Implementation and sustainment strategies for open visitation in the intensive care unit: A multicentre qualitative study

Practices of the ABCDEF care bundle in intensive care units as reported by nurses: A cross-sectional study from Turkey

BACKGROUND

Recent critical care guidelines recommended the evidence-based ABCDEF care bundle for intensive care unit (ICU) patients. However, limited information is available on the implementation of the bundle in Turkish ICUs.

AIM

To assess the current practices of the ABCDEF care bundle as reported by ICU nurses.

STUDY DESIGN

A cross-sectional study using a web-based survey was conducted. Researchers invited nurses with at least 1 year of ICU experience to participate by sending the link to the research questionnaires they created in Google Forms to the one ICU nurse association and one communication group of which they are members.

RESULTS

A total of 342 ICU nurses completed the survey. Although 92% of the participants performed pain assessments in their ICUs, 52.7% reported not using protocols. Based on the responses of the nurses, spontaneous awakening and breathing trials are performed in 88.8% and 92.4%, respectively, of ICUs. Fewer than half of the participants reported following a sedation protocol in their ICUs. Only 54.7% of ICU nurses surveyed reported routinely monitoring patients for delirium. It was reported that early mobilization was practised in 68.7% of ICUs, but non-ventilated patients were mobilized more frequently (70.2%), and 9.7% of ICUs had mobilization teams. Family members were actively involved in 95% of ICUs; however, 9.7% used dedicated staff to support families and 3.5% reported that their unit was open 24 h/day for visits.

CONCLUSIONS

While the implementation of most pain and sedation evaluations in ICUs were reported by nurses, many of them did not use structured delirium assessments. There is a need to encourage early mobilization programs and family participation.

RELEVANCE TO CLINICAL PRACTICE

Health institutions can improve patient care and outcomes by establishing and standardizing a protocol for each component of the ABCDEF care bundle in ICUs.

Impact of restricted family presence during the COVID-19 pandemic on critically ill patients, families, and critical care clinicians: a qualitative systematic review

BACKGROUND

We aimed to synthesize the qualitative evidence on the impacts of COVID-19-related restricted family presence policies from the perspective of patients, families, and healthcare professionals from neonatal (NICU), pediatric (PICU), or adult ICUs.

METHODS

We searched MEDLINE, EMBASE, Cochrane Databases of Reviews and Clinical Trials, CINAHL, Scopus, PsycINFO, and Web of Science. Two researchers independently reviewed titles/abstracts and full-text articles for inclusion. Thematic analysis was completed following appraising article quality and assessing confidence in the individual review findings using standardized tools.

RESULTS

We synthesized 54 findings from 184 studies, revealing the impacts of these policies in children and adults on: (1) Family integrated care and patient and family-centered care (e.g., disruption to breastfeeding/kangaroo care, dehumanizing of patients); (2) Patients, families, and healthcare professionals (e.g., negative mental health consequences, moral distress); (3) Support systems (e.g., loss of support from friends/families); and (4) Relationships (e.g., loss of essential bonding with infant, struggle to develop trust). Strategies to mitigate these impacts are reported.

CONCLUSION

This review highlights the multifaceted impacts of restricted visitation policies across distinct care settings and strategies to mitigate the harmful effects of these policies and guide the creation of compassionate family presence policies in future health crises.

REGISTRATION

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=290263 .

Development and Validity of the Japanese Version of the Questionnaire on Factors That Influence Family Engagement in Acute Care Settings

There exists an international consensus on the importance of family-centered care (FCC) in intensive care settings and the evaluation of collaboration between nurses and families; however, FCC is currently practiced blindly in Japan. In this study, we developed a Japanese version of the questionnaire, Factors that Influence Family Engagement (QFIFE-J) and examined its reliability and validity. A web-based survey was conducted with 250 nurses working in the intensive care unit (ICU). Exploratory and validatory factor analyses were used to ascertain factor validity. Criterion-related validity was tested using correlation analysis with the ICU Nurses’ Family Assistance Practice Scale. Internal consistency and reproducibility were verified for reliability. Following exploratory and confirmatory factor analyses, a 15-item measure emerged comprising four factors: “ICU environment”, “nurses’ attitudes”, “nurses’ workflow”, and “patient acuity”. Confirmatory factor analyses showed a generally good fit. Cronbach’s α for the overall scale was 0.78, indicating acceptable internal consistency. The intraclass coefficient for test–retest reliability was 0.80. It was found that the QFIFE-J was reliable and valid and may help determine the factors that promote or inhibit FCC. Additionally, this study has also clarified the current status and family support related issues in ICUs in Japan.

Ethical Issues in Using Behavior Contracts to Manage the "Difficult" Patient and Family

Long used as a tool for medical compliance and adhering to treatment plans, behavior contracts have made their way into the in-patient healthcare setting as a way to manage the "difficult" patient and family. The use of this tool is even being adopted by healthcare ethics consultants (HECs) in US hospitals as part of their work in navigating conflict at the bedside. Anecdotal evidence of their increasing popularity among clinical ethicists, for example, can be found at professional bioethics meetings and conversations and idea-sharing among practitioners on HEC social media. While there are a handful of papers gesturing toward a bioethical critique of behavior contracts of various types, the use of behavior contracts in the context of interpersonal conflict has not been vetted by bioethicists to determine their ethical legitimacy or efficacy. In this paper, we highlight a set of ethical concerns that we believe must be addressed before continuing or widespread implementation of behavior contracts to manage the "difficult" patient or family.

From Open to Closed: COVID-19 Restrictions on Previously Unrestricted Visitation Policies in Adult Intensive Care Units

BACKGROUND

In March 2020, rising numbers of COVID-19 infections contributed to changes in intensive care unit visitation policies, with some facilities allowing no visitors.

