Survey of caregiver opinions on the practicalities of family-centred care in intensive care units

Humanizing the intensive care unit experience in a comprehensive cancer center: A patient- and family-centered improvement study

OBJECTIVES

Improving family-centered outcomes is a priority in oncologic critical care. As part of the Intensive Care Unit (ICU) Patient-Centered Outcomes Research Collaborative, we implemented patient- and family-centered initiatives in a comprehensive cancer center.

METHODS

A multidisciplinary team was created to implement the initiatives. We instituted an open visitation policy (OVP) that revamped the use of the two-way communication boards and enhanced the waiting room experience by hosting ICU family-centered events. To assess the initiatives' effects, we carried out pre-intervention (PRE) and post-intervention (POST) family/caregiver and ICU practitioner surveys.

RESULTS

A total of 159 (PRE = 79, POST = 80) family members and 147 (PRE = 95, POST = 52) ICU practitioners participated. Regarding the decision-making process, family members felt more included (40.5% vs. 68.8%, p < 0.001) and more supported (29.1% vs. 48.8%, p = 0.011) after the implementation of the initiatives. The caregivers also felt more control over the decision-making process in the POST survey (34.2% vs. 56.3%, p = 0.005). Although 33% of the ICU staff considered OVP was beneficial for the ICU, 41% disagreed and 26% were neutral. Only half of them responded that OVP was beneficial for patients and 63% agreed that OVP was beneficial for families. Half of the practitioners agreed that OVP resulted in additional work for staff.

SIGNIFICANCE OF RESULTS

Our project effectively promoted patient- and family-centered care. The families expressed satisfaction with the communication of information and the decision-making process. However, the ICU staff felt that the initiatives increased their work load. Further research is needed to understand whether making this project universal or introducing additional novel practices would significantly benefit patients admitted to the ICU and their family.

Family visitation policies, facilities, and support in Australia and New Zealand intensive care units: A multicentre, registry-linked survey

OBJECTIVE

The objective of this study was to describe family visitation policies, facilities, and support in Australia and New Zealand (ANZ) intensive care units (ICUs).

METHODS

A survey was distributed to all Australian and New Zealand ICUs reporting to the Australian and New Zealand Intensive Care Society Centre for Outcomes and Resources Evaluation Critical Care Resources (CCR) Registry in 2018. Data were obtained from the survey and from data reported to the CCR Registry. For this study, open visiting (OV) was defined as allowing visitors for more than 14 h per day.

SETTING AND PARTICIPANTS

This study included all Australian and New Zealand ICUs reporting to CCR in 2018.

MAIN OUTCOME MEASURES

The main outcome measures were family access to the ICU and visiting hours, characteristics of the ICU waiting area, and information provided to and collected from the relatives.

FINDINGS

Fifty-six percent (95/170) of ICUs contributing to CCR responded, representing 44% of ANZ ICUs and a range of rural, metropolitan, tertiary, and private ICUs. Visiting hours ranged from 1.5 to 24 h per day, with 68 (72%) respondent ICUs reporting an OV policy, of which 64 (67%) ICUs were open to visitors 24 h a day. A waiting room was part of the ICU for 77 (81%) respondent ICUs, 74 (78%) reported a separate dedicated room for family meetings, and 83 (87%) reported available social worker services. Most ICUs reported facilities for sleeping within or near the hospital. An information booklet was provided by 64 (67%) ICUs. Only six (6%) ICUs required personal protective equipment for all visitors, and 76 (80%) required personal protective equipment for patients with airborne precautions.

CONCLUSIONS

In 2018, the majority of ANZ ICUs reported liberal visiting policies, with substantial facilities and family support.

