Effects of an Open Visitation Policy on Patient and Family Centered Care in the ICU

Effects of an Open Visitation Policy on Patient and Family Centered Care in the ICU

Introduction

More than 5.7 million patients are admitted annually to intensive care units (ICUs) in the United States for intensive or invasive monitoring (“Critical Care Statistics”, n.d). Among these 5.7 million patients, there is no way to predict how many of them will have family members present in the ICU. There are many reasons family might not be present, and one for example may be because they are not able to visit during the established visiting hours. Many facilities are developing an open visitation policy, which will allow patients to have visitors twenty-four hours a day. According to McAdam and Puntillo (2013), there are many benefits, for patients and families, to open visitation. Patients feel supported and safe, families are less anxious and satisfied with care, and healthcare providers have increased opportunities for communication and teaching. An open visitation policy has also been found to be beneficial to all members of the health care team.

While deciding a topic for my paper, I took into consideration what I have observed in the clinical setting. With that being said, the first topic of interest that came to mind was the presence of family. While on the floor, I have seen many patients who have not had any visitors throughout the day. After talking with the nursing staff, it became evident that these patients may not have had any visitors at all throughout their hospital stay. Some of these patients are scared and confused and may find comfort in having someone they trust to be with them and help in their decision-making. As a result, I think the encouragement of family presence, and an open visitation policy would be beneficial to the recovery of patients in the ICU. With this information, I decided to propose the question :In the adult intensive care unit (18 and older) (P), what are the effects of an open visitation policy (I), compared to a restricted visiting policy (C) on increased patient satisfaction and care (O)?

Search for Scholarly Literature

In the search to find scholarly research articles related to an open visitation policy I used the La Salle University library catalog. Upon using this catalog, I used databases such as CINAHL and PubMed to find studies or resourceful information about this topic. The reference range that was used to find articles was 2012-2017 and keywords used to search consisted of: open visitation policy, restriction, ICU, critical care, patient and family centered care. In an effort to find five primary sources and one systematic review I reviewed the abstracts of articles until I met the ones that met my criteria that I wanted to include in my research paper.

Primary Sources

Riley, White, Graham, and Alexandrov (2014) conducted a focus group study at a level one trauma, Magnet Recognition Program Hospital, to examine perceptions related to traditional (restricted) ICU visitation among patients’ families, nurses, and physicians. The study took into account the roles of families, communication, visiting times, and the relationship among the health care team and families, in an effort to better understand the barriers to patient centered care. In this study, five ICUs, consisting of trauma, surgical, medical, neurosurgical and cardiothoracic surgery, which have a traditional restrictive visitation policy, were the focus.  In order to participate in the study, the patient and visitors had to be at least eighteen years of age and English speaking. Also, the patient had to have a length of stay of at least seventy-two hours in the ICU and had at least two visits by family during that time. The study then consisted of six focus groups, three groups for the families, two groups for nurses and one group for physicians. Leaders aided in running the groups and the participants were voice recorded, with informed consent, in order to retrieve data. The voice recordings were then analyzed by the researcher and presented as part of the research.

Feelings and beliefs about families’ ICU visitation experiences varied among the patients’ families, physicians, and nurses (Riley et al., 2014). Overall, the family members felt as if they knew their family best and that they should be involved in their care. All groups agreed that the patients’ family is a vital part of the care and that they do belong in the ICU, but to the extent of their presence was where the differences laid. On the aspect of family communication, it was agreed that improvement is needed regarding the patients condition and their plan of care. However, there was a difference of opinion regarding the visitation policy. Families wanted around the clock visitation, but due to procedures being performed they understood why this could not happen. Therefore, the families wanted visitation time that they missed given back to them another time. The physicians stated that the 24-hour visitation was not logical due to the fact that it could interfere with patient care. As far as the nurses were concerned, they had different views on visitation. Some nurses said extended visitation hours would increase their workload, while others claimed that the families need the hours to make sure their family member is okay (Riley et al., 2014). The study was limited in the fact that it was difficult to schedule the interviews due to because the participants needing to stay close to the ICU. Generalizability of the findings is also limited. Future research should compare and contrast findings among patients’ families, nurses, and physicians on units that do not embrace a patient-centered philosophy (Riley et al., 2014). The study did in fact show barriers to care of the ICU patient, and suggests there are changes needed to promote the best care for the ICU patients. Additional research could have included with the actual patients in the study and took into consideration their opinions on the different aspects of the study.

