Family-Focused Care in Adult Critical Care
The Move Towards Open Visitation - This paper explores the issues surrounding family-focused care and open visitation in the adult critical care environment and is divided into three sections. The first section reviews the empirical and theoretical literature on family visitation and critically surveys the application of open visitation policies in the ICU. The second section examines the attitudes of nurses towards liberalized visitation. The final section seeks consensus on a model visitation policy. The importance of family-focused care is affirmed, providing a challenge to the status quo of rigid visitation policies in the ICU.
The Move Towards Open Visitation
There is a concerted move for a more family-centered approach in adult Intensive Care Units (ICUs). A growing body of research strongly suggests that the presence of family members at the bedside facilitates the healing process and may help decrease the patient's length of stay. Patient advocacy groups regard visitation as a necessary component for both family and patient well-being. family members of the critically ill patient want unrestricted access to their loved one in the ICU, and often consider this "their right." With the increased emphasis on patient satisfaction in healthcare, hospital administrators view a more liberalized visitation policy in critical care units as a means to improve customer relations (Roland, Russell, Richards, & Sullivan, 2001).
Open visitation in adult critical care units, however, remains a controversial topic, especially with the nursing staff. Some ICU nurses are very resistant to liberal visitation policies, because of possible alterations in patient physiologic status, interference with patient care, and increased nursing errors due to interruptions and distractions by family members. Nurses in critical care units are the gatekeepers, controlling visitation to protect the patient from stress and infection, and to promote rest (Ramsey, Cathelyn, Gugliotta, & Glenn, 2000). Points of contention are the amount of time allowed and the frequency of visits, who is allowed to visit, and the number of people allowed at the bedside at one time (Brinker, 2002).
Visitation in critical care units is based on practices developed with the first Intensive Care Units in 1965. At that time, the department of public health recommended visitation in the ICU be restricted to immediate family members for short periods of time only. Since then, many health providers have regarded the effects of visitation on the patient as negative. Ensuing restrictive visitation policies have been based on tradition and the preference of caregivers, not on evidence supported by research (Roland et al., 2001).
Clarification of Terms
For the purposes of this article, the following terms are employed:Critically-Ill Patient: "People requiring intensive care... after major surgery, with severe head trauma, life-threatening acute illness, respiratory insufficiency, coma, hemodynamic insufficiency, severe fluid imbalance or with the failure of one or more of the major organ systems" (thefreedictionary.com, 2004, 2).
Critical Care Unit: Any unit that attends to critically ill patients, including Intensive Care Units, Coronary Care Units, the Emergency Room, or the Post-Anesthesia Care Unit.
Family: "Two or more people whose inter-relatedness is determined by genetic or psychosocial bonds and who may or may not live together" (Picton, 1995, p. 33).
Family-Focused Care: A health care philosophy that views the family as the fundamental unit of care. Patients' needs do not exist in isolation and cannot be separated from those of their families (Picton, 1995).
Review of the Literature: Family Visitation in Adult Critical Care Units
Needs of Adult Patients
Family members are very important in the patient recovery process. Contrary to tradition, the literature supports family presence in the ICU as soothing and reassuring to the patient (Berwick, 2004). Hospitalized patients equate visits with relatives and close friends as demonstrating love and caring (Gonzalez, Carroll, Elliott, Fitzgerald, & Vallent, 2004). Patients with loved ones at the bedside in critical care units suffer fewer hallucinations and have less anxiety (Takman & Severinsson, 2003; Sullivan, 2001). Family visitation is correlated with stable or improving physiologic responses in the patient.
Kleman et al. (1993), in a study of 48 patients with a diagnosis of myocardial infarction (MI), concluded that there is no significant change in mean cardiovascular parameters before, during, or after family visits. Schulte et al. (1993) found no significant difference in heart rate or incidences of ectopy between groups of patients with restricted and unrestricted family visitation. Lazure and Baun (1995) reported less vital sign fluctuation with patient-controlled visitation than in visits controlled by nursing staff. Simpson (1991) determined that family visits were no more stressful than a 10-minute interview when measuring cardiovascular responses. As a matter of fact, both systolic and diastolic blood pressures decreased significantly during family visits.
