Yearbook on Journal of the Japan Society of Nursing Research 2017

The Family Support of Emergency Nurse that Become Clear from the Relation Between
Acute Disturbance of Consciousness Patient and the Family
Akiko Tanaka
Key Words :emergency nursefamilyacute dsiturbance of
consciousness patienttouchcommunication

ABSTRACTThe purpose of this study was to find the family support methods for emergency nurse from the relation
between the patient and the patient’s family. The study method was the qualitative descriptive method. The
object were three acute disturbance of consciousness patients and their each family. The data collection
went in critical care center of ICU.
The field description result : The family took especially the reaction of patient’s eyes. The family touched
the body of the patient while having special feelings for the patient. And the family alternated between hopeand despair from subtel change in the patient and the explanation of the doctor.
Emergency nurse has to do those as follows. i) to let the family notice by themselves that to touch thepatient is important for the communication between them. ii) to judge the time of the family intervention
by observing the relation of the patient and the family iii) to notices early the change of the consciousness
level by observing the slight reaction of the patient that only the family can knows. iv) to plan and do thecare with the family v) to explain the condition of the patient tothe family ,on the basis original conditional
understanding of the family.

I. Introductionthat the provision of information which helps them to havean image of patient’s conditions before seeing him/her is a
useful intervention for crisis prevention. Yamagiwa suggests
the need to engage in research on the family of patients inthe field of emergency nursing because they tend to be ina state of psychological and social crisis when they observe
patients who develop disease suddenly and reduce the level ofconsciousness9). There are many studies that consider family
members of a patient are “in a crisis situation” on the studyof family in the field of critical care. Medical professionals
must explain to them patient’s conditions which change by theminute. How do they understand their explanation and engage
with a patient? For answering these questions I considered it
necessary to understand the family of patients by examining
how they perceive the actual situations in a hospital.
There are many studies on family’s needs on family
understanding10), 11), 12). Yet, they focus only family members,
failing to see the problems through the lens of theirinvolvement with patients.
There have been few studies that attempted to clarify
family members’ involvement with patients with impaired
consciousness by participant-observer study and interviews
because it is difficult to focus on them in a tense situation of
emergency medicine.
Therefore, in this article I attempted to examine family
members’ involvement with patients immediately after they
were transferred to a critical care center by putting myself inemergency situations. We need to understand characteristics
of family members’ involvement with acutely ill patients with
impaired consciousness. I consider that this study would be
helpful for understanding how emergency nurses should
assist them.

Emergency medicine started in Japan in 1963, and the first,
second, and third emergency medical system was developedin 1977 in order to cope with the increase of sudden illness
and a shortage of hospitals that admit critically ill patients1).
The system of emergency life-saving technicians wasestablished in 1991, finding a new direction of prehospitalcare that provides initial treatment to emergency patients
who are in a state of cardiopulmonary arrest or disturbanceof consciousness2). Then, the knowledge and techniques of
emergency nursing ranging from emergency skills to thenursing of mental aspects of patients in a crisis situations havedeveloped, and the fostering of emergency nurses started in
1995 in order to put in practice their medical skills in a variety
of situations3). In 1997 17 certified nurses in emergency
nursing were certified for the first time in Japan4), so that the
spread and importance of roles nurses play in critical carecenters have been recognized.
Nurses in critical care centers often face patients nearing
death. Their family are shocked and stand motionless when
they meet unconscious patients for the first time. I wasoften not able to decide how to get involved in them as anurse in such a situation. Intervention using crisis theory is
proposed as a method of family intervention for patients inthe acute stage. Fink5), Aguilera and Messiek6), and Yamagiwa7)
developed crisis theory. Fink notes that crisis process starts
from the stage of shock, which shows the decline of the ability
to think and understand one’s situations. Hieida and others8)
clarified factors leading to family crisis and the effect of familyintervention based on Aguilera’s and Messiek’s crisis models.
They pointed out that family members of patients immediately
hospitalized fall into an emotional crisis due to the imageof medical emergency centers, the lack of information, thechange of a patient’s appearance, and the failure to know whatkinds of medical procedures are taken. Therefore, they argue

II. The Purpose of ResearchThis research aims to find out the things that need totake into account when emergency nurses engage in family
support by analyzing family members’ involvement withacutely ill patients with impaired consciousness transferred
to a critical care center.

School of Nursing and Rehabilitation Sciences, Showa University

Corresponding author. Tel.: +81 45 985 6528; Fax.: +81 45 985 6557.
E-mail address: akiko-t@nr.showa-u.ac.jp

11This paper was published at “the Japan Society of Nursing Research” Vol.33 No.2 in 2010.