Hart, Hardin, Townsend, and Mahrle-Henso (2013) conducted a correlational descriptive design at a location with five critical care units at a hospital in the southeastern part of the United States.  In order to understand if these variables have significant implications for the health and well being of the patient and family, the researchers examined the satisfaction of the family and nurse, and also the limited visitation on the unit. This study was that of a convenience sample that consisted of family members (n=104), and nurses (n=72). In order to be included in the study you had to be English speaking, twenty-one years old, and have a family member in an ICU at the hospital where the study was being conducted.  This study was based on the framework of the AACN Synergy Model for patient care with the assumption that the needs of the patient and family drive the characteristics or competencies of the nurse (Hart et al., 2013). The participants received a short survey regarding visitation on the unit to complete, either on discharge of the patient (family member), or during their shift (nurses).

This study found a significant difference of opinion between nurses and family on level of satisfaction, time preference, frequency of visitation, and length of visitation  (Hart et al., 2013). It was concluded that nurses were more disappointed with the visitation hours than the family members were.  The researchers used t- tests to identify these results.  This study was incongruent under the basis that it was not carried out in a consistent matter. Some nurses allowed visitation that was not part of the set visitation schedule. Additionally, some units did not follow the visitation policy.  The study was limited due to the fact that the visitation should be done in regards to how the patient is feeling not on a set schedule. Because families can also be a lot to handle during visitation, the nurses had to make sure the patients’ needs are met first and foremost.  Additional research could be done by making sure the visitation policies are carried out throughout the study, and by also making sure the patient is included in the care. Overall, family presence has been found to be a need of the critically ill patient. (Hart et al., 2013) Therefore, in an effort to improve patient outcomes a visitation policy that will be beneficial to the patients needs to be promoted.

Allen, Pascual, Martin, Reilly, Luckianow, Datner, Davis, and Kaplan (2016) conducted a nonrandomized, comparative, before and after trial of incorporating family members on rounds (July to December 2009 vs. January to July 2010). They wanted to ascertain if incorporating the family on rounds in the ICU would improve the patient and family knowledge. Also, they wanted to see if doing so improves team time management and satisfaction with the process (Allen et al., 2016). This study took place in the ICU at a quaternary center. Factors such as family members knowledge, the team’s satisfaction with the intervention, the frequency of meetings, and the physician’s workflow were evaluated. This study included family members on rounds between the hours of 0800 and 1200 for a six-month period, with one particular family member who was invited to participate in rounds and serve as a contact person for the healthcare team. During this study, the post period was compared to the pre period, where family members were not invited into rounds but were able to do so if they were present in the room.  The Pre and Post test groups were assessed using surveys, a log, and a query related to their knowledge and satisfaction, and also asked if they participated in rounds.

Findings related to incorporating the family were not found to be significantly different between the Pre and Post periods.  However, the number of family members on rounds significantly differed between the Pre (112/886 [12.6%]) and Post (571/847; 67.4%; p < 0.001) periods, underscoring the impact of specifically inviting the family participation on rounds (Allen et al., 2016). There was also no change in the number of nurses (n=49), and the amount of resources.  The nurses and intensitivits valued the family involvement where as the anesthesia and surgery participants thought that it took away from their time.  Overall, this study brought more satisfaction to the family, as they were able to receive answers in real time during rounds rather than wait for a doctor. This allowed them to make decisions as needed and also help in developing their loved ones plan of care. This study was limited under the basis that it was only performed at one institution, and only one specific patient population. The time the team spent with the family was also not measured. In addition to this, the study spent more time with the families compared to the patients.  This study also did not distribute follow up surveys to determine how satisfied they, the patients or family members, were with their care. More research could be conducted by expanding this study to multiple institutions. Also, there could be additional time developed for families who may need more questions answered regarding the care of their family member. Overall, this study was beneficial to the patient as the family was able to have a voice in regards to the plan of care and have their questions answered in real time.

Da Silva Ramos, Lins Fumis, Pontes Azevedo and Schettino (2013) conducted a observational and descriptive study to evaluate the perception of physicians, nurses, and respiratory therapists (RTs) regarding open visitation policies (OVP) in an ICU, and also to evaluate the length of stay of visitors in a patients room and the usual type of visitor.  This study was performed in the medial surgical and neuro ICU of a tertiary care center in Brazil. A total of 106 ICU workers participated in the study, as well as 59 patients and their visitors. During this study, family members were permitted to visit their family member during any time. But during two set time periods only two visitors are allowed in the room. During these specified periods, information was collected about the patients and visitors were also evaluated. The visitors were supplied with a badge, which tracked the amount of time they were present on the unit, that they use with each visitation.  As far as the ICU workers, they were given a questionnaire to complete, in regards to demographics, their perception of an OVP, and questions related to communication. These questions were calculated on a scale of one to four in terms of never, occasionally, and frequently. For these tests a p value < 0.05 was considered statistically significant.

