A Look at Critical Care Visitation

Transcription

1 A Look at Critical Care Visitation The Case for Flexible Visitation Jennifer M. Sims, MSN, RN, ARNP, CCRN; Vickie A. Miracle, EdD, RN, CCRN, CCNS, CCRC The topic of critical care visitation has been researched and discussed over the past 25 years and still remains controversial. There still remain many concerns over the benefits of open or flexible visitation. A review of some research conducted in the past several years, perceived barriers to open visitation, and the benefits will be presented in this article. Keywords: Visitation, Open visitation, Flexible visitation, Families [DIMENS CRIT CARE NURS. 2006;25(4):175/181] Critical care visitation is one of those topics that just will not go away and continues to remain controversial. Despite all the research conducted and articles written over the past 25 years extolling the benefits of flexible, open, or individualized visitation in critical care units, there is still much debate about this topic. In fact, a recent survey conducted by the American Association of Critical-Care Nurses (AACN) revealed that only 14% of adult intensive care units (ICUs) had open visitation at all times. 1 Another 44% of units had open visitation on a scheduled basis only, whereas 31% were open except for rounds or shift changes. These results have astonished many who have advocated for open visitation at all times based on the needs of the patient in critical care units. So why hasn t open visitation been more readily accepted? This article will review some of the research conducted and articles written on this topic. Perceived barriers to open visitation will be discussed as well. In addition, benefits of flexible visitation will be presented. For the purpose of this article, flexible visitation is defined as open visitation at the discretion of the nurse. The words flexible and open may be interchangeable in this article. REVIEW OF THE LITERATURE Over the past 25 years, much research has been conducted on the topic of critical care visitation. In addition, several authors have written about this subject. This article does not attempt to discuss all of these research studies and articles. However, a broad overview of some of the material in this area will be presented. Several authors have described their experiences when implementing an open visitation policy in their critical care units. Petterson 2 described the effort of implementing open visitation based on the fact that patients need support and reassurance that sometimes only families can provide. She stated several reasons why open visitation would be beneficial for patients. These reasons include: (1) the need for families to be present during a stressful time for both patients and family members; (2) some family members cannot visit at traditional visiting times due to work or other conflicts; and (3) allowing the family to come and go at various times can actually promote rest because there is no urgency for the patient to be awake at specific times for visitation. The process of implementing open visitation took approximately 1 year and the staff, July/August

2 patients, and families are pleased with the changes. Open visitation balances the needs of patients, families, and staff and improves communication. 2 Many nurses worry about possible detrimental effects of visitation on critically ill patients. However, numerous studies have shown this is not the case. In fact, several studies have found no significant changes in blood pressure, heart rate, and intracranial pressure during visitation. 3-7 A larger study examining this issue was conducted in Italy. 8 The purpose of this study was to compare complications in 2 groups of patients: those who had 1 visitor at any time and any length and those who had 1 visit for 30 minutes twice a day. The researchers found that flexible visitation did not increase complications due to infection and actually reduced cardiovascular complications. Patients were happier with the more relaxed visitation policy. Many nurses worry about the possible detrimental effects of visitation. Needs of family members can also be met through more flexible visitation. 9 Having a loved one in a critical care unit is a stressful event for families. Often family members have unmet needs while a loved one is hospitalized. 10 If the needs of families are not met, the family members may be unable to provide the necessary support to the patient during this time of crisis. 3 Recognizing the needs of family members and taking measures to meet them can lead to improved patient care outcomes. Flexible visitation is one measure critical care nurses can implement in an effort to meet some of the needs of family members as well as the needs of patients Another group of researchers examined the outcomes of changing the visiting policy. 