief, we believe that these results can guide nursing proposals focused on the family members, in line the associations found among variables length of hospitalisation and patient severity.
Funding sources São Paulo Research Foundation, Fapesp, Brazil – Process number 2014/21102-9.
Conflicts of interest None.
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Please cite this article as: S. Meneguin, C. F. Pollo, C. R. Benichel et al., Comfort and religious-spiritual coping of intensive care patients’ relatives, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2020.102805