Similarly, family presence was not associated with increased intracranial pressure (ICP) in patients with brain injuries in a pilot study by Prins (1989). Hendrickson, in a study of 24 patients with neurological conditions, noted a decrease in ICP with family visits in all but six cases (1987). A later study concurred with the finding of decreased ICP with family presence (Hepworth, Hendrickson, & Lopez, 1994).
Needs of Family Members
Liberalized visitation is also beneficial to the family. Critical illness, accidents, and trauma often occur suddenly and unexpectedly, leaving relatives and close friends in a state of shock and disorganization, with little time to adjust. The high morbidity and mortality associated with the ICU setting causes intense feelings of anxiety, uncertainty, and surrealism, compounded by the fact that most families lack experience with catastrophic events. illness in one family member can disrupt the synergy of the entire family (Johansson, Hildingh, & Fridlund, 2002; Nicholson, Montgomery, Craft, & Buckwalter 1993). Families suddenly face multiple stressors such as role changes, disruption of everyday routines, dependency on others, financial concerns, and emotional distress (Johansson et al., 2002). Allowing family members to be present during the critically ill patient's hospitalization helps them better cope with the overwhelming stressors (Gonzalez et al., 2004).
The literature has identified the following needs of families during a critical illness or injury: reassurance, proximity, information, convenience, and support. Reassurance is the need for honest answers to questions and the confidence that the patient is receiving the best care possible. Proximity is physical and emotional access to the patient, which brings comfort to the family and also enables the family to accurately assess the patient's situation. Families require frequent updates in information concerning the patient plan of care, any changes, and the patient's overall progress. They want to know specifically what is being done for their loved one and why. Information grounds the family in what can be reasonably expected and thereby decreases stress and anxiety (Hallgrimsdottir, 2000). A principal fear of family members is missing a vital piece of information concerning the patient's condition (Wagner, 2004). Convenience takes into consideration privacy and comfort, with amenities readily available such as a telephone, comfortable furniture, and refreshments. Support includes extended family members, friends, clergy, and the health care staff. Nursing support for the family engenders an atmosphere of mutual trust (Hallgrimsdottir, 2000). Family members are better able to cope with the patient's illness when these identified needs are met. Increasing family access to their loved one in the critical care environment is a way to fulfill these needs (Wagner, 2004; Marfell & Garcia, 1995).
Family members feel powerless when a loved one is in a potentially life-threatening situation, and they seek methods to cope. Johansson et al. (2002) identified four coping strategies commonly utilized by families with an adult relative in critical care: alleviation, recycling, mastering, or exclusion of feelings. Alleviation of feelings involves the refusal to fully accept the gravity of the loved one's illness. Relatives suppress their feelings to avoid emotional breakdown. Verbalizing their thoughts and feelings among a strong social support network is pivotal for these family members to see clearly and to come to terms with the situation. Recycling feelings is a coping strategy in which relatives mull over their feelings constantly. Feelings of depression and aggression are especially strong among this group. Relatives may vicariously place themselves in their imperiled loved one's situation, in an attempt to minimize their own pain. Mastering feelings involves acknowledging the situation on an intellectual level, but not allowing emotional responses to overtake rational control. This group maintains equilibrium by integrating the tasks of everyday life with duties to the patient and they are able to function at an optimal level during the entire period of illness and recovery. The final coping strategy, exclusion of feelings, involves relatives of patients who are very sick, but appear deceptively well. These critically ill patients are conscious and lucid, and this causes the relatives to have a false sense of assurance with an apparent lack of emotional response. these relatives are not particularly alarmed about the patient's future and lead an almost normal life throughout the course of the patient's hospitalization.
A Framework for Family-Focused Care
Neuman systems model provides a vibrant framework for family-focused care within the critical care environment. This model addresses the social context in which the patient lives (the family) and conceptualizes the patient and family as a single unit of care. The model represents the client within the system perspective, wholistically and multi-dimensionally. The individual patient, though important, does not exist in isolation, even in the hospital setting. The series of concentric circles represent the family and the lines of defense signify coping strategies the family may employ. The nurse's function is to assist the family in regaining the state of equilibrium. neuman systems model helps prevent service fragmentation and gives a clear sense of direction for organizing nursing activities within the ICU culture (Picton, 1995).