12 One unit implemented open visitation for 30 days and then surveyed the staff, patients, and families about the changes. There was a significant increase in patient satisfaction with the new policy. There was also a significant increase in family satisfaction. However, results were mixed from the nursing staff. A slight majority favored open visitation but several staff members wanted a stricter closed policy. Despite the reluctance of some staff, the unit decided to keep the liberal visitation policy and has seen a significant decrease in the number of complaints from family members and patients. Family members have become more involved in the patient s care, and communication between staff, patients, and families has improved. It must be noted, though, that staff satisfaction with the more liberal visitation policy has not improved. 12 Another group of researchers explained their unit s change to increase visitation. 13 The staff wanted to incorporate families into the patients care. The unit, following a quality improvement process, went from a highly restrictive visitation policy to open visitation, except at shift changes. The new policy has been in effect for 4 years with very positive results. In fact, any nurse interviewed for employment in this unit is asked about attitudes toward families and visitation. The authors describe a very successful approach to open visitation. 13 Many studies have found an increase in family satisfaction with a change in visitation policy In addition, many authors have documented an increase in staff satisfaction with a more liberal visitation policy. 12,13,16-18 Many authors have supported the use of a flexible visitation as a tool to improve patient, family, and staff satisfaction. 1,9,10,19,20 Patient satisfaction with flexible visitation was studied by another group of investigators. 21 As expected, patients believed visitation was not stressful because visitors offered comfort and reassurance. In fact, patients worried less when they were able to see families and friends. Some research has shown that some nurses are reluctant to implement flexible visitation. One study examined the variables which may affect a critical care nurse s attitudes toward visitation. 22 Variables studied included: (1) personal experience as a patient in critical care; (2) personal experience as a significant other in critical care; (3) age; (4) sex; (5) length of experience in nursing; (6) length of experience in critical care; (7) education; (8) position; and (9) religious beliefs. In a sample size of 325 critical car nurses, 18 (5.5%) had personal experience as a patient in critical care and 237 (73.5%) had experience as a family member in critical care. Most subjects (51.4%) favored open visitation from 7 AM to 9 PM at the discretion of the nurse, whereas 37.5% (n = 122) favored open visitation 24 hours a day. No relationship was found between visitation preferences and the following: (1) age; (2) sex; (3) length of experience in nursing; (4) personal experience as either a patient or significant other in critical care; and (5) entrylevel education. However, nurses in management and education positions preferred open visitation (P G.001). Staff nurses preferred restricted visitation (P G.001), which allowed visitation for 30 minutes 4 times a day. A surprising finding was that nurses with less than 1 year of experience in critical care favored open visitation (P G.001). The longer a nurse had worked 176 Dimensions of Critical Care Nursing Vol. 25 / No. 4

3 incritical care, the less he or she favored flexible visitation. In summary, the literature review shows that open visitation has been supported in research and by several authors. There is an increase in patient and family satisfaction and improved communication. Some studies show an increase in nurse satisfaction and improvements in patient and family outcomes. Research has not shown any physiologic detriments to more liberal visitation. PERCEIVED BARRIERS TO FLEXIBLE VISITATION So what is the problem with the implementation of open or flexible visitation in critical care units? Identified perceived barriers include 1. Visitation is too tiring for patients. 12,18,19 As discussed previously, visitation is not stressful for patients. In fact, patients feel more able to rest at various times instead of feeling the need to remain awake during specific times. Patient and family satisfaction are both increased with flexible visitation. Patient rest is actually promoted by a more liberal visitation policy. 2,12 Of course, there are times when patients must rest and visitors must be at the discretion of the nurse, patient, and/or family. Patient rest is actually promoted by a more liberal visitation policy. 2. Visiting could be physiologically harmful for the patient by increasing heart rate and blood pressure. Again, research has not shown this to be the case. Visits by family and friends do not increase, and in some cases will even reduce, blood pressure, heart rate, and intracranial pressure. Family members and friends can provide reassurance and calmness to a critically ill patient. 