Family Centered Care in the ICU Through Open Visiting Hours
Nurses today have a unique challenge and opportunity to effectively balance the provisions of critical care on the acutely ill patient while also striving to meet the needs of family members impacted by the patient’s critical illness. The concept of family has changed over the years and expanded to include blood relatives as well as people that are significant to the patient.
It is a fact that many people will either personally experience a critical illness or be impacted by a critical illness by a friend or family member (Gavaghan & Carroll, 2002).
The concept of family centered care and open visiting hours in the intensive care unit (ICU) has recently come into light as health care professionals, family members and researchers seek to examine the benefits of a more liberal policy for visitation. According to Farrell, Joseph, & Schwartz-Barcott (2005), visitation regulation have largely gone unchanged since the U.S. Public Health Service published visitation recommendations for the intensive care unit in 1962. The research on the subject matter remains limited and far more research is necessary in an effort to acquire empirical data relating to patient responses to a more liberalized visitation policy that is focused on family centered care.
This article seeks to examine the literature available to answer the compelling question as to whether open visitation policy within the critical care environment provides recovery benefits to the patient. Adjunctive to this question is the need to recognize the family as an extension of the patient and determine their needs and motivation. This paper will explore five comprehensive studies in an effort to develop information on the compelling question. Further, each study will be critically reviewed to determine commonalities among the research as well as differences. Finally, the results of the review will provide conclusions that support change in practice and provide strategies for hospitals to develop a visitation policy that is consistent with the research and focused on family centered care.
The first research article is a study conducted by Gavaghan & Carroll (2002) with a purpose to integrate current knowledge about family centered care as a means to develop nursing interventions that promote family centered approach to care in the ICU. The primary thrust of the research was focused on family centered care theory, where the family is viewed as a “social unit that has significant effect on the patient’s outcomes” (Gavaghan & Carroll, 2002, pg. 65). Gavaghan & Carroll (2002) hypothesized that family members have needs that must be recognized by nurses in the critical care environment. Further, the authors set out to clarify these needs through the development of the Critical Care Family Needs Inventory (CCFNI). The CCFNI focused on five conceptual areas that researchers felt were important to the family and included: proximity, assurance, information, support, and comfort. According to Gavaghn & Carroll (2002) psychometric testing of the CCFNI supported appropriate measurement of the data collected by the tool. The study sample consisted of forty family members that completed the CCNFI (N=40). The results of this inventory revealed that family members often felt that their needs for information as well as proximity were met. However, the study revealed that visiting hours, support and comfort were often inconsistently provided by nurses and medical staff. Of special interest is the notion that while the hospital had a posted policy for visitation, nurses were inconsistent in their application of the policy. This inconsistency often made the family feel a sense of distrust to the nurses.
The final conclusion of this survey provided for suggested recommendations to improve family relationships in the ICU and improved satisfaction. Nurses are the primary means of information and support because they are the health care professionals that have direct and constant access to the patient. The study suggests that as a means to improve satisfaction, hospitals develop a visitation policy that embraces family in the care of the patient. Further, the facility should develop a brochure about family centered care and visitation that provides the family with an orientation to the activities of the ICU. Lastly, the author suggested that the use of volunteers to engage families in the orientation process provided needed relief to the nurses and actively involves a group of people that have the time to spend nurturing the family needs.
Another research article written by Farrell, Joseph, & Schwartz-Barcott (2005), focuses on the need to balance patient, visitor and staff needs in terms of open visitation in the ICU. This phenomenological qualitative study was driven by the need to answer the question about nurse perceptions while working with visitors in the ICU. The study focused on a sample of nurses (N=8) that work in the ICU and have voiced concerns over balancing the care of the critically ill patient while attempting to meet the increasing needs of family members. The tools used for this research included observation, questionnaire and interviews with the sample participants. The measurement and analysis of the data included host verification, where the researcher validates the quotes from the sample participants and allows the participants to verify their answers (Polit & Beck, 2004).
