A Literature Review: Stress Management in The Family of Intensive Care Patients

ABSTRACT Introduction: Intensive care unit is a unit with a complex case and a stressor strainer. When patients enter intensive care families have a variety of stressors such as rapid decision making and costs are not small. The role of nurse as educator is very important in reducing family anxiety with patients treated in intesive units. Mothers of intensive care babies feel a great deal of anxiety over their child's condition, so there needs to be a good system support for the healing of her and her baby. Various ways nurses do in reducing stress experienced by the patient's family such as good communication between nurses and families of patients with intensive care. This review aims to get a picture of stress management that can be done on the family of intensive care patients. Methods: A literature review was conducted in the fields of ebscho, sience direct, elseiver, sage journals, scopus, and proquest, limited the range of the last 10 years from 2007-2017. The final sample included 18 articles. Results: The literature found that the causes of family stressors include rapid decision-making, fear of family emergency conditions, maintenance costs and length of care. Good communication and good information and skill support can decrease the stress experienced by intensive care patients' families. Conclussions: Intensive care is a unit with high complexity, unstable conditions and sophisticated technology. Conditions that require rigorous monitoring not only cause stressors for the patient, but become a stressor for the patient's family.


INTRODUCTION
Intensive care is a core component of comprehensive care for patients facing critical illness, regardless of age, diagnosis, or prognosis. The main domains of the intensive care unit include relieving perceived symptoms, effective communication of care goals, patient or family-focused decisionmaking, nearest outreach support, and continuity of care (Noome et al., 2016). Entrance ICU may be abrupt and unexpected, ICU complex environment is foreign and frightening, and can be considered as inhuman or burdensome. The sad psychological symptoms among the families of ICU patients are most common during critical illness and decline over time (Wintermannet al., 2016). Fifty percent of US hospital deaths occur during or after living in an intensive care unit (ICU), family members must make this difficult decision on behalf of their loved ones. While doing so, they may worry that one of their loved ones has suffered or that they have given up too soon, and two thirds of ICU death (Bloomer et al., 2013).
Intensive patient-family stress has been the main theme of numerous studies in the field of health psychology in recent years, the family stress incidence from various studies of the world varies considerably between 25% and 87% (Jongerden et al., 2013). This is reinforced by research conducted by (Turner et al., 2015) as many as 54.3% of families without direct blood relation stress and 75.7% of families with blood relations experience anxiety.
Various ways have been done to reduce anxiety in families of ICU patients and nurses have an important role in the process (Mitchell and Courtney, 2004). The nurse is the health worker who has the most interaction time with the patient's family, the nurse knows with certainty the stress experienced by the patient's family so that the nurse can also provide support to the patient's family (Jongerden et al., 2013).
The purpose of this study is to conduct a literature review on stress management in the family of intensive care patients. In this study, the authors identified the stress management publication journal on intensive care family families. The results of this review literature are expected to be applied to health services especially nursing.

METHODS
A literature search was conducted in the fields of ebscho, science direct, elsevier, sage journal, scopus and proquest. The term care was searched in combination with following key words: "Stress Management" AND Family AND Intensive Care.The search resulted in 183 citations. During this process, 129citation were excluded due to the title not being relevant. The 54 citation which were found relevant were retrieved for detailed evaluation. The titles and/or abstracts of these 26 article were read again by the authors. This process resulted in 21 articles, a further 3 were excluded because they did not discuss family stress in icu. The final sample included 18 articles.