Special Needs of Children with Hospitalized Family Members
Children are a special population whose needs must not be overlooked. They are frequently restricted or prohibited from visiting adult family members (Nicholson, Montgomery, Craft, & Buckwalter, 1993). Children with critically ill parents or siblings experience turmoil, disruption of family life, sorrow, anxiety, guilt, conflict, feelings of vulnerability, and a decreased sense of well-being. Isolating children from their sick loved ones stifles their development in cognitive skills and hinders their ability to adequately process the situation. Consequently, they may lack problem-solving strategies or ways to effectively manage their emotions, which further compromises their ability to cope (Titler, Bombei, & Schutte, 1995). Research has suggested that children who are screened for communicable illness are no more likely to spread infection in a hospital ward than adults (Brinker, 2002).
Family Presence During Cardiopulmonary Resuscitation
Controversy exists over allowing family members access during cardiopulmonary resuscitation (CPR). The push for family presence is increasing, because of favorable recommendations by professional organizations (the Emergency Nurse Association [ENA] and the American Heart Association), media attention, and supportive research findings. Studies indicate that having the patient's family present during CPR provides an opportunity to educate the families, facilitates families in the bereavement process, and does not increase healthcare providers' perceived stress (Maclean, et al., 2003).
The impetus for family presence during CPR began at Foote Hospital in Michigan in 1982. On two separate occasions, family members demanded to be present during resuscitation efforts. Positive feedback came from both staff and families regarding the two situations. This caused the facility to reevaluate its policy of keeping relatives out of the resuscitation room (Ardley, 2003; Newton, 2002).
Robinson, Mackenzie-Ross, Campbell, Egleston, and Prevost (1998) found that family members who had witnessed resuscitation had less symptoms of grief three months after the event. Allowing relatives to be present during CPR strengthens the wholeness and integrity of the family unit along the natural continuum from birth to death (Ardley, 2003).
Family Needs after the Patient Expires
Experts agree that the most important nursing intervention for family members immediately following the death of a loved one is to allow the family uninterrupted time alone with the body. Accommodation for religious customs should be made. The provision of a separate waiting room for relatives to be with the decedent is also very helpful, as is providing a nurse to offer culturally-sensitive emotional support and serve as liaison with the newly bereaved family (Kirchhoff & Beckstrand, 2000; Tye, 1992; Fraser & Atkins, 1990).
Attitudes of Nurses towards Liberalized Visitation
Nurses' attitudes and beliefs about visitation often do not correlate with those of patients and their families. Historically, nurses and hospitals have severely limited family visits to the adult intensive care units. Because their primary duty is to the patient, nurses contend that it is easier to give the family undivided attention when visitation is controlled (Brinker, 2002). Research studies of critical care nurses have shown that many nurses feel they lack the time, training, knowledge, and support for the intricacies of family care. Factors discouraging nurses' involvement with relatives include busy units, lack of clear guidelines and responsibilities, fear of conflict with doctors over divulging information, inadequate emotional support, and the absence of interdisciplinary consultation (Hallgrimsdottir, 2000; Chesla & Stannard, 1997; Titler, 1995; Tye, 1993).
Novice nurses lack organizational, assessment, and technical skills for the rigors of critical care and often have difficulty integrating the patient's family into the plan of care with very unstable patients. They also may feel insecure and uncomfortable having family members at the bedside who may scrutinize their performance (Brinker, 2002; Titler, 1995). One critical care nurse wrote:
When an RN is charged with the care of 2 critically ill adults, it is near [sic] impossible to meet your patients' needs, when you are constantly bombarded with family questions, comments, chit-chat, and family psychosocial needs. Most nurses have seen that patients and families don't always want 24-hour access. Nurses who are new to the profession need to concentrate on patient assessment and what they are doing for the patient, and these frequent interruptions lead to more errors and high frustration. I know this is one of the reasons many nurses have left the bedside. A nurse can not be all things to all involved and still meet his or her patient's needs first. I would hope that... we look seriously at not only patient and family needs, but to the bedside nurse and how we can best support their [sic] mission. Heaven knows we need to mentor and support the nurses we have left!
Additionally, many nurses feel that the critical care environment is not set up to accommodate families' constant presence at the bedside. There are concerns about privacy and confidentiality issues and frustration and resentment about family members being "in the way" (Brinker, 2002).