Yearbook on Journal of the Japan Society of Nursing Research 2017

III. The Definition of Terms(2) Interview
I interacted with family members of a patient after they met
a patient in order to let them describe their feelings. I was also
involved with them by walking them until they get out of a
critical care center for listening to their thoughts and anxiety
in a different atmosphere. I asked them to have an interview
after they started to talk to me. We used an interview roomin a hospital for it. The interview length was less than 30
minutes. The content of the interview was as follows: (a)What did you feel when you met a patient for the first time?;(b) Did you change your attitude on doctor’s explanation
after that?; (c) How were you trying to see patient’s disease?;and (d) about the things I failed to understand during myobservation on them. I conducted an interview by allowing
them to talk freely about anything. I recorded an interview
when permitted.

Family means a small group who conducts daily living
together. In this study family refers to those who had parentchild or husband-wife relations with acutely ill patients with
impaired consciousness and visited a critical care center formeeting them.
IV. Research Methods

1. Research Design
Family members of patients are shocked to see those whoare in serious conditions in a critical care center and often
stand motionless. They are in a perplexed state of shock after
knowing that the foundation of intimate relationship between
them collapsed. It is difficult to understand their feelings only
by watching their behaviors from the outside. Therefore, I
decided to conduct qualitative and descriptive research for
deciphering their subjective experience.

(3) Records
I got permission to see patients’ clinical and nursing
records to gain information on patients’ and their families.

2. Participants in the ResearchParticipants in this research were acutely ill patients with
impaired consciousness and their family members who meetfollowing conditions:a. a family member who engages with an inpatient who has
suffered from disturbed consciousness for more than one day.
b. a family member of a patient who cannot speak andwrite messages to communicate with others due to loss of
consciousness.
c. a family member who visits a patient every day.
d. a family member who understands the purpose of
research and agrees to participate in the research.

4. Methods of Data Analysis
I analyzed descriptive data gained from participantobserver study and interviews. I extracted parts expressing
acts at bedside and family’s thoughts and feelings for patients
gained from participant-observer study by focusing on
patients’ family members. Then, I examined descriptive data
gained from interviews for deciphering how patients andtheir family interacted with one another.
This is a concrete procedure for analysis:
1. Rereading fieldnotes and interview data for graspingfamily members’ involvement with patients.
2. I extracted sentences expressing their thoughts andfeelings from the description of family members’ involvementwith patients. Then, I added interpretation on each situationfrom the standpoint of family members.
3. I added interpretation on what kinds of involvementsfamily members engaged in and what are their meanings witha patient by adding interview data on the content of two.
4. Based on the data of one, two, and three, I restructured
family members’ involvement with patients in a chronologicalorder (the first day of sickness at the day of admission to a
critical care center). Then, I reexamined the scenes in whichfamily members were involved with patients, based on their
feelings and thoughts from their standpoint.

3. Methods of Data Collection
It took six months to collect necessary data by using
following methods.

(1) Participant-Observer Study
R. Emerson noted that it is important to observe subjects
from the inside by situating us in the midst of their living
in order to observe and understand critical situations on
their living13). A critical care center focuses on saving livesof patients from immediately after they are admitted to it.
I considered that I need to conduct a participant-observer
study based on the ideas of R. Emerson for grasping whatfamily members understand and engage with patients when
they see the scene of emergency medical care. Therefore,
I stayed in a hospital emergency room and observed how
family members accept, feel, and engage with a patient who
suddenly lost consciousness from the standpoint of him/
her. In this way I conducted participant observation by thebedside of patients for grasping them from their perspective.
I stayed with the family of a patient since they arrived in a
critical care center. The participant-observe study had been
conducted during the period from when family members wereallowed to see a patient to his/her discharge from hospital.
It is expected that they might be disturbed by the situation,
therefore, I created a relaxing atmosphere by the bedside ofpatients after observing their facial expression and behaviors.
I stayed with them when doctors or nurses explained patient’s
medical conditions to them.

5. Reliability of the Results of Analysis
This research attempts to restructure subjects’ experiencein a thorough way. Therefore, I checked whether datacollected from participant-observer study and interviews
are insufficient or mistaken or not by getting confirmationfrom subjects. In addition, a research adviser supervised andthe support group comprising five to eight researchers on
nursing read collected data and examined their interpretation
throughout the whole process of data collection and analysis
in order to avoid making biased interpretation.

6. Ethical Consideration
This research was approved by directors of nursing in a
hospital and a chief nurse in a critical care center under study.
Subjects were those who gained permission to investigate
from the chief nurse in a critical care center.
This research focused on patients and their family, but I
12This paper was published at “the Japan Society of Nursing Research” Vol.33 No.2 in 2010.