OBJECTIVE

To compare visitation policies of Magnet and Pathway to Excellence hospitals with prepandemic open visitation in adult intensive care units.

METHODS

A mixed-methods study was conducted from January through March 2021. Quantitative data on visitation policies were extracted from websites of 96 Magnet and Pathway to Excellence hospitals that had allowed unrestricted visits in adult intensive care units before the pandemic. Qualitative data were collected via semistructured interviews with 9 nurse leaders from these hospitals.

RESULTS

More than 1 year after the start of the pandemic, all of the hospitals had instituted restricted visitation policies. The policies varied, with little to no evidence-based justification. Restrictions included 83% of hospitals (n = 80) allowing just 1 visitor per day and 69% of hospitals (n = 50 of 72) allowing no visits at all for patients with COVID-19 in the intensive care unit. Five themes were found when nurse leaders' interviews were analyzed: visitors not welcome, doing harm, external decisions at system level, visiting within limits, and changes in critical care nursing work.

CONCLUSION

Results of the study suggest that despite the vast amount of evidence supporting the benefits of visitation and the harms of restricted visitation and expert recommendations for returning safe visitation to hospitals, Magnet and Pathway to Excellence hospitals continue to enforce restricted visitation policies in intensive care units. Patients, families, and nursing and health care staff must partner to create pandemic-proof visitation policies.

Impact of restricted visitation policies during COVID-19 on critically ill adults, their families, critical care clinicians, and decision-makers: a qualitative interview study

PURPOSE

During the first wave of the COVID-19 pandemic, restricted visitation policies were enacted at acute care facilities to reduce the spread of COVID-19 and conserve personal protective equipment. In this study, we aimed to describe the impact of restricted visitation policies on critically ill patients, families, critical care clinicians, and decision-makers; highlight the challenges faced in translating these policies into practice; and delineate strategies to mitigate their effects.

METHOD

A qualitative description design was used. We conducted semistructured interviews with critically ill adult patients and their family members, critical care clinicians, and decision-makers (i.e., policy makers or enforcers) affected by restricted visitation policies. We transcribed semistructured interviews verbatim and analyzed the transcripts using inductive thematic analysis.

RESULTS

Three patients, eight family members, 30 clinicians (13 physicians, 17 nurses from 23 Canadian intensive care units [ICUs]), and three decision-makers participated in interviews. Thematic analysis was used to identify five themes: 1) acceptance of restricted visitation (e.g., accepting with concerns); 2) impact of restricted visitation (e.g., ethical challenges, moral distress, patients dying alone, intensified workload); 3) trust in the healthcare system during the pandemic (e.g., mistrust of clinical team); 4) modes of communication (e.g., communication using virtual platforms); and 5) impact of policy implementation on clinical practice (e.g., frequent changes and inconsistent implementation).

CONCLUSIONS

Restricted visitation policies across ICUs during the COVID-19 pandemic negatively affected critically ill patients and their families, critical care clinicians, and decision-makers.

Visitors not Welcome: Hospital Visitation Restrictions and Institutional Betrayal

Healthcare organizations’ continued restrictions on hospital visitation during the COVID-19 pandemic can be considered a violation of the rights of hospitalized patients to receive family visitors. Despite expert opinion related to the safety of visitation and low risk of visitor transmission with appropriate monitoring and precautions, hospital visitation restrictions have continued beyond the initial crisis phase of the pandemic, with little transparency or inclusion of key stakeholders in the decision-making process. Particularly on critical care units, blocking access to family visitors can contribute to additional harm and trauma for care-dependent hospitalized patients and their families. Utilizing an institutional betrayal framework, the aim of this commentary on hospital ICU visitation policy is to provide a discussion of how hospitals who serve a care-dependent population have placed critically ill patients, families, and healthcare workers at risk for complex trauma. Hospital social workers should incorporate an integrated social work approach to advocacy efforts which address not only individual hospitalized patient service needs, but also the uneven power differential that can contribute to inequity in visitation, medical mistrust, and long-term community trauma. On the interprofessional ICU team, social workers can function as trauma informed systems experts, coordinating and facilitating supports to help patients and families cope with hospitalization, while also advocating within their institution and with elected officials for policy change to protect patient and family–centered visitation rights.

Practice of family-centred care in intensive care units before the COVID-19-pandemic: A cross-sectional analysis in German-speaking countries

OBJECTIVES

To provide insights into visiting policies and family-centred care practices with a focus on children as visitors in Intensive Care Units in German-speaking countries.

METHODS/DESIGN

Online-survey with a mixed methods approach. Leading clinicians (n = 1943) from German-speaking countries were invited to participate. Outcomes included the percentage of intensive care units with open visiting policies, age restrictions, family-centred care activities and barriers.

SETTING

Paediatric, mixed and adult units RESULTS: In total, 19.8% (n = 385) of the clinicians responded. Open visiting times were reported by 36.3% (n = 117), with significant differences between paediatric (79.2%), adult (21.3%) and mixed-age (41.2%) units (p < 0.01). Two-thirds of clinicians stated that their units had no age restrictions for children as visitors (n = 221, 68.4%). The family-centred care activities most frequently implemented were open visiting times and dissemination of information. Significantly more German units have open visiting policies and more Swiss units allow children as visitors, compared to the other countries (both p < 0.001). Barriers to family-centred care were concerns about children being traumatized, infection and workload.

CONCLUSION

The majority reported that family-centred care policies had been implemented in their units, including open visiting policies, allowing children as visitors without age restriction and other family-centred care activities.