2,4,6,9,12,19,21-25 Studies also show a decrease in ectopy with visitation. However, nurses have been shown to increase blood pressure, heart rate, and stress levels in critically ill patients. 23,24 One study, on the other hand, did find that visits of 10 minutes every hour did increase a patient s heart rate and blood pressure. The researchers concluded that the visiting schedule and not the actual visitation causes the increase in vital signs. 26 Again, highly individualized visiting is necessary for each patient. 3. The presence of visitors impedes the delivery of nursing and medical care. 9,14,17,19 This has not been supported in the literature. Instead, the family may be helpful to the provision of care, their presence for teaching, and can help facilitate communication between the patient and medical and nursing staffs. In some cases, the family can provide meaningful feedback about the patient s condition. 19 Perhaps nurses need more education on how to meet family needs, crisis management, and how to effectively deal with families. 9,10,22 4. Family members and friends become tired if they visit too much. 17,19 One of the responsibilities of the nursing staff is to help ensure that this does not happen. However, in reality, this does not happen often. Flexible visitation helps ease the anxiety of family members by allowing them to spend time with the patient that is good for them and not on a scheduled basis. Studies have shown that family members feel more relaxed and less anxious when they are able to visit at a time good for them and the patient. 19 Therefore, a few potential barriers to flexible, individualized visitation have been identified and may exist in some circumstances. However, arguments against the barriers are prevalent. The potential benefits of visitation outweigh any disadvantage. But just as in all things nursing or medical, this must be individualized. One of the roles of the critical care nurse is to monitor the patient and do what is best for that patient. In some cases, less visitation may be necessary. Again, weigh the benefits against the risks. BENEFITS OF FLEXIBLE VISITATION There are many benefits of flexible visitation for patients, families, and staff. These have been clearly identified in the literature. The first benefit is the reduction of anxiety of the patient. 8,9,16,18,19 Patients have commented that they feel more relaxed and less anxious when they can see their families and friends. They are less likely to worry about their family members when they can see them often. In addition, patients feel loved and more secure when they have more frequent visitors. 21 Family members are more satisfied with a liberal visitation policy. 2,9,12,16,18,19 With flexible visitation, family members can visit at time that are more convenient for them and not feel they have to be their all of the time or at specific times. In today s busy world, family members have many other responsibilities which may limit when they can visit. 2 In addition, family members may live long distances from the hospital. Open visitation allows them to see the patient whenever July/August

4 they arrive. Family members report less exhaustion with an open visiting policy. 2 A third benefit is communication is facilitated between the staff and families with flexible visitation. 2,12,16,19,20 Family members feel they receive more information about the patient s condition when they see the nursing staff more often. More frequent opportunities to see the patient and the staff can enhance the communication process. Family members have the opportunity to ask questions, be available for teaching, and can participate in the patient s care. Family visitation is crucial the recovery of the patient. 12,14,17,19 Family provides emotional support and reassurance that a critically ill patient desperately needs and that sometimes critical care nurses cannot supply. The fifth benefit of flexible visitation is that it can actually increase the patient s rest. 2,9 Patients can rest between visits and not try to remain awake at specific times. Family members can be encouraged to visit at a time when the patient is awake. This also works for families. They may feel better able to leave the hospital and rest if they realize they can see the patient any time. Another benefit of open visitation is the possible decrease in cardiovascular complications. 8 Several studies have shown a decrease in heart rate, blood pressure, and intracranial pressure with visitation. 2,4,6,9,12,19,21,25 The seventh benefit is increased job satisfaction of the nursing staff. 12 Although this has not been the case in several instances, overall it is possible and does happen. Open visitation can improve a nurse s job satisfaction by providing increased communication opportunities with the family. This can bring positive feedback. Also, increased visitation may decrease the stress of the patient and family and decrease the number of patient and family complaints. Flexible visitation creates more opportunities for family teaching. 