The findings of the survey demonstrated that nurses are central to access of the patient. Nurses hold the key to the gateway and depending upon their needs for the day can deny or grant access to the patient by family members. The major concern with this responsibility is the general lack of consistency by the nurses. One nurse may grant family access while another nurse denies access creating a disparity in the nurse-family relationship (Farrell, Joseph, & Schwartz-Barcott, 2005). Central to the nurse-family relationship is for the nurse to understand that family members have a need for information, and access to the patient. Likewise, families need to understand that nurses must balance the critical care of the patient, safety and have the ability to complete the nurse’s work while the family is present. The study also focused on how nurses manage family visitation during the patient’s routine care and when it is appropriate to ask a family member to leave. Study participants overwhelming cited that they asked family members to leave during the provisions of personal care (Farrell, Joseph, & Schwartz-Barcott, 2005). Further, nurses were conflicted as to whether family members should be present during codes. The study suggested that family presence during a code is very individualized and should be left to the discretion of the health care team and the family members (Farrell, Joseph, & Schwartz-Barcott, 2005).
In comparison to the first study reviewed by Gallaghan & Carroll (2002), Farrell, Joseph, & Schwartz-Barcott (2005) suggest that the ICU appoint one individual that can effectively manage the complex needs of the family, thereby allowing the nurse time to care for the patient. While Farrell, Joseph, & Schwartz-Barcott (2005) do not suggest a volunteer can manage this function, it is interesting to note that both studies made this recommendation.
Another study conducted by Livesay, Gilliam, Mokracek, Sebastian & Hickey (2005) detail the experiences of nurses that work in a Neuroscience Intensive Care Unit (NICU). The purpose of this study was to examine nurse’s perceptions about open visitation, determine if the nurses believe the policy needs to be changed, and how the actual policy in place impacts their patient’s recovery. This quasi-experimental research design had a participant sample of registered nurses and patient care technicians (N=30). The measurement tools employed were questionnaires that were distributed to study participants. Of the thirty participants, twenty-six responded (Livesay, et al, 2005). According to the study, 85% of the sample were aware of the visitation policy and provided this information to family members when they inquired about visiting hours. Nurses were more likely to be liberal with the visitation policy (10 of 25) if the patient’s condition was serious. Most of the nurses in the sample indicated they would ask family members to leave the ICU during normal care routines. The majority of nurses would recognize caregiver fatigue on the part of the family member and would suggest that the family member take a break to get a cup of coffee or go for a walk (Livesay, et al, 2005). An interesting point to note here is that the nurses studied most often recognized the family members need for information concerning the condition of the patient. Many family members were reluctant to leave the bedside if there were not some assurances from the nurse that they would contact the family member if the patient’s condition were to change. Another point of interest is that fact that when nurses provided the family with assurance that they would monitor the patient closely; the family member would leave the unit for a rest period (Livesay, et al, 2005).
The conclusion of this study resembled the conclusions of the two other studies reviewed. This study recommended that clear policy be established on visitation and that nurses apply the policy consistently across the board. In addition, the development of educational material and perhaps a contract for care is made between the family member and the nursing staff. This study identified the educational material be used as a means to provide the family with education about the patient’s needs, the nurses responsibilities and ways in which the family can be engaged in the care of the patient. Finally, like the other studies, this study also recommended that support personnel be included in the units of staffing in an effort to relief the nurse from the responsibility of meeting the complex needs of the family. Support personnel can provide the family member with needed information and contact during the critical care stay and increase the family’s satisfaction with the hospital (Livesay, et al, 2005).
The next study reviewed was one conducted by White (1994) that randomly selected 125 hospitals that had an intensive care unit (N=125) and to compare and contrast visiting policies for each hospital. 40% of the sample responded to the survey conducted by White (1994) during the study period. Of this 40% all participants had a visiting policy in place for pediatric and adult ICU. Visiting hours ranged from 8 hours to 14 hours with few having any form of visiting hours after 9:00PM. The general premise of the study was to determine if there were physiological reasons for more liberalized visitation as well as to describe the legal and ethical considerations for a more liberalized visitation policy.
As has been true throughout this literature review, most of the studies, including this study by White (1994) speak to the fact that the nurse is considered the gatekeeper. Use of this term employs the understanding that nurses are often the professional responsible for applying the policy of visitation within the critical care environment. In addition, the nurse directly impacts the family’s ability to have access to the patient or be denied access to the patient (White, 1994). The major difference in this research is the focus on ethical and legal considerations for visitation. According to White (1994), patients and their families have the right to be together through an acute illness. White (1994) suggests that as patients are isolated and in some cases forced isolation, this can and often does cause a general sense of distrust with the staff and increases the recovery period of the patient. Patients need the support and nurturing of their family during times of acute crisis or illness.
The conclusion of this survey suggested that nurses need to have a wide depth of understanding about the policy of the hospital in terms of visitation. Nurses often denied access to visitors if the business of the unit required such actions. Most often cited was the increased acuity of the patient or the staff limitations (i.e. shortages of staff members) (White, 1994).