Yearbook on Journal of the Japan Society of Nursing Research 2017

mandibular fracture, right forearm fracture, and cerebral
infarction. Medical treatment started immediately.
She had suffered from diabetes. Mr. A brought her primarycare doctor with him and observed her from head to tow
while he talked to a doctor in a critical care center on thefirst day of sickness. Then, he started to whisper something
about her ears. Yet, there was no response from her. Then,he said to her, “Mama, you understand me?” in a loud voice
while touching her hand, and went on to say, “Doctor T. cameto see you.” Then, a single tear slid down her face. Mr. A saw it
and said, “She shed tears.” On the second day of sickness her
friend since elementary school said, “Masayo-chan.” Then, she
opened her eyes a little and gazed around. Mr. A was relievedto see her movement of eyes, saying that “her response wasvery good.” Then, he checked her eyes again by pulling hereyelids up.
In this way Mr. A took her eye responses such as her
movement of eyes, tears, and eye-opening situations when
he talked to her as her responses.
≪Mr. B (father) received the blink and look in his eyes
as the responses to his words in his talking to a patient (hisson).≫
Masaki, his son, fell from the second floor at a buildingsite and hit him on the head and the lower back. He had
consciousness when he was taken by ambulance to thehospital. But he was starting to lose consciousness andexhibited anisocoria, so that cranitomy for removal ofhematoma was performed immediately.
On the fourth day of sickness Mr. B said to Masaki, “Hey,wake up. You’ve slept enough.” Then, his left eye opened
slightly and moved from left to right. He said, “I now know
he has consciousness,” and continued to call Masaki. On the
ninth day of sickness, Masaki open his eyes and stared at Mr.
B, who came to see him. Mr. B bowed to apologize again andagain, saying “Can you hear me? I’m sorry. I’m sorry for letting
this happen.” Then, he said at a distance from him, “Don’t lookat me so sharply. He also said to him, “I’m apologizing. Don’t
stare at me so sharply. You do not have to worry about yourwork.... Do you hear me?” Masaki was blinking as responses
to Mr. B’s voice. He said to Masaki, “You hear me, Masaki. I’msorry. I am really sorry for it. I had harsh words for you. I
made you cause physical harm to you. I would not say harshwords to you again. I want to get injured instead of you if it ispossible. Don’t stare hard at me, please. I’m saying I’m sorry.
Hey, Masaki.”In this way Mr. B took Masaki’s eye responses such as eyeopening situations, blinks, and sharp look when he talked tohim as his responses.
≪Ms. C (wife) was glad to see Taro (her husband)’s eyeopening as his response in her talking≫Taro said, “I want to drink cold water” after having lunch, so
Ms. C handed the bottle of water to him. As soon as he drank it,

also got permission to mention the behaviors and responsesof nurses and doctors when necessary in the fieldnotes ofthis study.
I just stayed by patient’s family as a staff member of a
critical care center for a few days because it was expectedthat they were quite shocked about patient’s conditions.
Then, I explained my positions and the purpose and content
of this research to them after they started to ask doctors andnurses about patient’s conditions actively. I also told themthat I had worked for a critical care center before, and I wasgoing to give top priority to patient’s life. This explanation
was conducted both orally and in a written form. I made thedata anonymous and explained to them that I did not use
them other than for this research. I also explained to themthat they could freely participate in this research, cancel it,
and did not have to talk about the things that they did notwant to talk about.
I followed critical care center’s treatment policies and themethods of family care, and reported nurses to the things I
could not answer family members’ questions. I also reported
to a chief nurse important information I got from interviews
with subjects after their approval.
In addition, I rechecked the content written in fieldnotes
by asking them as much as possible.
V. Results

Outline of Results
Subjects were three acutely ill patients with impaired
consciousness and their family members. Their family
relationship was two husbands-and-wives and one parentand-child (Figure 1).
The main characteristics of their involvement were as
follows: 1. Family members received patient’s eye movement
as his/her response; 2. They touched his/her body time andagain as responses to their feeling; and 3. They realized
patient’s recovery and imagined the worst situation fromdoctor’s explanation and patient’s slight responses.
In this article ≪≫, “ ”, and ‘ ’show aspects of family
members’ involvement with patients, the words of family
members, and my words, respectively.
The Description of Reconstruction
1. Receiving patient’s eye movement as his/her response≪Mr. A (husband) received eye movement and tears of
Masayo, his wife (patient), as her response to his words.≫
Masayo was lying down on the stairs of her home. When Mr
A. founder her, she was snoring and unconscious. Her eyelids
got swollen and the blood gushed from her nose when an
ambulance arrived. There was no response to ambulancecrew. In a critical care center she was diagnosed as basilar
fracture, traumatic subarachnoid hematoma, zygomatic andFigure 1 : Patients with Impaired Consciousness Hospitalized in the ICU of a Critical Care Center

Mr. A

Mr. B

Ms. C

Sex Agemale 65 to 69
years oldmale 65 to 69
years old
female 75 to 79
years oldInterview
The number ofinterviews
two times

two times

two times

PeriodRelationship11 dayshusband-wife

13 dayswife-husband

10 daysparent-child

Name

Masayo female
60 to 64 years old
Masaki male
30 to 34 years old
Taro male
75 to 79 years old

Patient
Past medical
history
diabetes
none

none

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This paper was published at “the Japan Society of Nursing Research” Vol.33 No.2 in 2010.