RESULTS
The review literature process of 18 journals obtained by the authors found 16 variable factors that influence the occurrence of stress in the family of intensive care patients. There are four dominant factors that influence the stress on the family of intensive care patients, namely rapid decision making, cost and length of care, risk of death threatening, and sudden change of condition.
Several methods have been undertaken to deal with stress that occurs in the patient's family such as good communication, support and empathy, as well as providing good information as a basis for decision making. Good nurse skills also affect the patient's family stress level.   (Carlson et al., 2015) Family members' distress and Perceptions cross-sectional descriptive survey The competency and skills of staff are much higher than the value of communication frequency, information needs, and support. The frequency of communication and the information needs met are strongly related to the support value (rs = 0.75 to 0.77) and the staff skills (rs = .77-.85), and the satisfaction and communication aspects show a negative relationship with gejaladepression (rs = .31 to -55) and PTSD (rs = -17 to -43) Nursing strategies to support family members of ICU patients at high risk of dying (Adams et al., 2014) Nursing strategies to support family members a prospective, qualitative descriptive study Family members describe five nursing approaches: Showing concern, building rapport, showing professionalism, providing factual information, and supporting decision making. This study provides evidence that when using this approach, nurses help family members to address the problem; to have hope, confidence, and trust; to prepare and receive the coming death; and to make decisions Supporting families in the ICU: A descriptive correlational study of informational support, anxiety, and satisfaction with care (Bailey et al., 2010).
anxiety, and satisfaction with care cross-sectional descriptive correlational The mean information support, judged by the modified version of CCFNI (Molter and Leske, 1983), is 55.41 (SD = 13.28; the theoretical range 20-80). The mean anxiety, judged by State Anxiety Scale (Spielberger et al., 1983) was 45.41 (SD = 15.27, the theoretical range 20-80). The mean satisfaction with treatment, assessed using AndrofactTM (Version 4.0, 2001), was 83.09 (SD = 15.49; the theoretical range 24-96). A significant positive correlation was found between information support and satisfaction with care (r = 0.741, p <.001). There is no significant relationship between information support and anxiety or between satisfaction with care and anxiety Symptoms of anxiety and depression in family members of intensive care unit patients before discharge or death (Pochard et al., 2005) Anxiety Depression A prospective multicenter study Symptoms of anxiety and depression were found in 73.4% and 35.3% of family members; 75.5% of family members and 82.7% of couples had symptoms of anxiety or depression (P = 0.007). Symptoms of depression were more common in non-survivor family members (48.2%) than survivors (32.7%) (P = 0.008).
Factors associated with symptoms of anxiety and depression: 1. Relationship with patient: severity 2. Family relationship 3. Neighborhood room with more than 1 bed Passive decisionmaking preference is associated with anxiety and depression in relatives of patients in the intensive care unit (Anderson, Arnold and Angus, 2009) Anxiety Depression observational pilot study 12 (25%) preferred active roles, 28 (58%) preferred to share responsibility with physicians, and 8 (17%) preferred passive roles. Of the 50 relatives, 21 (42%) had anxiety symptoms, and 8 (16%) had symptoms of depression. In groups that favored the active role, joint role, and passive role, respectively, anxiety levels were 42%, 25%, and 88% (P = 0.007), and depression rates were 8%, 11%, and 50% (P = .026). Relatives who prefer the role of passive decision making are the most likely to be anxious and depressed. Supporting families in the ICU: A descriptive correlational study of informational support, anxiety, and satisfaction with care. (Bailey et al., 2010) informational support anxiety satisfaction with care cross-sectional descriptive correlational pilot study A significant positive relationship was found between information support and satisfaction with care (r = 0.741, p <.001). No significant relationship was recorded between information support and anxiety or between satisfaction and treatment Anxiety Effectiveness of nursing interventions based on family needs on family satisfaction in the neurosurgery intensive care unit (Yousefi et al., 2012) Nursing interventions based on family needs. The effect of a family support intervention on family satisfaction, length-of-stay, and cost of care in the intensive care unit (Shelton et al., 2010) a family support intervention

Quasy Experiments
Provision of education information about the patient's condition, financing and estimation of the length of care done by the experts in the field of psychology can increase patient family satisfaction and can reduce the level of stress experienced by the family. Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study (Mitchell and Courtney, 2004) Reducing family members' anxiety Pre test -Post testgrup design There was a decrease in the level of strees and anxiety of the family, with a decrease in the number of families waiting / escorting from the ICU chamber to the general treatment room with P: 0.002 Nursing Interventions to Reduce Stress in Parents of Hospitalized Preterm Infants (Guo, East and Arthur, 2012) Nursing Interventions to Reduce Stress

Quasy Experiments
The nurse provides educational information to the family about the state of the patient, the role of the family in preterm infant care, the information is given whenever shift change can decrease the natural anxiety and stress8 family. A family nursing educational intervention supports nurses and families in an adult intensive care unit (Eggenberger and Sanders, 2016) nursing educational intervention supports nurses and families