The final research study that was reviewed was conducted by Eriksson & Bergbom (2007) and was designed to answer the question of whether family visitation actually helps the patient during recovery. While there is much discussion about family visitation, there is very limited research to support or deny the claim that increased visitation by family actually is beneficial to the patient. Eriksson and Bergbom (2007) used a prospective, explorative observational study design to answer the referenced question. They surveyed a sample group of 198 patients and their families during the study period (N=198). The nature of the study was longitudinal because it provided a study review period of eight months. The primary thrust of the study was to examine the results of family visitation on the clinical manifestations of the patient and whether these clinical results were related to increase family support. Data was collected over an eight month span of time and reflected a total of 198 patients. The data was analyzed via the Statistical Package for Social Sciences, Version 12 and deemed reliable (Eriksson and Bergbom, 2007).
At the completion of the study, the data revealed that there is really no conclusive evidence that increased family visitation had a direct positive or negative impact on the patient’s overall clinical performance. In fact, the researchers suggested that more research and study is needed in an effort to provide further evidence on the subject. The authors made reference to the fact that patients in the study that had no visitation during their stay in the ICU had a better mortality rate than those that had visitations (Eriksson & Bergbom, 2007). This result might lead one to believe that family visitations do not have any correlational relationship to clinical performance and recovery.
Each study reflected a reasonable design and analysis methodology. Some studies reflected the perception of nurses with open visitation policies, while other studies focused on the patient’s clinical performance with increased family visitation. In each study, the data was compelling and revealed that family members have a need for close proximity (access) to the patient, a need for information, and a way to be engaged and involved in the patient’s care. Further, most of the studies reviewed suggested that educational material be developed in an effort to provide family members with an orientation to the critical care environment and the stated visitation schedule. Nurses were recognized as the gatekeeper for access to the patient and when there is disparity among nurses in terms of enforcement of vitiation policies it can negatively impact the nurse-family relationship. Some studies went so far to suggest that when visitation policies are not consistently enforced that it can cause a distrustful relationship between staff and family members and reduce overall family satisfaction with care.
Some inconsistency with the studies center around the overall influence open visitation has on the clinical performance of the patient. The study by Eriksson & Bergbom (2007) provided empirical data to refute the hypothesis that increased family visitation actually improve patient’s overall mortality and decreases the recovery process. Evidence from their study is contrary to the new age assumption that open visitation makes a real difference to the patient. While the results of their data may be true, the authors of the study suggest that more research be conducted to in an effort to analyze more data on the subject.
Open visitation in the critical care environment is being widely discussed as a means to improve patient outcomes and provide families with proper access. Research on the topic continues to be very limited. However, there is enough evidence to suggest that family-center care theory can be used as the corner stone of this foundational understanding into human dynamic. Families are evolving and changing and health care professionals must recognize that people who are important to the patient must be considered family members (Gavaghan & Carroll, 2002). While the industry adapts to the changing family unit, there are several strategies that nurses and hospitals can employ in an effort to better meet the needs of patients and their families. Some of these strategies include: the development of consistent and fair visitation policies designed to address the needs of the family, educating nursing staff about the need to fairly and consistently apply the visitation polices across the board without the need for disparity, and the development of educational material designed to orient the family member to the critical care environment as well as provide them with written information about stated visitation schedules. Further recommendations suggest that a member of the volunteer staff be appointed as a family liaison and conduct the family orientation. Also the development of a family engagement contract was suggested by one study in an effort to involve the family with the provisions of care. Finally, in an effort to provide ample access to the patient and allow fatigued caregivers the opportunity to take reasonable rest breaks, one study suggested that the hospital invest in beepers that can be assigned to family members that leave the ICU for breaks. Beepers provide the family member with a peace of mind that if they are needed or if the patient has a change in condition, the nursing staff will have ready access to alert them of these changes.
As hospitals and critical care environments develop their policies, they must keep in mind that nurses play a critical role as gatekeepers for the patient. The primary concern must always be for the well-being of the patient, but the family and their complex needs must be met as well. The challenge faced by today’s professional nurses is truly in the balance of these two different priorities.
Eriksson, T. & Bergbom, I. (2007). Visits to intensive care unit – frequency, duration and impact on outcome. British Association of Critical Care Nurses 12(1). 20-26.