Disease namebasilar fracture andcerebral infarction
acute subdural hematoma
and pelvic fracture
encephalopathy after
resuscitation

Yearbook on Journal of the Japan Society of Nursing Research 2017

he lost consciousness and fell down. Ms. C noticed that he did
not breathe, so that she called ambulance. Ambulance crew
performed cardiopulmonary resuscitation. He was diagnosed
as encephalopathy after resuscitation.
On the third day of sickness he just opened his eyes without
blinking them. His wife, daughter, and grandchild came tosee him. His grandchild says, “Grandpa,” then he nodded. His
daughter said to him, “Dad opens his eyes.” Ms. C moved herface close to him. As soon as she looked into his eyes, she said
with a look of surprise, “Yeah, he opens his eyes. Taro, do you
hear me?” She moved his hand over his face and checked the
movement of his eyes, but he just opened his eyes without
blinking them. On the tenth day of sickness, she whispered tohim: “I came here with D-chan and E-chan.” He immediately
opened his eyes. Ms. C said, “You hear me,” and smiled at him.
In this way Ms. C took Taro’s eye-opening when she talked
to him as his response.

my attitude on illness differs from others. Others would not
be able to understand me.” He had an experience of curing
his own disease by doing finger pressure, the technique helearned in karate. The thought that we can cure a disease bypressing acupuncture points came from his own experience.
So, he continued to press his son’s acupuncture points ofhands with his thought that his son would also recover from
illness by doing that.
In this way Mr. B repeated his acts of touching his son’s
hands with the thought that pressing his acupuncture points
would lead to his recovery from illness.
≪Ms. C (wife) continued to touch Taro (husband)’s forehead
and rubbed his legs.≫
Ms. C saw Taro immediately after being lectured that
he was in critical condition by a doctor on the day he wastransferred to critical care center. He had a tube in his throat
to help him breathe and the mechanical sound of a ventilator
was reverberated. In this situation Ms. C hesitated to comeclose to him. After a while she approached him nervously
and called out to him, but there was no response. Then, Ms.
C pulled off bath sheets and massaged his legs from an ankle
to a knee gently. She looked at his feet and tried not to look at
his face. She touched his forehead and called out to him again.
Then, she moved around his feet and started to massage hislegs again. Her daughter was standing on her opposite side.
Ms. C handed a handkerchief to her and whispered, “Is he ina sweat? Wipe it with this, please? Ms. C tried to hand it toher daughter for wanting her to check his conditions but she
gave her surprised look. She noticed that her daughter wasupset over it, so she put away the handkerchief and cameclose to him for checking his conditions by herself. Then, shetouched his forehead again and said, “Otosan.” She knew that
his forehead was not moist and massaged his legs again.
On the tenth day of sickness Taro started to open hiseyes when he was called. Ms. C massaged his legs, saying“Otosan,” and said to me, “He moves his legs a lot. I think hefeels heavy in his legs. He must also have a sore back because
he always lies on his back.” She then said, “he looks painful,”and extended wrinkles between the eyebrows. She said, “hiswrinkles disappeared as I extended them,” laughing with her
grandson. She thought that he had to move his legs actively
with knitting his brows because his legs felt heavy. She
continued to massage his legs in order to relieve his lassitude.
In this way Ms. C repeatedly touched his legs with thethought that it would relieve his lassitude.