Changing the Culture of a Unit
Family-focused care is a challenging concept to implement into practice in the critical care setting. Changes in the culture do not occur overnight. In attempting any type of planned change concerning visitation, nursing support is essential. Positive beliefs and attitudes of nurses are pivotal in promoting family visitation. Nurses need time to change their way of thinking concerning visitation in critical care and must be convinced of the benefits. Rigid visitation policies should transition gradually into visitation guidelines to allow nurses time to adjust to the shift towards family-focused care. Some nurses may need education, mentoring, skill building, and role-playing opportunities to work comfortably with flexible guidelines and increased family presence and participation. Over a period of several months and in an orderly step-wise progression, visitation guidelines will morph from flexible visiting to open visitation (Brinker, 2002; Titler et al., 1995).
The entire multidisciplinary team must be involved in the transition, if the cultural shift to open visitation is to succeed. There should be clear hospital policies and procedures written to address family visitation. adequate staffing, proper guidance, and support personnel must be provided to the nurses, as well as evidence-based education and mentoring for meeting families' needs. Social workers, chaplains, and child life specialists should be readily available to intervene in crisis situations (Brinker, 2002).
The physical design of the unit must also be adapted for open visitation and to ensure patient privacy and confidentiality. Private rooms are more practical than open wards. There should also be a large, comfortably-furnished room available for newly-bereaved families (Titler et al., 1995; Tye, 1993).
Model Visitation Policy
Visitation policies that are flexible and offer guidelines, not rules, best meet the needs of families, patients, and health care staff. A successful transition to open visitation in the 16-bed shock and trauma ICU was accomplished at Geisinger Medical Center in Danville, Pennsylvania, in August of 2003. Geisinger Medical Center is a 437-bed hospital that provides a wide variety of health care services for more than two million people throughout 38 counties in central and northeastern Pennsylvania (Ondash, 2004; Geisinger Health System, 2003).
The successful transition was brought about after a failed attempt a few years prior. The earlier endeavor lacked sufficient planning and chaos ensued. "It didn't go very well," remarked Lani Kishbaugh, clinical nurse educator of the unit. "Some families would camp out in the ICU. They were sometimes in the way. The doctors felt they couldn't get the work done in there" (Institute for Healthcare Improvement [IHI], 2004, - 8, 9). So the hospital abandoned the open visitation practice and reverted to a strict visitation policy of six 30-minute segments during the day.
An extensive communication program was instituted for the second go-round. Intricate planning and preparation ensured that both families and staff received adequate education, guidelines were set into place, and nurses received training on therapeutic interaction with families. "Having an open visiting policy doesn't mean you simply fling the doors open and stand back," remarked Valerie Johnson, IHI Project Manager for Critical Care Work. "There still have to be guidelines" (IHI, 2004, - 11).
Families are given handouts with important guidelines, which are reinforced by nursing staff. The guidelines are contained in an informal contract, which the family signs when the patient enters the ICU. Establishing a contract with families instills hope and gives a sense of control. The contract ensures consistency with visitation rules, facilitates family involvement, and requires the family to appoint a family spokesperson. It is the job of the spokesperson to field all questions from the family; this alleviates the burden of repetitive questions for the nursing staff. The family participates in patient care, reinforces patient teaching, clarifies expectations, and assists with patient assessment. Family involvement makes discharge a much smoother and seamless process (Marfell & Garcia, 1995).
We tell them we aren't eliminating the rules about visiting. We still remind them that patients who are recovering need rest and uninterrupted sleep. We still limit visitors to immediate family. We still limit the number of visitors. We still ask families to step out when nurses update the next shift on patients' conditions or when a clinician asks them to. We have expectations about how families can use the open hours, and we are working on communicating those expectations effectively.
Family members at Geisinger's are given beepers so they will not feel "tied down" to the unit. Reassurance is given that if changes occur in their loved one's condition, they will be promptly notified. Family members are also allowed to be present during cardiopulmonary resuscitation, if they so desire. A nurse is appointed to stand with the family for support and to answer questions during the resuscitative event (IHI, 2004).
As demonstrated by Geisinger Medical Center, it is possible to incorporate a family focus and successful open visitation policy into the culture of critical care. Visitation policies should be transformed into visitation guidelines, which include anyone the patient regards as "family." Meeting the needs of the patients' family members becomes an essential responsibility of the Intensive Care Unit.