Farrell, M., Joseph, D., & Schwartz-Barcott, D. (2005, January). Visiting hours in the ICU: finding the balance among patient, visitor and staff needs. Nursing Forum, 40(1), 18-28. Retrieved January 29, 2008, from CINAHL Plus with Full Text database.
Gavaghan, S., & Carroll, D. (2002, March). Families of critically ill patients and the effect of nursing interventions. Dimensions Of Critical Care Nursing: DCCN, 21(2), 64-71. Retrieved January 29, 2008, from MEDLINE database.
Livesay, S., Gilliam, A., Mokracek, M., Sebastian, S., & Hickey, J. (2005, April). Nurses' perceptions of open visiting hours in neuroscience intensive care unit. Journal of Nursing Care Quality, 20(2), 182-189. Retrieved January 29, 2008, from CINAHL Plus with Full Text database.
Polit, D. F., & Beck, C. T. (2004). Nursing research: Principles and methods (7th ed.).Philadelphia: Lippincott Williams & Wilkins.
Verhaeghe, S., Defloor, T., Van Zuuren, F., Duijnstee, M., & Grypdonck, M. (2005, April). The needs and experiences of family members of adult patients in an intensive care unit: a review of the literature. Journal Of Clinical Nursing, 14(4), 501-509. Retrieved January 29, 2008, from MEDLINE database.
Whitis, G. (1994, January). Visiting hospitalized patients. Journal Of Advanced Nursing, 19(1), 85-88. Retrieved January 29, 2008, from MEDLINE database.Last edit by Joe V on Jan 12, '15
Jun 7, '08The organization I work for recently adapted patient and family centered care (PFCC). I am grateful for the literature review that this article provides. My perception is that the organization adopted PFCC as a customer service plan rather than an attempt to improve patient outcomes. It looks as if there is not solid data supporting PFCC has a positive affect on patient outcomes.
I work in the Cardiothoracic ICU where a two week trial on open visitation had some interesting outcomes. After two weeks, open visitation was aborted due to risk to the patient and violation of HIPPA. Some rooms in the ICU are not private. Post open heart patients were frequently admitted into a cramped room with 3 beds. The open heart population at this hospital is comprised of very sick patients on which other hospitals refused to perform surgery.
The hours following time to arrival in the ICU of the post open heart patient are busy. Often nurses (2-3) other than the admitting nurse are in the room for the first hour helping to settle the patient. It is frequently in this time period when a patient who is bleeding internally or has other complications declares so with critical vitals. During these episodes, quipment such as a code cart or an open chest cart is brought to the bedside and often the patient is rushed back to the OR. Our experience was that family members from the open heart patient or her/his roommates were repeatedly in the way of staff members and vital equipment, affecting the care of this critically ill patient. Visitors were also at risk as staff members rushed the heavy code cart or open chest cart to the bedside. Staff are aware of the gravity of the situation and expecting the equipment while visitors could be walking one way while looking the other.
Additionally, bedside discussion of a patient during rounds or at other times violated patient privacy as family members of other patients were present in the multi bed rooms. Often visitiors would come into a room during patient care such a a bath or assesment where the patient is exposed. The drawing of a curtain does not always keep visitors from approaching the bedside.
In my experience it is true that nurses are inconsistent with enforcing visitation policy. The idea of a liason orienting family to the unit sounds like a good idea; I would like to see how it works in practice. I also like the idea of the point of contact carrying a beeper. Not only does it introduce the idea of a point of contact (limiting calls to the RN so that she/he can perform patient care), but it sounds like a plan that could decrease family member anxiety.
Thanks for the post. This is a relevant and timely issue.Jun 9, '08Thank you for the nice comments. I agree and also believe this review to be very timely. As a current and functioning ICU nurse, I find that family memebers are generally misunderstood and nurses simply do not have the time to deal with their needs and the needs of the patient. When I conducted the literature review, I was curious to know what research on the subject matter had been done lately. As I mention in the article, there is very little relevant research and far more needs to be done. But I really do believe that Family Centered Care Theory should play a big role in how a hospital puts together visitation policy. And, nurses need to be involved with this policy development as well.
Thanks for your feedback and I am glad to read that you enjoyed the piece.Jun 9, '08It's a fad.
There are real reasons for closed visitation. When most units move to open visitation, they will again be reminded of those reasons.
1. Put a Swan in everyone. No, don't.
2. Levophed = Leave 'em dead. No, it's good for you.
3. Open visitation is a good idea. No, it's not.
There are cycles. This is one. It won't last. It's not patient advocacy. It's not family advocacy.