2. Repeating the acts of touching patient’s body as the thoughtof his/her family≪Mr. A (husband) repeated flexion and extension
movement of Masayo, his wife (patient)’s legs.≫
On the second day of sickness Mr. A understood that Masayo
was in critical condition, so that he brought her intimate
relatives and friends to a hospital and repeated flexion andextension movement for her while explaining her conditions
to them. On the fourth day of sickness Mr. A said to me, “herjoints would become stiff without exercise” while turning
around her foot joints with strength. He then held her knees
and ankles and repeated flexion and extension movementwith all his strength. His daughter said, “Stop moving themso hard, Dad!” Yet, Mr. A continued to do it, saying emotionallythat “flexing is good because it stimulates her muscle.” I said
to him, ‘you are accustomed to moving legs.’ Mr. A answeredthat “I took care of my mother with cerebral infarction for
two and a half years.” He helped his mother to change diapers
and encouraged her to exercise. Based on this experience, herepeated flexion and extension movement for her. Mr. A has
played golf for a long time and has won a golf championshipin a senior division. He said, “I like to play golf very much.
Legs are important for golf. Legs are really important.” He
loved golf so much that it became a central aspect of his life.
He also does foot exercises and swing every day. He made ita rule to move legs, therefore, he continued to move her legs
so as not to weaken her legs. On the sixth day of sickness hefelt that her legs were gradually weakening. Her head moved
up and down while he did flexion and extension movement
for her, but he failed to notice it because he concentrated too
much on her legs.
In this way Mr. A repeated to touch Masayo’s legs withthe thought that the flexion and extension movement of legs
would lead to Masayo’s recovery.
≪Mr. B (father) continued to press acupuncture points in
the hand of Masaki (son).≫On the second day of sickness Mr. B said to him, “Masaki,
do you hear me?” while he massaged each hand alternately.
I felt an urge to ask him why he massaged Masaki’s hands
alternately. Therefore, I said to him, ‘You are massaging
each hand of your son alternately whenever you came tosee him. Why do you do it?’ He answered, “I am pressing
acupuncture points. I learned karate when I was young. My
karate master taught me how to press acupuncture points,
so I know many acupuncture points. This is the reason why

3. Family members of patients realized their recovery andexpected the worst by listening to doctor’s explanation andobserving a subtle response of patients.
≪Mr. A (husband) understood doctor’s explanation andperceived Masayo (wife)’s eye-opening situations and movementof her legs.≫
On the fourth day of sickness a doctor said to Mr. A, “Shealso had a stroke, and the current level of consciousness
suggests that her blood vessels are not completely blocked
and there is a dribble of blood.” Mr. A listened to it with afrown. He said, “I think she is in a difficult situation because
her consciousness failed to come back in one or two days. She
also can’t open her eyes completely. I must take into accountthat she is severely diabetic.” Mr. A, his son and daughter met
her after a doctor explained her medical conditions to Mr. A.
Masayo slowly opened her eyes and tried to answer
something when her son said, “Your eyes today is more open

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Yearbook on Journal of the Japan Society of Nursing Research 2017

than yesterday. You hear me?” He thought her conditions were
better than yesterday from this situation. On the other hand,
Mr. A understood that her conditions were serious because
he got an explanation of her conditions from the doctor, sothat he failed to notice Masayo’s movement of eyes. He said
to his daughter and son, “Do you see it?” and tried hard tolook around her eyes. He could not believe that she moved
her eyes, so checked the movement of her eyes by pulling her
upper eyelid. His daughter said, “Daddy, don’t do it. It hurtsher,” but he was thinking about the worst situation without
noticing Masayo’s subtle changes and his daughter’s words.
On the sixth day of illness as soon as he stood at bed side,
he said to me, “The doctor told me that her movement of legs
has become smaller than ever before. After that he lifted up
her legs, twisted and moved ankle joints up and down forobserving the movement of her legs. He held her knees andankles and repeated the flexion and extension movement withthe hope that she might recover from illness.
On the eighth day of sickness she opened her eyes slightly
and moved them when he moved her legs. Then, he said
gently to me, “She would be transferred to F Neurosergical
Hospital on referral from the doctor. I guess I lucked out.”
In this way Mr. A felt she was recovering and thought
about the worse by seeing her eye movement, eye-opening
situations, and the slight changes of the movement of her legs.
≪Mr. B (father) grasped doctor’s explanation, Masaki (hisson)’s responses when he talked to him, and the changes of
his face and legs≫
The doctor said to Mr. B, “I’m going to treat him for saving
her life,” and performed surgery on him. After surgery he cameto see Masaki and called out to him but there was no response.
He despondently said, “How did this happen?” On the third
day of sickness, he said to me, “I thought he slammed his hip
on something at first because he retained consciousness. In
the ambulance he said he had a headache, so his head wascooled. But it turned out this way.” He considered that his son
became unconscious due to surgery. Yet, the swelling of his
face and legs has subsided as the days went by, and his legs
started to move when Mr. B called to him. Then, he began toengage with Masaki with the thought that he was just sleeping
now, and “he must become conscious in a week.” On the fourth
day of sickness Masaki had a fever of 38 degrees C. Yet, Mr. B
said gently, “his condition is good today. The swelling of his
face subsided and his face also looks good.” On the fifth dayof sickness he noticed that Masaki failed to breathe. So hesaid to me, “Masaki sometimes stop breathing.” Masaki juststarted to practice removing a ventilator in order to breatheby himself. He often failed to breathe by himself, therefore
nurses frequently came to check his conditions at bed sideor through a monitor. A doctor told Mr. B that Masaki’s highfever was not due to brain damage, therefore, even if Masaki
failed to breathe, he said, “His eyes shined today, so he isgood. I mean, his eyes were shining when I opened his eyes
a little ago.” Mr. B judged that he was good by observing his
eye conditions.
On the ninth day of sickness Masaki’s knees started tobend, and he was able to ride on a wheelchair with his kneespressed together. Mr. B felt Masaki was gradually recoveringfrom illness. On the tenth day Masaki closed his eyes. Mr. B
said, “Masaki” but there was no response. He said, “Did hebecome unconscious? I think he would be all right because
his face looks different, but I’m worried. His face looks likethe one when he sleeps, so I think it’s OK. But I worried thathe might get unconscious again.” Mr. B understood that
Masaki’s conditions were stable, but whenever Masaki failed
to open his eyes when called, he started to worry that his
condition worsened and he might get unconscious again. In
this way Mr. B realized Masaki’s recovery and the worse caseby listening to the doctor’s explanation of his conditions and
Masaki’s conditions such as edema in his face and legs, thesubtle changes of leg movement, and eye-opening situations.
VI. Discussion