It is the nurse's role as holistic caregiver to attend to the family as well as to the patient. Within the paradigm of family-focused care, patients are no longer seen in isolation but within the normal framework of their family system. Health care professionals, not the family, are the true visitors in patients' lives. The critical illness of the family member is not a single event, but rather an overwhelmingly stressful occurrence on a dynamic continuum involving both the family's past and future. This shift in focus strengthens the family's lines of defense and aids in patient recovery. As family needs are met, anxiety, anger, and hostility decrease. Visitation becomes a necessary, expected, and welcome component of patient and family well being.
Nurses need support to change their beliefs and attitudes, and must be educated regarding visitation myths and the necessity to base visitation protocols on research. Incorporating families into the critical care environment may be difficult, but it is a challenge well worth pursuing.Last edit by Joe V on Jan 12, '15
VickyRN has '16' year(s) of experience and specializes in 'Gerontological, cardiac, med-surg, peds'. From 'Under the shadow of His wings...'; Joined Mar '01; Posts: 12,044; Likes: 6,452.7Nov 8, '07 by ZASHAGALKAIt's a fad.
Once managers and administrators remember exactly why we implemented closed visitation policies in the first place, they will creep back in. Closed visitation is patient advocacy.
"In attempting any type of planned change concerning visitation, nursing support is essential. Positive beliefs and attitudes of nurses are pivotal in promoting family visitation. Nurses need time to change their way of thinking concerning visitation in critical care and must be convinced of the benefits. Rigid visitation policies should transition gradually into visitiation guidelines to allow nurses time to adjust to the shift towards family-focused care. Some nurses may need education, mentoring, skill building, and role-playing opportunities to work comfortably with flexible guidelines and increased family presence and participation."
I don't just need more education or cultural change. Open visitation is wrong. It is wrong for patients. It is wrong for families. It is wrong for nursing.
And your advice here is contradicted by the IHI. THEY recommend sudden change and nursing concerns be danged. Their official recommendation is a cold turkey switch for 2 months and refusal to support staff or hear problems and concerns during that window. See, IHI understands that the nursing support you deem critical will just not be there, and so, per usual management, they switch to a concept of 'buy in' (AKA - 'shut up').
No wonder there is a nursing shortage.
I said this in one of the threads linked below: "Before you change a standard, you do well to examine why the standard was implemented in the first place."
But, I rated your article excellent. Good job! Even if I disagree, I can admire the effort and work put into it.
(NICU and PICUs are different stories. I think parents should be their for their minor children. THAT is a different focus, for a variety of reasons.)
A thread that includes my critique of open visitation to the President of AACN:
LONG thread on open visitation:
Master's Thesis: Suzanne Boswell, E. TN State Univ. May 2004
The Effect of Closed Versus More Liberal Visitation Policies on Work Satisfaction, Beliefs, and Nurse Retention
Long thread with very articulated arguments for and against family presence during codes:
Timothy.Last edit by ZASHAGALKA on Nov 8, '071Nov 10, '07 by cmo421Evidence based practice is what is vogue now and the safest,best way to go,in my opinion. I have long advocated for more family visitation in the ICU's. Guidelines are needed of course,but the proof is there that it works and actually can help prevent errors,pt abuse(yes it is happening) and promotes healing and lowers the incidents of ICU delerium.
Great,well written article! Thanks
Christine3Nov 10, '07 by canoeheadI think in papers and in practice we should emphasize a difference between open visitation in general, and open visitation for family. It should be clear to staff and visitors that opening the ICU doors does not mean the next door neighbor, or coworkers are welcome to come. A critically ill patient should be given privacy and peace to heal.
When our town manager had a MI he had constant visitors from business leaders, employees, and well wishers. It was amazing how many educated and well intentioned people didn't realize that he needed rest, and perhaps wouldn't want to meet his public in a johnny-shirt. Unfortunately he was a type A, and reluctant to cut off the stream, and finished every day exhausted. Other patients have the same problem but on a less obvious level- neighbors, babysitters, etc.1Dec 4, '07 by HoozdoI don't agree with open visitation either, but I agree, beautifully written article.
My unit recently implemented open visitation via this method:
"Having an open visiting policy doesn't mean you simply fling the doors open and stand back," remarked Valerie Johnson, IHI project manager for Critical Care work. "There still have to be guidelines" (IHI, 2004, ¶ 11).
The result has been a nightmare.....but management doesn't care. It is now part of my job to BRING VISITORS FRESH COFFEE, or they complain! No unit clerk, no nursing assistants, unit flooded with visitors even during report.................a new job is looking good to me about now. Down with uncontrolled open visitation!