Virtual visiting in the intensive care unit: implementation, utilisation and provider acceptance in an Australian metropolitan health service

We describe the design and implementation of an intensive care unit (ICU) virtual visiting program in a metropolitan ICU in Melbourne, Victoria, Australia, to examine patterns of use, and describe clinician acceptance of this technology.This was a mixed-methods study, comprising a retrospective analysis of virtual visits from 18 August to 30 September 2020. Patterns of utilisation included duration and time of visits, as well as bandwidth used. A post-implementation survey on a Virtual Visiting program based on the technology acceptance model was sent to clinicians; results were reported on separate scales for usefulness and usability. Publicly available telecommunication solutions were unsuitable for virtual visiting, whereas dedicated telehealth solutions needed modification to improve accessibility by patients and families. During the study period, 69 virtual visits were made with a median length of 10 min (range 1-80 min). A total of 72.5% of calls were made during office hours (09:00-17:00 h), with the latest occurring at approximately 21:30 h. Virtual visits required a mean bandwidth of 1224 kbps (download) and 940 kbps (upload), and consumed 0.7 GB (range 0.0-7.0 GB) and 0.5 GB (range 0.0-6.7 GB) of download and upload data. Clinicians reported a mean score of 2 (range 1-4) for perceived usefulness and 3 (range 1-6) for the perceived ease of use.Virtual visiting is a feasible alternative in the ICU, with good acceptance by clinicians. Challenges include safety and usability of videoconferencing platforms, as well as bandwidth requirements. Future health service design should consider support for dedicated virtual visiting solutions, as well as ensuring adequate bandwidth capabilities for this service. Further studies are needed to assess patient and family acceptability of this technology.

Staff perceptions of family access and visitation policies in Australian and New Zealand intensive care units: The WELCOME-ICU survey

BACKGROUND

Family-centred critical care recognises the impact of a loved one's critical illness on his relatives. Open visiting is a strategy to improve family satisfaction and psychological outcomes by permitting unrestricted or less restricted access to visit their family member in the intensive care unit (ICU). However, increased family presence may result in increased workload and a risk of burnout for ICU staff.

OBJECTIVES

The objective of this study was to evaluate ICU staff perceptions regarding visiting hours and family access in Australian and New Zealand ICUs. Secondary outcomes included an evaluation of current visiting policies, witnessed events in ICUs, and barriers to implementing open visiting policies.

DESIGN

A web-based survey open to all healthcare workers in Australia and New Zealand ICUs was distributed through local, state-based, and national critical care networks. Open visiting was defined as ICUs open for visiting >14 h per day.

MAIN RESULTS

We received 1255 valid responses. Most respondents were nurses (n = 930, 74.1%) with a median critical care experience of 10 y. Most worked in open visiting ICUs (n = 749, 59.7%). Reported visiting hours varied greatly with a median of 20 h per day (interquartile range: 10-24 h). Open visiting was perceived as beneficial for the relatives, but less so for patients and staff (relatives: n = 845, 67.3%, patients: n = 561, 44.7%, staff: n = 257, 20.5%, p < 0.0001). Respondents from closed visiting units and nurses identified more risks from open visiting than other professional groups. Generally, staff preferred not to change from their current practice.

CONCLUSION

We report that staff perceived open visiting as beneficial for relatives, but also identified risks to themselves, including increased workload, a risk of burnout, and a risk of occupational violence. Reluctance to change highlights the importance of addressing staff perceptions when implementing an open visiting policy.

Factors influencing family member perspectives on safety in the intensive care unit: a systematic review

PURPOSE

Patient safety has developed as a strong marker for healthcare quality. Safety matters are important in the intensive care unit (ICU) where complex clinical decisions are made, intensive technology is used, and families hold a unique role. The aim of this review was to identify and describe factors that influence family member's perceptions of safety in the adult ICU.

DATA SOURCES

Searches were conducted between September and November 2018 and repeated in July 2020 using CINAHL, MEDLINE (EBSCO), PubMed and PsycINFO databases.

STUDY SELECTION

Published primary studies undertaken in adult ICUs and involving adult family member participants exploring safety or feeling safe. No date restrictions were applied.

DATA EXTRACTION

A data extraction form collected information about sample, study design, data collection methods and results from each paper. Methodological quality was assessed using the QualSyst tools for qualitative and quantitative studies. Narrative synthesis was undertaken.

RESULTS OF DATA SYNTHESIS

Twenty papers were included with 11 papers published since 2010. The majority of papers reported on qualitative studies (n = 16). Four factors were identified that influenced whether family members felt that the patient was safe in ICU: family visiting, information and communication, caring and professional competence.

CONCLUSION

In detailing specific practices that make families feel safe and unsafe in ICU, these review findings provide a structure for clinicians, educators and researchers to inform future work and gives opportunity for the family role in patient safety to be reconsidered.