1. Family members touched patient’s body since the first dayof meeting.
They had communicated each other by using words, butthey were at a loss over how to engage with unconscious
patients who could not respond to their words. Then, they
started to touch patients. It would be that they started totalk to patients through the acts of touching. Ichikawa notesthat “The body as an object is not an object detached from asubject. In a case where I touch my hand, this touched handis also a touching hand14).” In this way it is considered thatfamily members interacted with patients through the acts of“touching” and “touched.”
Three family members touched patient’s bodies wheneverthey came to see patients by their own ways, such as
massaging his/her legs, repeating flexion and extension
movement, or pressing acupuncture points. Davis notes that“touching is the most fundamental communicative form as ahuman being15).” It is considered that family members in thisstudy also communicated with patients by relying on theirsense of touching patient’s body. Nakamura mentions that“touching performs acts of holding and grasping things withthe help of muscular sense and motion sense, and this is an actof grasping a total picture16).” It suggests that family members
tried to grasp the whole situation of patients and know how
things really are through touching.
Arthur W. Frank notes that “people’s suffering can beendured by sharing it17)” through his own experience ofcancer. It can be estimated that three family members also
spent time worrying about how to engage with unconscious
patients who could not communicate by using words which
they had used before. It is considered that they endured
the current situation by touching patient’s body as asharing of suffering with them. As Sato notes that “physicalcommunication exists in intimate family relationship18)”, themore family members try to communicate with patients,
the more likely they touch patient’s body spontaneously.
Kashiwagi argues that smooth communication, whether it islinguistic or not, for mutual understanding is indispensablefor the maintenance of communal relationship19). Family
members also touched patient’s body by their own will fromthe first day of sickness for maintaining their relationshipwith patients. This act may look like a unilateral act of family
members but it can be considered that an interactive formof communication between them is realized by the act oftouching. As long as communication starts, the perceptionthat both share suffering contributes to the maintenance ofrelationship between family members and their patients.
For this reason, emergency nurses must encourage family
members of patients to perceive that it is necessary forthem to touch patients in a variety of ways for maintaining
communication between them.
15

This paper was published at “the Japan Society of Nursing Research” Vol.33 No.2 in 2010.

Yearbook on Journal of the Japan Society of Nursing Research 2017by his acts of putting his hand on his forehead when his
conditions were not good. Suzuki notes that “each family
member observes his/her physical and mental conditions one
another daily, so they can respond to his/her subtle changes
and detect an abnormal thing at an early stage25).” Family
members regarded the change of the look in patient’s eyes
and the moist condition of his/her forehead at a meeting ina hospital as his/her responses. They had lived with patients
together. Therefore, they observe patients with a knowledge
that can be acquired only by living together (e.g., a patient
tends to suffer from fever when he/she becomes ill and havepeculiar eyes for others when something upsets him/her).
One could consider that they capture the feature of patientsin an unconscious way.
Nurses usually check the conscious level of patients
based on Glasgow Coma Scale (GCS). They treat patient’s
conscious level as E-1 in a case where they fail to open theireyes when they are called and pain stimulation is given.
Patient’s response perceived by family members may not betreated as conscious response in GCS. Yet, checking patients’
conscious level without failing to examine their responses
that family members noticed would be helpful to detect theirslight movement of eyes and a desperate response by using
their arms and legs. It is considered that emergency nurses
are likely to notice the change of patient’s conscious levelby consciously observing his/her responses which family
members perceived.