In short, it's a fad.
Timothy.Jun 14, '08Hi Timothy,
Interesting that you say it is a fad. I reminds me of the nurse that says, "we did it that way and it never worked." I believe that many nurses are beginning to see the value of evidenced-based research and knowledge acquisition as a means to learn more and improve their practice. I really believe that as more hospitals move to open their ICUs to open visitation, there really needs to be a focused effort to define a program of visitation that works for the caregivers (i.e. nurses) and works for the family.
In the literature review I detailed the painful errors that can occur if hospitals and nurses to not fairly apply a resonable visitation policy across the board. It sets up a sense of "us against them" attitude with the family and the nurses. Really, when a patient is critically ill, the nursing staff and the family should be working in concert to bring about wellness. I think a well researched and thought out program of visitation will be a win-win for both nurses and families. To simply have a willie nillie policy does not benefit anyone.
Thanks for your response.Jun 16, '08After having PFCC for greater than 10 years our ICU/CVCU is finally ending this horrible "experiment". Families constantly interefere with care, refuse to leave when asked, can not understand the need for their loved ones to rest and insist on "patting on them constantly". I have had families walk into other patients rooms, in crisis situations, to tell me that their loved just pooped the bed and become irate because I wont immediately tend to them despite the fact that someone else is nearly coding and requiring two to three nurses to care for them. Staff satisfaction finally reached an all time low and the turnover was so high management finally agreed to listen to the nursing staff and rescind this "LUDICROUS" concept. Oh, and I just loved it when family members expected me to be their personal waitress/flight attendant. Of course this policy will not apply to those actively dying.Jun 17, '08I too have experienced the same frustrations as you detail in your post. It can be very difficult to manage a critically ill patient (or more) when a family member is unreasonable and demanding about the care "their" family member needs. This was the reason I conducted the literature review. It has helped my unit make a policy that is "care" driven and focused, but also takes into consideration the needs of the nurses, patient and family members.
Family can be difficult to deal with when you are trying to give care, but a hospital that defines their policy can go a long way to make the lives of nurses a little less frustrating.
Thanks for your response.Jun 17, '08It sounds like your unit has made a point of including the nursing staff in policy development. That is a consideration that is unusual in my experience. I work PRN at regional hospitals in addition to my staff job and have seen decisions made that have substantial implications for clinical practice without the input of the nursing staff. Everything from unit remodel to CIS to PFCC or "open door policy". Many of these units are Magnate and Beacon units.
I think many nurses feel we are expected to please everybody all the time while having little input on decision making. PFCC strikes a particularly sensitive nerve because it is the families and visitors that typically have the most distorted understanding of the role of the RN (particularly in ICU). When PFCC comes down as a mandate from management in order to improve customer service, most likely in response to CMS posting customer satisfaction results on their website, it feels like yet another occurance of the work falling on bedside nursing (as if we were not already overtaxed).
Until hospitals across the board realize this will not be a success without the support of the bedside nurse, PFCC will be met with animosity and resistance.Jun 18, '08LackeyRN - this was the reason I conducted the literature review in the first place. My hospital simply opened the ICU doors to families without any consideration of the nursing implications for this radical change in policy. The director read some where that open visitation in the ICU was the "new age" thing to do and she simply changed the policy. All of the sudden we (the nurses) found our quiet ICU consumed with families and family issues that we had never had to deal with before. Besides family visitors, we also were negotiating a new computerized EMR - it was an overwhleming experience.
I remember being in a staff meeting and telling the director that we really needed to better manage the family issue in the ICU when she said that open visitation was here to stay and we should get use to it. That is when I went on the literature review to learn as much as possible about the subject. The literature review posted here was one that was presented to my leadership (director and CNO) in an effort to better educate them on the consequences of a willie nillie visitation policy.
All too often nurses feel powerless in the policy arena, but if we take the time to do a little foot work - we can make a difference through evidenced-based practice initiatives that directors hopefully pay attention too. In my case - the director paid attention and we discovered that a focused policy that included the nursing staff could work and provide reasonable family engagement and also provide the nurses with a little relief so they could care for patients. It still has some kinks in it, but is working far better than pervious policies.
Thanks for your reply.Jun 19, '08RNPATL -
Thank you for sharing your experience. It is articles such as your literature review and behavior like your response to your administrations actions that are needed to allow for nursing to be accepted as a profession rather than a trade.
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