12 Families may become more involved with the care of the patient. Therefore, visitation has many benefits for patients, family members, and nurses. These benefits can lead to improved patient care outcomes, family satisfaction, patient satisfaction, and job satisfaction of the staff. IMPLICATIONS So, if the benefits outweigh the barriers, why don t more critical care units practice open visitation? In reality, many units do practice flexible visitation despite their posted visiting schedule. Critical care nurses are very good at identifying the needs of their patients and families and then taking appropriate measures to meet those needs. The problem arises when not all nurses practice the same policy. For example, one nurse may allow the family to visit any time while the next nurse strictly enforces the posted visiting hours. This is confusing for patients and families and can lead to resentment. The visiting policy must be highly individualized to meet the needs of the patient and family as well as the needs of the unit. Perhaps the ideal policy is one that allows visiting at the discretion of the nurse based on the patient s condition. Patients, if possible, should be encouraged to actively participate in the decision-making process of determining an appropriate visiting schedule for them. There are some patients who need the nurse to serve as a gatekeeper for visitors whereas others are comfortable performing this role themselves. The visitation policy must be highly individualized to meet the needs of the patient and family as well as the needs of the unit. Based on the results of the AACN survey, most units are not practicing open visitation at all times despite the strong support of this policy in research and literature. What are some actions critical care nurses can do to make flexible visitation a reality in their units? First, discuss your unit s visiting policy with the staff and nurse managers. Determine why the policy is the way it is. Does everyone follow the policy? Does it meet the needs of the patients and families? Is it designed to meet the patients needs or the unit s needs? A frank, open discussion is crucial before any change can be made, if needed. Remember, change does not occur overnight and is not easy. People are naturally resistant to change. Be prepared for the change process to be a lengthy one. Ask the staff to identify any barriers to flexible visitation and whether these barriers are realistic based on the findings in the literature. Identify any personal concerns or variables which may affect a nurse s attitude toward visitation. Perhaps a nurse may have had bad experiences dealing with families or may not feel comfortable interacting with family members. Address all these concerns early in the process. Second, use research studies to examine what is known about the subject and what has already been studied. Do not reinvent the wheel. Research is there for a reason. Use it. Perhaps a few nurses could volunteer to conduct a literature review and share their findings with the staff. 178 Dimensions of Critical Care Nursing Vol. 25 / No. 4

5 Third, provide continuing education courses to present topics such as the benefits of visitation, interacting with families, crisis management, dealing with angry patients/family members, and needs of families of critically ill patients. Education is one of the keys to a successful implementation of a change in visiting policy. Develop a flexible visitation policy which meets the needs of patients, families, and staff and then test it in the unit. Evaluate the policy with quantitative data: number of complaints, number of compliments, satisfaction surveys, and so forth. Also, look at qualitative data. What are some of the comments? Decide which visitation policy may work best for your unit. For example, try one of the following: (1) open visitation at all times at the discretion of the nurse; (2) open visitation at the discretion of the nurse except at shift changes; (3) open visitation from 7 AM to 9 PM; or (4) any variation of these. Try one to see if it works for the unit. If it does not, try another. Remember, effective change comes slowly. After the visiting policy has been in effect for awhile, evaluate it again. Visiting is like everything else in healthcare. It is constantly evolving and changing based on new information and findings. Be prepared to make changes if necessary. The success of a liberal visiting policy is dependent on education of the staff and staff compliance. All staff members must be willing to comply with any changes in visiting. Without this, the process is doomed to fail. Education is critical to the achievement of success. CONCLUSION Open or flexible visitation in critical care units remains a controversial issue. Despite all the research and