2. Family members’ acts of touching patients has graduallychanged.
Family members who met a patient for the first time spoke
to him as usual and tried to grasp the current situations bylooking at him/her. Yet, they soon realized that observation
was not enough to do it after hearing the mechanicalsound of a ventilator and the alarm sound that indicatedan abnormality of patients. It is considered that they wereforced to touch patients for knowing patient’s situations. Ms.
C was at a loss over how to accept Taro’s conditions at first,
so she timidly touched his legs. Mr. A engaged with Masayo at
first with the thought that she would not survive. Nakamura
noted that “touch is not only a skin contact but also a contact
with life itself 20). Each family in this study is also considered
to realize patient’s life through the act of touching a patient.
Ms. C actively engaged with Taro by looking into his faceand extending wrinkles between the eyebrows as Taro is
being pulled back to consciousness. Mr. A noticed that Masayo
slightly moved her legs when he touched them. Then, hemoved her legs based on the method of strengthening legs
acquired through his experience of caring for his motherand through his own hobby. As Ikegawa notes that “we canunderstand the world that patients experience by touchingthem21),” family members understand the process in which
they are becoming conscious gradually by touching theirbody.
Then, Mr. A noticed that Masayo’s legs were weakening as
the days went by, so he started to move her legs very actively.
It would be considered that Mr. A engaged in “acts on the wayof death in the middle of life22)” because he realized that her
conditions were deteriorating.
Therefore, emergency nurses must understand that family
members’ acts of touching patients show that their feelings
emerge as acts such as the act of ascertaining whether
they are alive or not, and the act of realizing their recovery
or death. For this reason, they must also observe family
members’ involvement with patients. They can judge whether
family intervention should be actively conducted or family
members’ involvement with patients should be watchedwithout intervention by observing family conducts.

4. Family members take part in care.
Family members came to see patients every day and shared
the place with them. If they spoke to patients and touched
their hands and legs, they responded to them by opening theireyes and moved legs. Milton Mayeroll notes that being in aplace represents the actual involvement with others in theworld, and this would be continually renewed and reaffirmed
each time26). Family members stayed at the bedside of patientsand tried to have a new relationship with them throughtheir responses. Nishimura notes that “the attitude that tries
to stay by a patient is essentially an act of care27).” Family
members continued to stay by patients whenever they cameto see them in a hospital, and conducted a variety of acts
such as acts of speaking to them, engaging in the flexion andextension movement, and touching their legs. As a reply tothese acts patients opened their eyes and moved their legs.
It is considered that this was created by family members’ actof staying by patients.
Tachiban notes that “It is noted that consciousness iscomposed of two parts: external consciousness (such aspain) that can be comprehended from the outside andinternal consciousness that cannot be shown in voices andbehaviors. Then, from Toyokura’s own experience that cameback alive from penicillin shock, it is important to reassure
patients by giving them an encouraging voice and holdtheir hands for recovering their consciousness28).” In otherwords, even unconscious patients can sense and perceive
both auditory and tactile stimulation, thereby affecting theirinternal consciousness, which in turn may get them to become
conscious. Kaetsu mentions that “in medical tests that involve
pain patients become relaxed by speaking to and touch
them29).” Many tubes are inserted into the body of patientswith impaired consciousness. They lie down on the bed withthe dominating mechanical sound. Therefore, they are in aterrible state of tension. In this situation family members’

3. Family members do not miss slight responses of patients.
It is considered that family members were not only shocked
to see changed unconscious patients but also tried to grasp
their current conditions by their own way which differed fromthe perspective of medical staff.
Mr. B regarded Masaki’s stare as a glaring act. I argued that“some family members who engage with patients hovering
between life and death intensify feelings of guilt and become
traumatized as they meet them in a hospital over and overagain23). Mr. B thought back on his strict attitude toward
his son and began to think that he was responsible for his
disturbed consciousness as he met his sons in a hospital manytimes. Yanagida notes that through the involvement withbrain-dead son “a wordless conversation can be continued
by touching patient’s chest which is warm and breathing. Only
the second person who has cherished and shared life withhim/her can experience it24).” In this way family member’s
response to patients is affected by peculiar past interaction
between them.
Ms. C was surprised to the sudden occurrence of Taro who
had not suffered from a serious disease. It is considered,however, that she tried to understand Taro’s conditions
16

This paper was published at “the Japan Society of Nursing Research” Vol.33 No.2 in 2010.

Yearbook on Journal of the Japan Society of Nursing Research 2017acts of speaking to and touching patients help them to feel
good and get relaxed, which in turn contributes to relieve
their unvoiced pain.
For this reason it is considered that a patient is more likely
to reduce his/her tension and respond to nurse’s touchingcare by family members’ acts of speaking to him/her. Thatis, it is recommended that emergency nurses should plan andcarry out nursing care by cooperating with patient’s family.

disease in order to let them have a new way of looking at it.