Findings related to this study had a negative view of the visiting policy. 53.3% of the participants do not think that the OVP consistently increased family satisfaction with a patients care; 59.4% of ICU workers think that the OVP impairs the organization of the patients care; 72.7% of participants believe that their work suffers more interruptions because of OVP (da Silva Ramos et al., 2013). There is an increasing agreement in adoption of the philosophy that an ICU policy is very important to both critical ill patients and family members (da Silva Ramos et al., 2013). Because all staff have different perceptions of the OVP, this study has fascinating findings.  They agree that families play an active role in the patient care and decision-making, but also agree that OVP interferes with their care of the patient and their work.  It was also found that the nurses feel uncomfortable with the OVP as they feel the family becomes too comfortable and has higher demands. In conclusion, an OVP was found to be beneficial for the patient. This study was limited due to the fact that the questionnaire was not formally validated, and lack of qualitative interviews done with the ICU staff.  This study was also only done at one location in a setting that is unique to only that institution, and did not focus on the family and patients perceptions. Further research could be done to ascertain the impact that the OVP has on the outcome of the patient, and to implement more effective communication skills.

Jacob et al. (2016) conducted an exploratory descriptive study designed to identify the effects of continuous family visitation in the neuroscience ICU on patients’ family members and their needs and experiences during their time in the unit.  The study took place at a twenty seven bed neuroscience ICU at an academic medical center in Atlanta, Georgia.  In order to participate in the study, patients had to be mentally competent and have a family member or friend who had been in the neuroscience ICU for at least forty-eight hours during the preceding three days.  Participants were then recruited via a convenience sample of family members that was studied for two months.  The participants completed short surveys that were composed from three different sources: the Critical Care Needs Inventory (CCNI), the Family Satisfaction in the ICU (FS-ICU) survey, and investigator developed statements specific to the neuroscience ICU at the facility (Jacob et al., 2016). These surveys were measured using both a 4-point and a 5-point Likert scale, and there was also room for the participants to write suggestions about improvement.  The families completed these surveys on their own time, before they were collected by the investigator.

This particular unit designed an environment that would be welcoming to the families. They were made to feel at home and were encouraged to stay in the patient’s room for twenty-four hours a day. Findings related to this study revealed different information than in past studies. The most important needs identified by a family member on the CCNI survey were items related to information about the patient, visiting the patient, being given hope, talking with a doctor each day, and being assured that the best care is being given to the patient (Jacob et al., 2016).  The least important aspects of the study were the needs of the families themselves. According to these surveys, the family members were highly satisfied with improvement being needed in the communication aspect.  This study is limited in the fact that only family members who spent significant time on the unit were surveyed. Another limitation was that this was a newly designed unit with a goal to promote open visitation, if this study was done on an older unit the same results may not have been yielded. Lastly, the study only focused on the needs of the family and not the needs of the staff. Additional research could have been performed by interacting with the patients more to assess whether or not their needs were met. In conclusion, it was evaluated that the need for an open visitation policy is high.

Secondary Source

Goldfarb, Bibas, Bartlett, Jones and Khan (2017) conducted a level I systematic review and meta-analysis to determine whether patient and family centered care (PFCC) interventions in the ICU improve outcomes. Thorough research was done using MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library. Search terms for this study consisted of critical care or ICUs, patient or family centered care, and outcomes and outcome assessments. At the conclusion of the search, forty-six articles were included in the study. In order to be included in the study there had to be PFCC interventions and measured outcomes for patients in the ICU greater than or equal to eighteen years old. They included studies that reported patient and family desired outcomes, such as morbidity, mortality, self reported satisfaction, psychologic symptoms, functional status, quality of life, and comprehension, and measures of resource use, such as use of life sustaining therapies, length of critical care unit or hospital stay, and cost of care (Goldfarb et al., 2017).

