BACKGROUND: Factors that can lead to breakdown in the care of the families of patients in the ICU include gaps in the healthcare providers' education and skill in working with families, unclear lines of responsibility for various aspects of family care, and insufficient support or supervision for the difficult emotional work of family care. OBJECTIVE: The purpose of this study was to highlight instances in which negative or difficult aspects of nursing care of family members of ICU patients were evident, so that needed changes in caring for the families could be emphasized. METHOD: Interpretive phenomenology was used to analyze transcribed audiotape recordings of interviews with 130 nurse participants and clinical observations of 48 nurse participants. The interpretive account is based on more than 100 narratives of patient care relayed in interviews and on observational notes that focused on care of the family. RESULTS: The five general nursing approaches that constrained family care in ICUs were nurses' efforts to (1) distance the family physically from the patient and the patient's bedside, (2) distance themselves from the patient and the patient's family, (3) characterize the family's perspective as pathological, (4) dissipate responsibility for family care, and (5) take an elemental rather than a systemic perspective. CONCLUSIONS: The breakdowns in family care observed in this study were neither new nor unique. In order to truly realize a patient- and family-focused healthcare system, an infusion of knowledge and skill must occur at the bedside with individual nurses.

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