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Salon 1 15 kasim 11.00 12.00 mari̇on mi̇tchell
- 1. Flexible Visiting in Critical Care Marion Mitchell - Associate Professor, Griffith University ; ICU Princess Alexandra Hospital, Australia. 11th Congress of the Turkish Society of Medical & Surgical Intensive Care Medicine & 10th international Congress of World Federation of Critical Care Nursing, 12-15th November, 2014.
- 2. Background • Admission to CC is stressful to families; • Families need: 1/. Assurance; 2/. Information about their relative; 3/. To be physically close to their relative. • Communication in CC is recognised as an area that needs improving; • Restrictive visiting hours limit access.
- 3. Project Aims 1/. Compare families’ satisfaction with care; 2/. Describe families & patients’ experience of flexible visiting; 3/. Explore ICU staff’s perception of flexible visiting.
- 4. The Princess Alexandra Hospital
- 5. Method • A descriptive mixed-method before/ after study; • Site: 25 bed tertiary referral ICU in Australia; • Participants: 1/. ICU patients; 2/. ICU patients’ family members; 3/. ICU staff
- 6. Method cont’ • Visiting prior to project: 2 at a time; between hours of 11am and 8pm; Outside this was at the discretion of nurse.
- 7. Method cont’ • Intervention Extensive consultation; Development of both staff and visitor guidelines; Open all hours except 8am- 11am
- 8. Method cont’ • Data collection: 1/. Family members - FS-ICU; 2/. Patients – interview in ward; 3/ ICU staff – survey & focus groups. • Recruitment: Notices in ICU waiting room, email to staff, purposeful sampling of patients. Ethical approval received hospital and university HRECs.
- 9. Method cont’ Data Analysis • Surveys: descriptive statistics; bi-variate analysis or t-tests to detect any before and after group differences; FS-ICU; P < 0.05. • Interviews and focus groups: content analysis where data were grouped around central, recurrent ideas.
- 10. Family Member Characteristics Before FV (n=41) Frequency (%) With FV (n=140) Frequency (%) Sex - female 26 (63) 89 (65) ICU experience 18 (44) 59 (43) Live outside city 25 (64) 84 (61) Live with patient N/A 55 (40) Visit weekly N/A 69 (83) Emergency N/A 112 (82)
- 11. FS-ICU results Subscale Pre FV n=41 Mean (SD) During FV n=140 Mean (SD) P value Care: Item 17 Item 18 Total Care 63.7 (20.7) 15.7 (22.2) 70.3 (13.0) 55.6 (22.1) 71.0 (13.8) 69.8 (14.4) 0.03 <0.01 0.98 Decision-making total 64.6 (21.2) 65.1 (19.2) 0.82 FS Total 64.6 (20.3) 68.2 (17.2) 0.30
- 12. Family Satisfaction & Experience of FV (n=135)
- 13. Families’ self reported visits Duration of visit Frequency (%) < 30 mins 12 (8) 30 – 60 mins 19 (14) 1 -2 hrs 15 (11) > 4 hrs 58 (42) Time of visit N 12 mn – 6am 18 6am – 9am 35 11am – 2pm 115 2pm – 6pm 81 6pm – 8pm 72 8pm – 12mn 30
- 16. Staff’s Satisfaction & Experience of FV (n= 84)
- 17. Staff’s focus group results (n=24)
- 18. Discussion • Patients, families and ICU staff supported greater access to patients; • In contrast to the study with cardiovascular patients, patients did not find having visitors disruptive but rather, of enormous benefit; • Similar to other studies, 80% of family visits occurred during what was the pre-intervention visiting hours, resulting in little change for care delivery. • One quarter of family visits occurred outside previous visiting hours indicating that families took advantage of the increased hours as a way to meet their own needs.
- 19. Discussion cont’ • Some nurses were challenged by balancing patient care and family presence; Some nurses wanted privacy; Guidelines for staff and families was of benefit. • With flexible visiting, families were significantly more satisfied with the level or amount of health care their relative received.
- 20. Limitations • Single ICU; • Has had family-centred care philosophy; • FS-ICU is lengthy; • Interviews with families may have given more detail.
- 21. Conclusions • Families and patients felt connected; • Families provided support; • Patient’s needs remain paramount; • Visiting guidelines worked well to support junior staff.