The Limitation of This Research and Future Tasks
The subjects examined were only three and their average
period of hospitalization in a critical care center were just 11
days. In this research I attempted to stay by patients and theirfamily members, observe family members’ involvement withpatients, think about the meaning of their acts, and describe
what happened on them. My research adviser advised me tocollect and interpret data precisely, and we held a series of
discussion with members of the support group periodically.
However, this research was conducted in a tense situation
where subjects were in a state of shock. In such a situation it
was sometimes difficult to estimate family members’ feelings.
Therefore, I asked them to talk about their feelings only when
it was judged to be acceptable, and collected data mainly byobserving their behaviors based on participant-observer
study.

5. A Difference of Opinions on Disease Condition Between
Patient’s Family and Medical Professionals
The doctor explained Masayo’s medical condition from
cerebral blood flow, but Mr. A understood it from severe
diabetes from which she suffered for a long time. Mr. B
understood that Masaki was conscious in an ambulancebut showed disturbance of consciousness after undergoing
surgery. He also believed that shiatsu (finger pressure) cures
his disease, so that he pressed acupuncture points in thehands and legs of Masaki in his hospital room. Even if doctors
and nurses explain to family members the current medical
condition and the future treatment in great detail, they tend
to understand patient’s disease situation based on responses
perceived from the perspective of the previous daily life andthe past medical history.
We look into other’s eyes when we talk to them ineveryday life. Mr. B must have also looked into Masaki’s eyes
when he spoke to him. Masaki’s eyes shined, so that Mr. B
was confident that his conditions were good and remained
undisturbed although his breathing temporarily stopped. Mr.
B understood Masaki’s medical condition by looking at hiseyes. On the other hand, nurses considered Masaki just to
be a patient receiving subdural hematomal removal surgery
because they did not know about him before admission to a
hospital. Then, they carefully observed his general condition(especially respiratory condition) because intermittent
arrest of breathing would deteriorate his clinical condition.
This situation suggests that there is a great discrepancy ofperspective between nurses and patient’s family.
Kay Toomes argues on it that doctors are trained to perceive
disease essentially as an aggregate of physical characteristics
and symptoms, but patients experience disease in terms ofinfluence on daily life30). In this way medical personnel must
realize that they tend to try to understand the condition of adisease from patient’s physical symptoms. In addition, family
members need to understand patient’s medical conditions
from their experience of staying with them daily. Watanabe
notes that “family in a serious crisis tends to have cognitive
distortion, so that the communication gap with nurses
sometimes occur31).” Yet, we must not only understand thatpatient’s family members just perceive that one of theirmember is in a crisis but also have an inclination to grasp
his/her medical conditions by their knowledge acquired
through their living with him/her and their involvement withhim/her at the bedside. In order to make Mr. B understandpatient’s conditions, doctors and nurses must encourage
him to become conscious of a type of breathing on which
he failed to focus by explaining that Masaki would suffocatefrom lack of air and cause the lack of oxygen in the brain if
Masaki fails to breathe as Mr. B also become breathless if heholds his breath. In this way family members of a patient are
expected to enhance their understanding of his/her medical
conditions by explaining to them his/her current conditions
with consideration of each family’s peculiar understanding ofVII. Conclusion

This research revealed that there are three aspects ofinvolvement: 1. Family members receive patient’s eye
movement as his/her response; 2. They touch his/her bodytime and again as responses to their feeling; and 3. They
realize patient’s recovery and imagine the worst situationfrom doctor’s explanation and his/her slight responses.
Based on these aspects this research clarified how family
members engaged with patients and the following emergency
nurses’ technique of family support: (i) Encouraging family
members to notice that touching behaviors are necessary tomaintaining communication; (ii) Judging the timing of familyintervention by observing family members’ involvementwith patients; (iii) Noticing the change of patient’s conscious
level instantaneously; (iv) designing and carrying out a careplan which can be conducted with family members; and(v) explaining patient’s medical conditions based on family
members’ peculiar understanding of disease.
Acknowledgments

I appreciate all patients and their family members who
participated in this research. I also gratefully acknowledge
the director of nursing, the chief nurse and other nurses ina critical care center who helped to conduct this research.
Professor Minako Morita and members of the support
group also helped and encouraged me in my research. This
article was revised and developed from the master’s thesis
submitted to the Master’s Program in Nursing, Japanese Red
Cross College of Nursing.
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This paper was published at “the Japan Society of Nursing Research” Vol.33 No.2 in 2010.