FAMILY CRISIS IN THE CONTEXT OF BONE MARROW TRANSPLANTATION: AN INTEGRATIVE REVIEW

Esta revisión integrada de la literatura se trata de la crisis vivenciada por los parientes del paciente con trasplante de médula ósea (TMO). La muestra se constituyó de 25 publicaciones, una de ellas obtenida del Lilacs y 24 del Medline. Los resultados mostraron la inexistencia de estudios experimentales, y que las intervenciones se dirigen a los aspectos psicológicos y sociales. Considerando los aspectos de la crisis familiar apuntados en los artículos, se observó que el 100% mencionó la característica del evento (diagnóstico de la enfermedad y TMO) y la amenaza percibida; el 52% citó como relevantes los recursos ofrecidos y el 20% indicó que experiencias de crisis pasadas influencian la crisis vivenciada. La comprensión de los elementos de la crisis familiar y la identificación de intervenciones apropiadas ayudan el enfermero en la atención a parientes de pacientes sometidos al TMO.

This study presents an integrative literature review about the crisis experienced by relatives of bone marrow transplant (BMT) patients.The sample consisted of 25 publications, one of which came from Lilacs and 24 from Medline.The results evidenced that there were no experimental studies and that interventions are aimed at psychological and social aspects.In terms of aspects of family crisis indicated in the articles, all publications discussed the characteristic of the event (diagnosis of the disease and BMT) and the perceived threat; 52% of the articles mention the resources offered as being relevant and 20% mention that past crisis experiences influence the current crisis.Understanding  Moreover, there are studies that highlight its use in cell regeneration of the hematopoietic organ.
BMT is defined as a procedure involving intravenous infusion of stem cells -CD34 (removal of bone marrow from a compatible donor, previously selected) -into a previously conditioned recipient.The aim of this procedure is to reconstitute the hematopoietic organ, which has been debilitated either by infiltration of leukimic cells in the bone marrow or by diseases that harm and change blood-cell production (1) .This therapeutic procedure triggers a compromised state of multiple organs and tissues, as well as severe immune depression.This causes higher predisposition to systemic infections and effects due to previous treatments involving chemotherapy, radiotherapy, and use of hepatotoxic and nephrotoxic drugs.Thus, recipient patients need both professional and family support in order to feel secure throughout treatment phases.
In general, hospitals with BMT units allow a family member to accompany the patient throughout the process, from admission to discharge; hence, that person experiences all of the phases and complications involved in the BMT.In such cases, a nursing professional, along with a multidisciplinary team, must provide assistance to both the patient and his or her readaptation of the BMT patient to his or her regular social life (2) .
The primary sources of social support, families have shown changes in terms of demographics and the roles of each element within the family nucleus (3) .Nursing professionals must take the various family universes into consideration: legal (blood relatives, adoptive children, spouses); biological (those genetically related to the patientchildren, parents); social (groups of close friends from the patient's social life); psychological (people who are intimately important to the patient, such as people who co-habit -monasteries, convents, fraternities, and boarding houses; and alternative families, as in the case of homosexuals) (2) .A family may also be formed by people related by marriage or blood who have a relationship that follows rules that are specific to them.Such rules determine the functions and distribution of roles within the group, all of which share the same system of beliefs and loyalties (2) .
Not always are family members ready to deal to deal with and adapt to a crisis: characteristic of the event, perceived threat, evaluation of family resources, and former crisis experience (4) .This analytic model provides the basis for evaluating both the meaning that the crisis has to the family and the

RESEARCH OUTLINE
The present study is an integrative literature review that aims to gather and synthesize pre-existing knowledge about the proposed theme (5) .
Integrative reviews, when critically developed, have the same standards of primary research in terms of clarity and rigor.It is an appropriate strategy for situations in which studies covering a particular subject are insufficient for metaanalysis research to be conducted (6) .
The stages in performing an integrative synthesis of the evidence obtained in the analyzed articles, based on a critical method (5)(6) .
The guiding question of the present study is: how have nursing professionals approached the family crisis theme in BMT?
The LILACS and Pub Med databases were used which have broad coverage of scientific journals in the area of healthcare.Consulting such a large base ensured compliance with the literature recommendation of searching for publications in different sources (7) .The articles were identified in the journal section of the Central Library of the University of São Paulo -Ribeirão Preto Campus.Articles that were not located in this section were requested through the university's Bibliographic Commuting Program (COMUT).
Inclusion criteria for the articles were: journals had to be indexed in the LILACS and MEDLINE databases; published in either English, Spanish, or Portuguese; published during the period from January 1990 to May 2005; applied to human beings independent of color, ethnic group, or religious beliefs; used the descriptors "bmt", "family", "bone marrow transplantation", and "family", respectively in the three languages; approached the subject of assistance to the families of BMT patients.
Once the study sample had been established, the next step was to read the articles with the aim of identifying relevant data in the data collection instrument.
Certain methodological steps were followed to assure higher study reliability: identification of the publication; method used in the publication; methodological problems identified in the development of the investigation; level of evidence in the articles; nursing care strategies and the model of crisis used in the study.
In order to analyze the methodology used in the studies, publications were identified by the following items: journal name, volume, number, page number, year/month of publication, authors, title, type of study, subjects (8) .To analyze evidence found in the articles, a 6-level classification was done (1-evidence obtained from meta-analysis results of randomized clinical trials; 2-evidence obtained in an experimental-design study; 3-evidence obtained in quasi-experimental research; 4-evidence from descriptive studies or a qualitative method approach; 5-evidence from case or experience reports; and 6-evidence collected based on the opinions of experts or lawmakers (9)(10) .To identify the crisis concept used in the studies, they were analyzed following the family crisis model ( 4 Intervention Classification (NIC) (11) for nursing diagnoses: "Interrupted family processes" and "Compromised family coping".Such nursing diagnoses were chosen because they represent the studied family crisis framework.