The needs of traumatic brain injury survivors' caregivers and the implication required during the COVID-19 pandemic: Public health issues

Background: Traumatic brain injury (TBI) survivors require attention and dependence from their primary caregiver. This is because TBI is a defect that affects both the psychological and physical functions of the victim. Caregivers play an essential role in providing the adequate care victims need to adjust to the new problems they may experience due to their condition, as family members alone may not be able to provide for their needs. In particular, TBI caregivers may face specific challenges when assisting their patients in handling unexpected changes to their daily routines. Therefore, this quantitative study aims to explore the needs of caregivers, their coping mechanisms towards stressful and traumatic circumstances, and how they provide care to their loved ones during the COVID-19 pandemic. Design and Methods: It was conducted with ten caregivers of individuals suffering from traumatic brain injury, that were selected using a theoretical sampling method. Data were obtained using a semi-structured interview guide, which helped the caregivers provide their responses. Meanwhile, data analysis was performed using the NVIVO analysis software. Results: The results showed that there were, three significant themes namely, (a) Support needed, (b) the information need for care, and (c) developing self-resilience. The results also showed that caregivers really need support from the various parties, and the participants lack information on specific care techniques for the severe traumatic brain injury (TBI) survivors. Conclusions: In conclusion, caregivers require approval and seek more useful information to provide excellent care to their loved ones. Being aware of the caregiver’s needs would enable them to offer improved customized care.

Patients, family members and providers perceive family-administered delirium detection tools in the adult ICU as feasible and of value to patient care and family member coping: a qualitative focus group study

PURPOSE

While studies report on perceptions of family participation in delirium prevention, little is known about the use of family-administered delirium detection tools in the care of critically ill patients. This study sought the perspectives of patients, their family members, and healthcare providers on the use of family-administered delirium detection tools to detect delirium in critically ill patients and barriers and facilitators to using family-administered delirium detection tools in patient care.

METHODS

In this qualitative study, critical care providers (five physicians, six registered nurses) and participants from the Family ICU Delirium Detection Study (seven past patients and family members) took part in four focus groups at one hospital in Calgary, Alberta.

RESULTS

Key themes identified following thematic analysis from 18 participants included: 1) perceptions of acceptability of family-administered delirium detection (e.g., family feels valued, intensive care unit (ICU) care team may not use a family member's results, intensification of work load), 2) considerations regarding feasibility (e.g., insufficient knowledge, healthcare team buy-in), and 3) overarching strategies to support implementation into routine patient care (e.g., value of family-administered delirium detection for patients and families is well understood in the clinical context, regular communication between the family and ICU providers, an electronic version of the tool).

CONCLUSIONS

Patients, family members and healthcare providers who participated in the focus groups perceived family participation in delirium detection and the use of family-administered delirium detection tools at the bedside as feasible and of value to patient care and family member coping.

TRIAL REGISTRATION

www.ClinicalTrials.gov (NCT03379129); registered 15 December 2017.

Effectiveness of an intensive care unit family education intervention on delirium knowledge: a pre-test post-test quasi-experimental study

PURPOSE

To create, validate, and refine an intensive care unit (ICU) delirium education intervention to prepare family members to partner with the ICU care team to detect delirium symptoms and prevent and manage delirium using nonpharmacological strategies.

METHODS

In this pre-test post-test quasi-experimental study, consecutive eligible family members of critically ill patients admitted to an ICU completed an ICU Family Education Delirium intervention in two parts: 1) six-minute video on ICU delirium (risk factors, prevention/management, symptoms, communication with the ICU care team), and 2) two case vignettes to practice detecting delirium using family-administered delirium detection questionnaires (Family Confusion Assessment Method [FAM-CAM] and Sour Seven). Family members' delirium knowledge was measured before, immediately after, and two weeks following the intervention using the Caregiver ICU Delirium Knowledge Questionnaire (CIDKQ).