After identifying all articles, Goldfarb et al. (2017) examined these studies as a formal meta-analysis. Each study was designed to test the effects of specialized counseling interventions compared with usual care (Goldfarb et al., 2017). The outcomes were based on satisfaction, achievement of medical treatment goals, comprehension, and mental health sequelae. In terms of satisfaction, there was said to be an improvement in regards to communication involving the family members and offering a more liberal visiting policy. As far as achievement of goals, it was found that a palliative care intervention early on was thought to be effective. Comprehension was found to have no significant difference with the patient’s status, communication, and care. The mental health of the patient was also identified to have an improvement. Thirteen studies measured mortality, and only one study reported an improvement in mortality with the intervention. On the other hand twenty studies examined the effects of PFCC interventions on ICU length of stay and 75% of these studies (15/20) were associated with a decreased ICU length of stay (Goldfarb et al., 2017). The length of stay was said to be decreased with the consultation of ethics. Overall PFCC has been shown to be beneficial in decreasing the length of stay, adding to patient satisfaction, and decreasing anxiety.

This systematic review was limited by the quality of retrieved studies, recorded information, limited strength of conclusions, and not including other interventions that may be included in the broader definition of PFCC process; such as noise reduction and sleep improvement (Goldfarb et al., 2017). Further research could be conducted using a wider range of interventions to gain a better understanding of the patients’ feelings. Overall PFCC-focused interventions are associated with patient and family satisfaction, improved mental health status, and decreased resource utilization in ICUs; including decreased length of stay but not with changes in mortality rates (Goldfarb et al., 2017).

Summary

In conclusion, these research findings support that family is an essential part to patient care. Whether it is through an open visitation policy, being included on rounds, or improved communication with the family, it was shown to have a significant improvement on the patients’ outcomes. An open visitation was most beneficial to the patients rather than the family or the staff. The patients were able to be more comfortable during their hospital stay and have the company of someone they trust as an advocate for them. Further research can be done on a wider range of settings instead of units in the same hospital. More studies could also be done that are experimental rather than surveys and questionnaires.  Additional training in communication should also be supplied, as many felt uncomfortable in this category.

Recommendation

I feel there is significant evidence to prove that open visitation is beneficial to the patient’s outcome. Open visitation allows for the families to be involved and see improvement in their family members care. If family members are only allowed during specified times they could be missing essential information on their family member. A family member being in attendance allows them to know exactly what is going on with the patient and allows them to prepare for the care they will have to provide outside of the ICU setting.

References

Allen, S. R., Pascual, J., Martin, N., Reilly, P., Luckianow, G., Datner, E., . . . Kaplan, L. J.

(2016). A novel method of optimizing patient and family centered care in the ICU: Family presence on ICU rounds. Journal of Trauma and Acute Care Surgery, 82 (4), 582-586. doi:10.1097/TA.0000000000001332

Critical Care Statistics (n.d). The Society of Critical Care Medicine. Retrieved from

http://www.sccm.org/Communications/Pages/CriticalCareStats.aspx

Da, S. R., Fumis, R. R., Lins, Azevedo, L. C., Pontes, & Schettino, G. (2013). Perceptions of an

open visitation policy by intensive care unit workers. Annals of Intensive Care, 3(1), 1-8. doi:http://dbproxy.lasalle.edu:2101/10.1186/2110-5820-3-34

Goldfarb, M. J., Bibas, L., Bartlett, V., Jones, H., & Khan, N. (2017). Outcomes of patient- and

family-centered care interventions in the ICU: A systematic review and meta-analysis. Critical Care Medicine, 45(10), 1751-1761. doi:10.1097/CCM.0000000000002624

Hart, A., Hardin, S. R., Townsend, A. P., Ramsey, S., & Mahrle-Henson, A. (2013). Critical care

visitation: Nurse and family preference. Dimensions of Critical Care Nursing, 32(6), 289-299. doi:10.1097/01.DCC.0000434515.58265.7d

Jacob, M., Horton, C., Rance-Ashley, S., Field, T., Patterson, R., Johnson, C., . . . Frobos, C.

(2016). Needs of patients’ family members in an intensive care unit with continuous visitation. American Journal of Critical Care : An Official Publication, American Association of Critical-Care Nurses, 25(2), 118-125. doi:10.4037/ajcc2016258

McAdam, J. L., & Puntillo, K. A. (2013). Open visitation policies and practices in US ICUs: can

we ever get there? Critical Care, 17(4), 171. http://doi.org/10.1186/cc12763

Riley, B. H., White, J., Graham, S., & Alexandrov, A. (2014). Traditional/restrictive vs. patient-

centered intensive care unit visitation: Perceptions of patients’ family members, physicians, and nurses. American Journal of Critical Care: An Official Publication, American Association of Critical-Care Nurses, 23(4), 316-324. doi:10.4037/ajcc2014980

Matrix for Primary Articles (5)

Systematic review Matrix