RESULTS AND DISCUSSION
The final sample was reached after initially analyzing 807 studies obtained from the Medline database.Among these, 783 studies were about medical aspects of BMT and 24 covered family crisis, the theme proposed for the present study, though using a different term.Two additional studies from Lilacs were considered, of which one was a master's dissertation and was included in the sample.Thus 24 (96%) of the analyzed studies were extracted from the Medline database and one (4%) from the Lilacs database.
As for the journals' country of origin, it was observed that 18 (72%) were from the United States, one (4%) from Greece, one (4%) from Canada, one (4%) from Poland, and one (4%) from Brazil.It was impossible to determine the origins of three journals (Clinical Transplant, Support Care Cancer and Psychother Psychosom).The journal with the highest incidence of publication was Oncology Nursing Forum (20%), followed by Cancer Nursing (12%), Social Science Medicine (8%), Canadian Journal Psychiatry (8%), and Yale Journal Biological Medicine (8%).The other journals had only one publication each.
Regarding year of publication, studies showed higher incidence in the years 1990 (16%), 1996 (20%), and 1999 (16%), as shown in Figure 1: and requires greater attention from researchers.The literature states that the best clinical evidence is obtained by experimental clinical studies, taking into consideration accuracy, precision, and practical applicability (12) .
As to the evidence levels (9) , most studies show level four (64%), followed by levels six (28%) and five (8%).Such results demonstrate that the Further studies are needed in order to evaluate the response of family members to different strategies.
family.This study aims to encourage nursing professionals to ponder the emotional crisis that family members of BMT patients may be exposed to.It aims to synthesize the knowledge available in scientific literature concerning family crisis from 1995 to 2005.The family of the BMT patient BMT complexity is capable of producing deep psychological effects on patients, family members, and healthcare professionals.Ignoring such factors and simply considering the procedure's technical aspects may bring serious consequences to all involved.Throughout BMT, the patient and his or her family undergo changes in their psychosocial structures.Hence, nursing professionals have an important role in this adaptation so that the best quality of life may be achieved.The family is an ally of the nursing team in that it provides security and psychological support to the transplant patient during with the situations imposed by BMT.Many times they may not be prepared, know how to ask for help, or simply stand by a loved one.BMT treatment may exceed the patient's or family's adaptation and coping abilities.The treatment necessitates the restructuring of family routines.This is caused by factors such as role changes and the search for financial and emotional resources.Various models of family crisis are stated in the literature.The model chosen for the present study indicates four factors influencing the family's ability family's capacity to adapt to the situation.Moreover, it allows for the identification of family strengths and weaknesses.This makes possible the application of nursing intervention strategies to the situation.The present study was developed with the aim of obtaining knowledge about the family crisis phenomenon.If the BMT patient's family receives emotional and social support, the patient will obtain, in addition to knowledge of the situation, better care and support from the family during treatment.
review are: a) identifying the theme or question of the integrative review: consists of determining the guiding theme of the research in a clear and specific manner, with clinical and theoretical reasoning by the researcher, and then choosing the key words that will be used in the literature search; b) sampling or searching the literature: begin the search in the selected databases to obtain the studies that will be included and analyzed; study selections must be made according to certain criteria in order to obtain internal validity of the review, and such criteria must be clearly and concisely stated in the text; c) studying categorization: consists of defining the information to be extracted from selected studies, using a previously created instrument; d) evaluating studies included in the integrative review: the selected studies must be submitted to critical evaluation, taking into consideration the researcher's clinical experience; e) interpreting results: discuss the analyzed data and compare to pre-existent theoretical knowledge; f) synthesizing knowledge evidenced in the analyzed articles or presentation of the integrative review: ): characteristic of events, perceived threat to family relationships in terms of their status and goals, evaluation of family resources, and past crisis experience.Nursing interventions identified within the text were associated with the interventions proposed by the Nursing

Figure 1 -
Figure 1 -Study distribution by year of publication

LA FAMILIA EN EL CONTEXTO DE TRASPLANTE DE MEDULA ÓSEA: UNA REVISIÓN INTEGRADA
the elements of family crisis and identifying appropriate interventions help nurses in care delivery to BMT patients.