RESULTS

Of 99 family members recruited over eight months, 81 (82%) completed the intervention and 63 (63/81, 78%) completed all follow-up questionnaires. Family members' delirium knowledge improved significantly following the intervention (pre-CIDKQ, 14; 95% confidence interval [CI], 13 to 15; post-CIDKQ, 17; 95% CI, 16 to 17; P < 0.001) and was retained two weeks after the intervention (CIDKQ 16; 95% CI, 16 to 17; P < 0.001). This included increased knowledge regarding delirium risk factors (e.g., medication, mechanical ventilation), prevention/management (e.g., orientation, day/night routine), and symptoms of delirium. More family members correctly detected delirium symptoms in case vignettes using the Sour Seven (92%) compared with the FAM-CAM (78%).

CONCLUSIONS

A video-based ICU delirium education intervention is effective in educating family members about prevention, detection, and management of delirium.

Concept Analysis of Family-Centered Care of Hospitalized Pediatric Patients

AIM

The purpose of this concept analysis is to provide a background of family-centered care of the hospitalized pediatric patient, clarify its components, and validate its significance to nursing practice and research.

BACKGROUND

The concept of family-centered care in the hospital environment has been discussed in the literature for over 60 years, yet its principles remain unclear and poorly implemented. Further analysis of this concept is warranted and has the potential to promote its integration into current nursing practice by increasing awareness and clarifying the essential attributes.

DATA SOURCES

A systematic review of the literature yielded thousands of resources which were narrowed to a comprehensive list of 37 sources rich in valuable and applicable content.

REVIEW METHODS

This analysis utilized the 8-step methodology of concept analysis described by Walker and Avant.

FINDINGS

The majority of research investigating the concept of family-centered care and the hospitalized pediatric patient found was focused on defining family-centered care and surveying both families and nurses on their understanding of the concept. Little research was found exploring the relationship of family-centered care with patient and family outcomes, or patient and family satisfaction.

CONCLUSION

Family-centered care of the pediatric patient in the hospital environment remains an abstract concept. It is recommended as a cornerstone of modern nursing practice, yet nurses report they lack sufficient education regarding its operationalization into practice. Elucidation of characteristics coupled with education regarding principles of the concept has the potential to augment further integration of family-centered care in the hospital environment.

Implementing the SCCM Family-Centered Care Guidelines in Critical Care Nursing Practice

Family-centered care is an important component of holistic nursing practice, particularly in critical care, where the impact on families of admitted patients can be physiologically and psychologically burdensome. Family-centered care guidelines, developed by an international group of nursing, medical, and academic experts for the American College of Critical Care Medicine/Society of Critical Care Medicine, explore the evidence base in 5 key areas of family-centered care. Evidence in each of the guideline areas is outlined and recommendations are made about how critical care nurses can use this information in family-centered care practice.

Reappraisal of visiting policies and procedures of patient's family information in 188 French ICUs: a report of the Outcomerea Research Group

Background

The relatives of intensive care unit (ICU) patients must cope with both the severity of illness of their loved one and the unfamiliar and stressful ICU environment. This hardship may lead to post-intensive care syndrome. French guidelines provide recommendations on welcoming and informing families of ICU patients. We questioned whether and how they are applied 5 years after their publication.

Methods

We conducted a large survey among French ICUs to evaluate their visiting policies and how information was provided to patient’s family. A questionnaire was built up by intensivists and nurses. French ICUs were solicited, and the questionnaire was sent to all participating ICUs, for being filled in by the unit medical and/or nursing head. Data regarding the hospital and ICU characteristics, the visiting policy and procedures, and the management of family information were collected.

Results

Among the 289 French ICUs, 188 (65 %) participated. Most ICUs have a waiting room 118/188 (62.8 %) and a dedicated room for meeting the family 152/188 (80.8 %). Of the 188 ICUs, 45 (23.9 %) were opened on a 24-h-a-day basis. In the remaining ICUs, the time period allowed for visits was 4.75 ± 1.83 h (median 5 h). In ICUs where visiting restrictions were reported, open visiting was allowed for end-of-life situations in 107/143 (74.8 %). Children are allowed to visit a patient in 164/188 (87.2 %) regardless of their age in 97/164 (59.1 %) of ICUs. Families received an information leaflet in 168/188 (89.3 %). Information was provided to families through structured meetings in 149/188 (79.2 %) of ICUs at patient admission with participation of nurses and nursing assistants in 133/188 (70.4 %) and 55/188 (29.2 %), respectively. Information delivered to the family was reported in the patient chart by only 111/188 ICUs (59 %). Participation in care was infrequent.