- 22. • Acknowledgement: Australian College of Critical Care Nurses for funding this study. TThhaannkk yyoouu
Editor's Notes
- Aims: 1) Compare family members’ satisfaction with care as measured by the Family Satisfaction in the Intensive Care Unit survey (FS-ICU) (32) before and with flexible visiting; 2) Describe family members’ and patients’ experience of flexible visiting hours; 3) Explore ICU staff’s perception of flexible visiting.
- The study was conducted in a general ICU in a 750 bed tertiary-care public hospital in Australia. The ICU was a combined surgical and medical unit with 25 beds admitting approximately 2,000 patients per year. The unit had 13 single rooms with the remaining bed areas separated by fixed or curtained side walls and a curtain front of the cubicle. Many of the rooms have large windows to the outside but these are situated behind the head of the bed. A visitors’ waiting room is located approximately 20 metres outside the main ICU entrance which has a locked front door and intercom system. Between the hours of 9am to 3pm, Monday to Friday, a hospital volunteer greets visitors, assists them with making contact with unit staff, and escorts them to their relative’s bedside once permission to visit is granted by unit staff. The unit has hosted previous studies with a Family-Centered Care philosophy.
- The nursing model for the unit is one-on-one care provided by registered nurses (RNs), around 60% of whom have critical care post graduate qualifications. RNs are responsible for all aspects of care including mechanical ventilation. Before the commencement of the project the unit had a closed visiting policy with visiting limited to between 11am until 8pm daily. Generally, two visitors at a time were permitted. In practice however, individual RNs and /or patient situations resulted in families being permitted to visit for periods outside the stated visiting hours but this was the exception rather than the norm and often related to the specific context (such as the young age of the patient, or a patient’s imminent demise). All signs and information on visiting stated the hours clearly as outlined above. The unit had collected family satisfaction data for six months prior to the commencement of this project using the FS-ICU survey which had been adapted in terminology to suit the Australian context (32).
- Changed visiting processes to facilitate flexible visiting were developed. Extensive consultation was undertaken with all members of staff and guidelines for family members and ICU staff were developed (see Appendix A). Opportunities for family to visit relatives in ICU were available at all hours except 8 - 11am daily. University and hospital ethical approval were received before the project commenced.
- Families: A self-reporting survey was used with three sections: demographic data (eight items), questions relating specifically to the flexible visiting (four items) and the FS-ICU validated survey with 34 items (32, 33). The FS-ICU survey has two sections – overall care (22 items) and decision making (12 items). The majority of the FS-ICU items have a five point scale with possible responses from poor to excellent. We had been collecting FS-ICU for 2 years Patients: Inclusion criteria for patients were broad and purposeful sampling ensured patient characteristics such as gender, age, home location (that is, geographical distance from the hospital), length of stay and admission type (elective or emergency) were included. Patients needed to be able to converse in English. Potential participants were identified from the ICU discharge list and were approached in the ward. Explanation of the study was provided and informed written consent sought. Six questions were developed to obtain a patient view of flexible visiting. These were administered within two days following their discharge from ICU. The interview was conducted in the patient’s room in the general ward by the first author. Verbatim notes and comments were made and read back to the participant at the conclusion of the interview. Staff: (1) All ICU staff, were eligible to participate in the study (N=260). Survey Monkey TM provided the platform for the survey. A reminder email was generated three weeks after the original email communication. The surveys were anonymous and completion of a survey was considered to indicate consent. The 16 item survey contained demographic items, and a combination of forced questions and open ended questions to explore perceptions of flexible visiting. (2) focus groups were held with staff to facilitate additional detail. Focus group were held with staff during quiet periods of the day to facilitate staff attendance during work hours. Informed written consent was obtained prior to commencement of the discussion and participants were assured of confidentiality. Each group discussion commenced with an open ended question on their perceptions of flexible visiting in the ICU. Verbatim notes and comments were taken at the time by the researcher who presented these to the group prior to the completion of the session to check for accuracy and completeness.
- Univariate analysis was undertaken and included Kolmogorov-Smirnov and Chi-square tests or t-tests to detect any before and after group differences related to demographic or clinical characteristics including sex, previous ICU experience, place of residence and satisfaction levels FS-ICU All scores were compared with scores from before and after the introduction of flexible visiting using Wilcoxon’s signed rank test as the data were not normally distributed. The level of significant was set at 0.05. Notes were taken from patient interviews and focus groups with staff. Comments were analyzed using content analysis where data were grouped around central, recurrent ideas (35, 36). Emerging themes and meaningful units within each participant’s responses and across the data from all respondents occurred (36).