information provided in the literature, open visitation is still not practiced, at least on paper, in most critical care units. However, flexible visitation is practiced more frequently by many critical care units despite the posted visiting hours. A more liberal visiting policy can improve patient care outcomes, reduce patient anxiety, improve family satisfaction, and improve communication between patients, families, and nurses. Visitation has been shown to improve the quality of care for both patients and families. Critical care nurses should remain the gatekeeper for visitors. Nurses are in the best position to identify the needs of patients. Not all patients need visitors at all times. Base your decision on visitation on the needs of the patient which will vary from time to time. Highly individualized visitation must be structured around the needs of the patient. The visiting policy for the unit must reflect this. There should be no universal restriction in a visiting policy. Take steps to remove any obstacle to visiting in critical care unit. Become more comfortable interacting with families. Examine your own thoughts and beliefs about visitation. Then take the necessary actions to devise a visitation policy which is highly individualized for each patient and one that meets the needs of patients, families, and staff. In the end, all will benefit. References 1. Kirchhoff KT, Dahl M. American Association of Critical-Care Nurses National Survey of Facilities and Units Providing Critical Care. Am J Crit Care. 2006;15(1): Petterson M. Process helped gain acceptance for open visitation hours. Crit Care Nurse. 2005;25: Chaves CW, Faber I. Effect of an education-orientation program on family members who visit their significant other in the intensive care unit. Heart Lung. 1987;16: Fuller VF, Foster GM. The effect of family/friend visitors vs staff interaction on stress/arousal of surgical intensive care unit patients. Heart Lung. 1982;11: Schulte DA, Burrell LO, Gueldner SH. Pilot study of the relationship between heart rate and ectopy and unrestricted vs restricted visiting hours in the critical care unit. Am J Crit Care. 1993;2: Simpson T, Shaver J. Cardiovascular responses to family visits in critical care unit patients. Heart Lung. 1990;19: Hendrickson SL. Intracranial pressure changes and family presence. J Neurosci Nurs. 1987;19: Fumagalli S, Boncinelli L, LoNostro A, et al. Reduced cardiocirculatory complications with unrestrictive visiting policy in an intensive care unit. Circulation. 2006;113: Cullen L, Titler M, Drahozal R. Family and pet visitation in the critical care unit. Crit Care Nurse. 2003;23(5): Miracle VA. Educational needs of families of critically ill patients. Ky Nurse. 1994;42(2): McClowry SG. Family functioning during a critical illness: a system theory perspective. Crit Care Nurs Clin North Am. 1992;4(4): Roland P, Russell J, Richards KC, Sullivan SC. Visitation in critical care: process and outcomes of a performance improvement initiative. J Nurs Care Q. 2001;15(2): Giuliano KK, Giuliano AJ, Bloniasaz E, Quirk PA, Wood J. A quality-improvement approach to meeting the needs of critically ill patients and their families. Dimens Crit Care Nurs. 2000;19(1): Ramsey P, Cathelyn J, Gugliotta B, Glenn LL. Restricted vs open ICUs. Nurs Manage. 2000;31(1): Simpson T, Wilson D, Mucken N, Martin S, West E, Guinn N. Implementation and evaluation of a liberalized visiting policy. Am J Crit Care. 1996;5(6): Ramsey P, Cathelyn J, Gugliotta B, Glenn LL. Visitor and nurse satisfaction with a visitation policy change in critical care unit. Dimens Crit Care Nurs. 1999;18(5): Carlson B, Riegel B, Thomason T. Visitation: policy vs practice. Dimens Crit Care Nurs. 1998;17(1): Simon SK, Phillip K, Badalamenti S, Ohlert J, Krumberger J. Current practice regarding visitation policy in critical care units. Am J Crit Care. 1997;6(3): Berwick DM, Kotagal M. Restricted visiting hours in ICUs. JAMA. 2004;292(6): Brilli RJ. Restrictions on family presence in the ICU. JAMA. 2004;292(22): Gonzalez CE, Carroll DL, Elliott JS, Fitzgerald PA, Vallent JH. Visiting preferences of patients in the intensive care unit and in a complex medical unit. Am J Crit Care. 2004;13(3): Stiles A, Miracle V, Basham K, Wigginton M. Variables which July/August

