Parental presence in Italian pediatric intensive care units: a reappraisal of current visiting policies

Mothering children at a paediatric intensive care unit with strict visiting hours: A qualitative study

BACKGROUND

Although a child- and family-centred care (CFCC) philosophy has been emphasized and adopted for decades in paediatric critical care settings in several countries, numerous issues from parents' perspectives regarding the philosophy remain unresolved. To facilitate the full translation of CFCC into clinical practice, health care professionals need an in-depth understanding of family experiences. Real-life mothering experiences, including maternal roles and identities, remain largely unknown at paediatric intensive care units (PICUs) in the Republic of Korea, where family visitation, presence, and participation are restricted.

AIM

To explore mothering experiences at a PICU where family visitation is strictly constrained, and to identify maternal needs and values.

STUDY DESIGN

We conducted a qualitative descriptive study of eight individual in-depth interviews with seven mothers of hospitalized children. Qualitative data were analysed using inductive thematic analysis.

FINDINGS

Five major themes, along with four subthemes, emerged: (1) shifts in maternal roles and responsibilities, (2) shifts in interpersonal relationships, (3) desire for CFCC in the PICU, (4) practising self-defined mothering roles, and (5) reconstructing maternal identities. The themes revealed the experiences of becoming mothers of a child in a constrained PICU. Ultimately, mothers demanded that the unit improve its physical and cultural environments through, for example, liberalized family visitation and participation in the care of their children.

CONCLUSIONS

Nursing professionals should lead the charge for humanizing a restrictive PICU in the Republic of Korea by ensuring a safe and open environment and mothering continuity based on child- and family-centred holistic care.

RELEVANCE TO CLINICAL PRACTICE

Effective interventions must be developed and tested to globally establish and fully implement strong evidence-based CFCC in PICUs; constant co-commitment among children, families, health care professionals, and institutions is also necessary.

Moral Distress in the Italian PICUs: The Role of Individual and Organizational Factors

OBJECTIVES

To assess the interplay between individual and organizational factors on moral distress in PICUs.

DESIGN

Cross-sectional, article-based survey administered between June and August 2017.

SETTING

Twenty-three Italian PICUs.

SUBJECTS

Of 874 eligible clinicians, 635 responded to the survey (75% response rate), and 612 correctly completed the survey. Clinicians were 74% female; 66% nurses and 34% physicians; and 51% had between 6 and 20 years of experience from graduation.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Clinicians completed the "Italian Moral Distress Scale-Revised," the "Connor-Davidson Resilience Scale," and a sociodemographic questionnaire inquiring about sex, profession, years of experience, and spiritual/religious belief. PICU organizational characteristics were also collected (e.g., number of admissions, mortality rate, nurse-patient ratio, presence of parents in PICU, presence of parents during physical examination). To identify individual predictors of moral distress, we used stepwise linear regression. To determine the impact of organizational factors on moral distress, we used analysis of covariance, controlling for those individual factors that emerged as significant in the regression model. Moral distress was associated with being a nurse (B = -0.094; p < 0.05) and not having spiritual/religious belief (B = 0.130; p < 0.01), but not with resilience. Clinicians working in PICUs with a medium number of admissions per year (between 264 and 468), a lower nurse:patient ratio (1:3), and where parents' presence during physical examination were never allowed experienced higher moral distress even controlling for profession and spiritual/religious belief.

CONCLUSIONS

Organizational factors (medium number of admissions, lower nurse:patient ratio, and parental exclusion from physical examination) played a stronger role than individual factors in increasing moral distress. To decrease moral distress, attention should be paid also to organizational aspects.

Family presence in Canadian PICUs during the COVID-19 pandemic: a mixed-methods environmental scan of policy and practice

BACKGROUND

Despite their broad commitment to family-centred care, children's hospitals and associated pediatric intensive care units (PICUs) restricted family presence during the COVID-19 pandemic. This study aimed to describe family presence policies and practices in Canadian PICUs from March to May 2020, and their evolution by August to December 2020.

METHODS

We conducted an environmental scan of family presence policies and restrictions in all 19 Canadian PICUs using 2 methods. We conducted a literature review of public-facing visitation policy documents in June 2020 using a standardized data extraction form. We also administered a cross-sectional survey of PICU leadership (managers and physician chiefs) between August and December 2020 by telephone or videoconferencing. We used inductive content analysis to code qualitative data, generating summative count data. We analyzed quantitative data descriptively.