- Surgical admission 36 (36) Medical admission 35 (34) Trauma admission 31 (30)
- 17 Atmosphere in waiting room - 63.7 (20.7) 55.6 (22.1) 0.03* 18 Satisfaction with amount of care 15.7 (22.2) 71.0 (13.8) &lt;0.01* The families in the flexible visiting period (n=140) were asked specifically about the flexible visiting hours. Eighty-five percent were either completely satisfied or very satisfied with the opportunity for flexible visiting (see Figure 1) and this translated to over 90% indicating they had a positive experience. Nearly half wrote that they stayed for four or more hours. They visited predominantly between 11am and 8pm (76%); however, 24% of the visits (n=83) extended or occurred outside what was ‘usual visiting hours’ (see Table 3).
- The families in the flexible visiting period (n=140) were asked specifically about the flexible visiting hours. Eighty-five percent were either completely satisfied or very satisfied with the opportunity for flexible visiting and this translated to over 90% indicating they had a positive experience. Nearly half wrote that they stayed for four or more hours.
- They visited predominantly between 11am and 8pm (76%); however, 24% of the visits (n=83) extended or occurred outside what was ‘usual visiting hours’
- The first theme of the importance of flexibility in visiting referred to the family members’ need to be with their relative at various times of the day and night as depicted in these quotations: “[I] understand late night visits aren&apos;t preferred but my profession’s hours are afternoon ‘til night, so providing a more flexible late night [visit] is helpful.” “[You] want to see your relative as and when you need/want to see them.” The second theme was that the patient comes first conveyed the message that although the family was important, the patient&apos;s needs were the first priority irrespective of their own needs. The following quotes from family members convey this idea: “I found the only restrictions were when the nurses were attending to my daughter. This was to be expected. Apart from this I felt completely free and welcome to visit any-time. I very much appreciated being able to visit out of regular hours.” “…the nurse and Drs are doing their best with my son so I understand that sometimes I have to wait until I can see him. His welfare comes above all else. I will visit whenever I am allowed to visit him.” The third theme related to the importance of communication to the family as they waited to see their sick relative and focused on their need to be kept informed as stated below. “My husband was an emergency… we just sat and waited all day. We needed to wait to speak to Doctors.” “When we are told to wait before we can visit sometimes the time we are told is less than the reality. I know my dad’s care is important, vital and prime to us but we worry something has gone wrong.”
- For this, a purposive sample of 12 patients was interviewed. They aged between 20 and 80; both short and long term; emergency and planned admission; city dwelling and outside; Universally, patients were very positive about flexible visiting and the number of visits worked well with just two patients’ expressing a desire for more visits. Patients were asked “what was the best part of having family with you in ICU?” This elicited comments indicating it filled their need for a connection with their relative(s), for example: “They gave me moral support…pleasurable having them there…made me happy.” “[I] hated being by myself…you need someone when you are so sick.” “[My] family must be worried, so good to have them there.” Patients indicated that flexible visiting was a good idea and that there was a great benefit to them as patients but also for their family. “I felt safer [with them there].” “Without them being here I would not be here today.” “[I] had hallucinations, so good to ask “did this really happen?” … helps with reality.”
- The majority of respondents were female and included nurses, doctors, physiotherapists and receptionists. Nurses across all levels of appointments were represented with well over half having post graduate qualifications. Seventy-seven per cent of the staff (n=65) were satisfied with flexible visiting and over two thirds (n=58, 69%) indicated that their experiences were positive (see Figure 2).