6 affect a critical care nurse s attitude toward visitation. Ky Nurse. 1996;44(3): Krapohl GL. Visiting hours in the adult intensive care unit: using research to develop a system that works. Dimens Crit Care Nurs. 1995;14(6): Gurley MJ. Determining ICU visitation hours. Med Surg Nurs. 1995;4: Giuliano KK, Giuliano A. Cardiovascular responses to family visitation and nurse-physician collaborative rounds. Heart Lung. 1992;21(3): Brown A. Effect of family visitation on the blood pressure and heart rate of patients in the coronary care unit. Heart Lung. 1976;5: ABOUT THE AUTHORS Jennifer M. Sims, MSN, RN, ARNP, CCRN, is an adult nurse practitioner with Cardiology of Louisville in Louisville, Ky. She also serves on the editorial board of DCCN. Vickie A. Miracle, EdD, RN, CCRN, CCNS, CCRC, is the editor-inchief of DCCN. She also works as a lecturer at Bellarmine University School of Nursing in Louisville, Ky. Address correspondence and reprint requests to: Jennifer M. Sims, MSN, RN, ARNP, CCRN, Cardiology of Louisville, 4003 Kresge Way, Louisville, KY (JS3944@aol.com). Erratum May WA Jr. He s got a gun! Weapons in the emergency roomyyou can survive! Dimens Crit Care Nurs. 2006;25(2): In the article that appears on page 82 of the March/April 2006 issue of DCCN, the legends for Figures 1 and 2 were inadvertently omitted. The figures are given below with their legends. The editor sincerely apologizes for the omission. Figure 1. Smith & Wesson.357 Magnum Revolver (6 shot). NOMENCLATURE OF A REVOLVER (called a revolver because the cylinder, which holds the ammunition, revolves each time the trigger is pulled) 1. MuzzleVend of barrel where bullet exits. Speed of bullet can be in excess of 1,000 to 1,200 feet per second (fps). 2. Front sightvused to align the barrel/muzzle to achieve proper aim to strike intended target; used in conjunction with rear sight. 3. BarrelVlong, tube-like structure in which the fired bullet travels before exiting the muzzle. 4. Rear sightvused to align the barrel/muzzle to achieve proper aim to strike the intended target; used in conjunction with the front sight. 5. HammerVwhen it falls forward, will strike the cartridge in the cylinder directly underneath. Cartridge has a primer. Primer sets on fire the gunpowder. Expanding burning gases in cartridge push the bullet out of the casing and down the barrel. Bullet exits barrel at muzzle. 6. Cylinder releasevused to free the cylinder from the frame of revolver; used to both load and unload revolver or to check and see if revolver is loaded. 7. GripsVused to grip revolver firmly and securely; may be made of wood, plastic, rubber. 8. Trigger guardvprotects trigger from rearward movement by accident, such as from falling or from being dropped and striking a hard surface which might push the trigger to the rear. Rearward movement of the trigger causes a rearward movement of the hammer, causing a potential firing of the weapon. 9. TriggerVwhen pulled to the rear, causes movement of the hammer to the cocked position. When the hammer falls forward, the revolver will discharge. Refer to no CylinderVround chamber that holds ammunition (usually 6 rounds or cartridges; some smaller revolvers, called snub-noses, may hold 5; smaller caliber revolvers may hold 7 or more). 11. Ejector rodvused to push loaded to empty cartridges from the revolver, emptying it for reloading or for storage with the cylinder clear of any cartridges. 180 Dimensions of Critical Care Nursing Vol. 25 / No. 4

7 Figure 2. Sig-Sauer 9-mm semiautomatic pistol (a common police sidearm and popular with shooters). REMEMBERVNEVER POINT THE MUZZLE OF A REVOLVER OR SEMIAUTOMATIC PISTOL AT ANYTHING OR ANYONE YOU DO NOT INTEND TO SHOOT. Firearms are nonthinking pieces of equipment that know neither friend nor foe. Anything in a direct line with the muzzle will be struck if the weapon discharges (by accident or purposely). NOMENCLATURE OF THE SEMIAUTOMATIC PISTOL 1. MuzzleVend of barrel, where bullet exits; can be in excess of 1,000 to 1,200 fps. 2. Front sightvused to align barrel/muzzle to achieve proper aim to strike intended target; used in conjunction with rear sight. 3. Ejection portvempty cartridge case is ejected here to make room for a new cartridge to be fired. 4. Rear sightvused to align barrel/muzzle to achieve proper aim to strike intended target; used in conjunction with front sight. 5. HammerVwhen it falls forward after being cocked, strikes a firing pin. Firing pin is pushed forward forcefully, striking rear of cartridge. Cartridge has a primer. Primer sets gunpowder on fire. Expanding burning gases in cartridge push the bullet out of the front of the casing. Bullet travels down the barrel, propelled by hot gases. 6. GripsVused to hold weapon firmly; may be made of plastic or wood. 7. Magazine wellva long tube used to hold ammunition for a semiautomatic pistol; is removed when empty. 8. Magazine releasevwhen wanting to eject empty magazine, depress button and empty magazine can be removed for reloading. 9. Decocking levelvsafely lowers a cocked hammer to a safe, resting position. 10. TriggerVwhen pulled to rear, causes movement of hammer. Hammer will fall forward, causing a bullet to be fired if pistol is loaded. Refer to no Trigger guardvprotects trigger from rearward movement by accident (such as a fall from being dropped or striking a hard object which might push the trigger, causing the hammer to move backward also). 12. FrameVbody of the pistol containing internal parts. A simple safety rule to always remember is thisvdo NOT PLACE YOUR FINGER INSIDE THE TRIGGER GUARD OR ON THE TRIGGER UNLESS YOU WANT THE WEAPON TO FIRE. July/August