RESULTS

As part of the literature search, we collected 2 (12%) PICU-specific, 14 (82%) pediatric-specific and 1 (6%) hospital-wide visitation policy documents from the early pandemic. One policy document provided guidance on all of the policy elements sought; the number of enabled caregivers was not included in the documents for 7 of 19 units (37%). All 19 Canadian PICUs were represented among the 24 survey respondents (15 physician chiefs and 9 operations or clinical managers). Before the COVID-19 pandemic, all units allowed the presence of 2 or more family members. Early in the pandemic, reported practices limited the number of adult caregivers for patients without SARS-CoV-2 infection to 1 (n = 21/24, 88%) or 2 (n = 3/24, 12%); all units prohibited siblings. Some centres restricted caregivers from switching bedside presence with one another (patients without SARS-CoV-2 infection: n = 16/23, 70%; patients with confirmed or suspected SARS-CoV-2 infection: n = 20/23, 87%); leaving their child's PICU room (patients without SARS-CoV-2 infection: n = 1/24, 4%; patients with confirmed or suspected SARS-CoV-2 infection: n = 16/24, 67%); and joining in-person rounds (patients without SARS-CoV-2 infection: n = 9/22, 41%; patients with confirmed or suspected SARS-CoV-2 infection: n = 17/22, 77%). All respondents endorsed policy exceptions during end-of-life care. Some reported policies and practices were adapted over the study period.

INTERPRETATION

Early COVID-19-related family presence policies in Canadian PICUs varied among centres. Although some centres adapted policies and practices, this study revealed ongoing potential threats to family centred care at the mid-pandemic stage.

Family Presence and Visitation Practices in Latin American PICUs: An International Survey

Over the last two decades, there has been a worldwide cultural shift toward family-centered intensive care. In this article, we conducted a survey of 47 pediatric intensive care units (PICUs) across 11 Latin American countries to assess visitation practices and bedside family presence (with a 97.9% response rate). All PICUs had at least some form of parental visitation. The prevalence of unrestricted (24 hours/day) parental visitation was 63%. Sibling visitation was permitted in 23% of PICUs, while 35% allowed family presence during procedures, and 46% during resuscitation. Only 1 PICU allowed pet visitation. Family visitation and bedside presence are still restrictive in Latin American PICUs, with wide practice variation among the various intensive care units.

Improving communication toward ICU families to facilitate understanding and reduce stress. Protocol for a multicenter randomized and controlled Italian study

OBJECTIVE

Families of ICU patients have a pressing need for information: they find themselves suddenly in a complex technical environment often because of a life-threatening illness of a loved one. Some evidence suggests that specific communication tools (like websites or brochures) could improve the experience of ICU families.

DESIGN

Randomized, multicenter, stepped wedge trial for large-scale assessment of the effectiveness of a multitasking intervention to improve communication with families of critically ill patients.

MAIN OUTCOME

correct understanding of the prognosis.

SECONDARY OUTCOMES

correct understanding of medical treatments, prevalence of anxiety, depression and post-traumatic stress symptoms in the first ICU week. Prevalence of PTSD 6 months from ICU discharge. Empathy and burnout among ICU staff. Prevalence of refusals for tissues/organ donation, and medical claims.

SUBJECTS

2100 ICU relatives of critically ill patients.

INTERVENTIONS

The intervention employs specific tools especially designed to raise the correctness of information and to improve the quality of communication: a website presenting the ICU world and justifying the relatives' emotions, with a webpage specifically dedicated to each participating ICU; a standard brochure; eight posters for the families' waiting room and a signboard for the ICU door.

MEASUREMENTS AND MAIN RESULTS

The study plans to assess these materials in up to 300 Italian ICUs that will participate, according to a five waves program, each one with randomized starting order. This way the effect of the intervention will be evaluated simultaneously.

CONCLUSION

This is an educational study, aiming to spread good medical practices, while also verifying their real effectiveness in a large number of ICUs.

TRIAL REGISTRATION NUMBER

NCT03438175.