Pilot study
From the results of this study found that education by nurses to the family impact on the family coping of patients who are disturbed due to treatment experienced by patients. So the need for education by nurses is needed by the family to overcome the problem coping experienced Patient, familycentered care interventions within family-centered care Systematic review PPFC involves interprofesional (all health workers). PPFC itself can be used by patients and families the adult ICU setting: An integrative review (Mitchell et al., 2016) related problems facing patients. Of the 48 articles discussed in this journal found that PFCC can improve patient cure and is recommended to be applicable in ICU Nursing care of the family before and after a death in the ICU-An exploratory pilot study (Bloomer et al., 2013) Nursing care Pilot study Discovering that involves the family in the healing process of the patient. The nurse provides patientrelated information that can help the family to make decisions well and appropriately. And nurses can help meet emotional support and comfort for the family. Exploring family experiences of nursing aspects of end-of-life care in the ICU: A qualitative study (Noome et al., 2016) family experiences Phenomenology It found that most families have contributed to the end-of-life care of the patient, especially supportive care. Families express care support is very important, especially they are willing to answer questions from family and invite family to participate in care A family intervention to reduce delirium in hospitalised ICU patients: A feasibility randomised controlled trial  Family intervention RCT Family members can play an important role in preventing and reducing the development of delirium in Intensive Care Unit (ICU) patients. Family members are seen as important partners of care, and their involvement gives many positive results for ICU patients and for themselves. However, doctors should note that the family is also the focus of care, in addition to the patient, and any involvement should occur at the level / frequency most appropriate for family members and, moreover, have no adverse impact on them or their relationship to the patient.

DISCUSSIONS
In the results of the above review found 4 dominant factors that affect the occurrence of stress in the family of intensive care patients are fast decision-making, cost and length of care, the risk of death that threatens, and changes in sudden conditions.
Decision-making at risk and within a short time is a separate stressor for the patient's family, improper decision-making can lead to deterioration of the patient's condition (Azoulay, Chaize and Kentish-Barnes, 2014). Families are sometimes confronted with difficult choices related to the condition of the patient, the intensive patient decision-making is in the family due to the inability of the patient to make a choice (Noome et al., 2016).
Intensive unit is a service with high technology and complicated procedures, the cost of the patient is not in small amounts. Special actions and equipment make costly expenses expensive (Shelton et al., 2010).
Intensive care requires extra monitoring because the patient's condition is unstable and may change in worse conditions over a short period of time, it also becomes a stress for the patient's family due to fear of death or worse conditions (Creutzfeldt et al., 2017 ). Limited family access to patient conditions and poor communication from healthcare providers add stressors to families (Edwards, Voigt and Nelson, 2017) Nurses as holistic service providers in patients including family, family stressor is a separate problem that must be overcome, from the literature review conducted got some methods that can be used in stress management family of intensive patients.
Skill of the nurse is one of the things that can increase or decrease patient's family's anxiety (Anderson, Arnold and Angus, 2009). A qualified, well-nurtured nurse will foster family trust in the nurse and assure the family that the patient is in the right hands.
Good communication by means of correct delivery will make a better family response and reduce anxiety in the patient's condition (Schubart et al., 2015). The patient's family wants as much information as possible about the condition and treatment process that is given to the patient, whereas in the intensive care the access to information is not very good due to the needs of the patients who require very strict monitoring (Azoulay, Chaize and Kentish-Barnes, 2014). Support and empathy provided by the nurse can increase optimism and tranquility for the patient's family, the family feels that the patient will be carried out well because the nurse knows exactly what the patient needs (Wetzig and Mitchell, 2017).

CONCLUSSIONS
Intensive care is a unit with high complexity, unstable conditions and sophisticated technology. Conditions that require rigorous monitoring not only cause stressors for the patient, but become a stressor for the patient's family. Through this Review Literature, the author tries to identify the appropriate stress management and can be applied to intensive patient families. After knowing stress management for family of intensive care patient is expected to be a reference in handling stress that happened to family and can be applied in health service.