- (including nurses, doctors, receptionists, social worker and assistants in nursing). Participants were asked their opinions about flexible visiting in the unit and what they saw as the benefits and barriers to the more open visiting policy. A strong theme was the acknowledgement that flexible visiting was good for families and patients alike. Staff commented that with flexible visiting there was “no separation”; “decreased anxiety for family members” and “relatives appreciate being able to visit outside normal hours” for both work and other reasons. ICU staff considered that if they walked in the shoes of the family members they may be more able to accept the culture change of inclusivity. Some suggested that with family presence, there was the capacity to invite them to help with some of the patient care. Others suggested that having family members there allowed ongoing education and an opportunity to learn about the patient. This was seen to be a benefit by some participants and a barrier by others as they perceived it as time consuming. Other barriers to flexible visiting were seen to revolve around the need for patient privacy and the needs of nurses. One participant stated that “relatives are always there watching you – added pressure as some families critique care”. Some thought that families needed to leave the ICU and at times: “have to peel people away from patients – especially stable patients” but then others acknowledged that “our version of stable is very different to relatives”. They felt that there was a “need to give permission to go home to rest”. Complex family dynamics were felt to be unaffected by the visiting policy “families we have trouble with, we will always have trouble with”. Another highlighted that the increased flexibility of visiting hours worked in a positive way for some families with relationship issues as it “allows conflicting relatives greater time and flexibility to miss each other”.
- 2. Study in Paris ICU - Garrouste-Orgeas M, Philippart F, Timsit J, et al: Perceptions of a 24-hour visiting policy in the intensive care unit. Crit Care Med 2008; 36:30-35 37. Carroll DL, Gonzalez CE: Visiting preferences of cardiovascular patients. Prog Cardiovasc Nurs 2009; 24: 149–154 In the current study, the vast majority of ICU staff reported being satisfied with the new visiting policy and this may have been related to their positive experiences and an understanding that family members need to be near their sick relative (30, 46). This may also have been because there were clear visiting guidelines which are advocated by both the American (4) and English professional nursing associations (28). Some nurses in the current study indicated that they would send family members home albeit when they (the nurse) perceived the patient to be stable or if they considered the family member needed to rest. This suggestion (if taken up by family) meant that nurses no longer had families at the bedside which was important to some who felt families’ presence took them away from patient care. The challenge for some nurses in balancing patient and family care is similar to findings by others and remains an ongoing genuine concern for some nurses who hesitate to provide patient care when family members are present (22, 43, 47-49). The nurses’ need for privacy may be a reflection of their lack of ICU experience and they may benefit from support by senior colleagues and facilities where role modelling family inclusion and a family- centered approach occurs (50). An identified important aspect of having family present is the ability of families to help the staff ‘know’ the patient and individualise their care (29). Family members’ satisfaction with care remained good after flexible visiting was introduced and is in line with other studies’ findings of families’ satisfaction with care (55-57). Although one could argue that there is a lack of ability to discriminate using ICU satisfaction surveys, they can provide an important assessment of family feedback over time for a particular site. The other significant result between the two time periods indicated that family members were significantly more satisfied with the level or amount of health care their relative was receiving in the ICU following the increase in visiting hours (p&lt;0.01). It may be that as families were present for perhaps longer and more periods of time, during which they were able to develop a greater appreciation of the highly specialised care their sick relative received.
- Although overall nurses supported FV, some nurses indicated that they would send family members home albeit when they perceived the patient to be stable or if they considered the family member needed to rest. This suggestion (if taken up by family) meant that nurses no longer had families at the bedside which was important to some who felt families’ presence took them away from patient care. The challenge for some nurses in balancing patient and family care is similar to findings by others and remains an ongoing genuine concern for some nurses who hesitate to provide patient care when family members are present (22, 43, 47-49). The nurses’ need for privacy may be a reflection of their lack of ICU experience and they may benefit from support by senior colleagues and facilities where role modelling family inclusion and a family- centered approach occurs (50). An identified important aspect of having family present is the ability of families to help the staff ‘know’ the patient and individualise their care (29). The other significant result between the two time periods indicated that family members were significantly more satisfied with the level or amount of health care their relative was receiving in the ICU following the increase in visiting hours (p&lt;0.01). It may be that as families were present for perhaps longer and more periods of time, during which they were able to develop a greater appreciation of the highly specialised care their sick relative received.
- Flexible visiting was successfully introduced into an Australian ICU with family visiting permitted for 21 hours each day. A flexible visiting policy facilitated families’ ability to connect and support critically ill patients who overwhelmingly reported wanting the additional time with their family. Patients’ needs remained paramount but every opportunity to include family should be taken as it has the potential to enhance communication, information sharing and reduce the occurrence of psychological morbidities for family members Staff that are hesitant regarding family presence can be supported by clear guidelines and experienced clinicians role modelling family inclusion. Flexible visiting provides a way forward to improve critically ill patient care and recognises its importance to families and patients in their illness recovery.