Conclusions

Although French ICUs do not follow the consensus recommendations, slow progress exists compared to previous reports. Implementation of these recommendations is largely needed to offer better welcome and information improvement. Further studies on that topic would enable evaluating remaining obstacles and increasing caregivers’ awareness, both critical for further progresses on that topic.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-016-0185-x) contains supplementary material, which is available to authorized users.

A proposed model of person-, family-, and culture-centered nursing care

BACKGROUND

For decades person-, patient-, family-centered, and culturally competent care models have been evolving and conceptualized in the literature as separate. To our knowledge, there has not been a systematic approach to comparing all four of these conceptual models of care.

PURPOSE

To explicate and compare four conceptual care models: person-, patient-, family-centered, and culturally competent care.

METHODS

A comparative concept analysis informed by Rogers' evolutionary concept analysis was used to compare 32 nursing research on person-, patient-, family-centered care, and culturally-competent care published between 2009 and 2013.

RESULTS

Collective results of analyses of 32 nursing research articles found 12 attributes: collaborative relationship, effective communication, respectful care, holistic perspective, individualized care, inter-professional coordination, self-awareness, empowerment, family as unit of care, interpersonal relationships, cultural knowledge, and cultural skills. Antecedents included: lack of empirical evidence, poor patient outcomes, implementation problems, knowledge deficits, patient/parent emotional distress, poor patient-provider relationships, and health disparities. Consequences included: improved health-related outcomes, increased satisfaction, enhanced patient/family-provider relationships, reduced hospitalization, improved quality of life, improved quality of parent-child relationships, increased trust, enrollment in research, insights about biases, and appreciation for cultural differences. Social justice, advocated by scholars and national organizations, was absent from all studies.

CONCLUSIONS

Findings informed the proposed blended conceptual care framework that embraces the attributes of each care model and includes social justice.

The Parents', Hospitalized Child's, and Health Care Providers' Perceptions and Experiences of Family-Centered Care Within a Pediatric Critical Care Setting: A Synthesis of Quantitative Research

Family-centered care (FCC) purports that unlimited presence and involvement of the family in the care of the hospitalized child will optimize the best outcome for the child, family, and institution. A systematic appraisal was conducted of peer-reviewed, English-language, primary quantitative research conducted within a pediatric critical care setting reported from 1998 to 2014. The aim of this review was to explore the parents', hospitalized child's, and health care providers' perception of FCC within pediatric critical care. Fifty-nine articles met the criteria that generated themes of stress, communication, and parents' and children's needs. This review highlighted that communication tailored to meet the parents' and child's needs is the key to facilitating FCC and positive health outcomes. Health care providers need to be available to provide clinical expertise and support throughout the health care journey. Future initiatives, education, and research are needed to evaluate the benefits of parent- and child-led FCC practice.

Nurses' perceptions of working with families in the paediatric intensive care unit

BACKGROUND

Research exploring nurses' experiences working with families in paediatric intensive care unit (PICU) is limited. No studies have been undertaken in a mixed adult-paediatric ICU.

OBJECTIVES

To explore nurses' perceptions of working with families of critically ill children in a mixed adult-paediatric intensive care unit (ICU).

DESIGN

Descriptive qualitative design.

METHODOLOGY

Five PICU nurses participated in semi-structured interviews. Data were analysed using thematic analysis. Trustworthiness was enhanced using an audit trail, member checks and peer review of all data.

RESULTS

Three main themes and one overarching theme emerged. Role confusion and delineation examined the roles which nurses ascribed to themselves and the families; and demonstrated the conflict which could arise if roles were challenged. Information sharing demonstrated the positive and negative ways in which nurses utilized information with families in their daily practice. The contextual environment of the PICU scrutinized the physical, cultural and institutional factors which impacted on the nurses' ability to work with families in the PICU. Finally, the overarching theme Competing values explores the interplay between the nurses' personal values and those of the PICU and the institution.

CONCLUSIONS

Working with families in a mixed adult-paediatric ICU is influenced by multiple personal and institutional factors. The value placed on families and on the time nurses spent with them often competed for priority with nurses' other values and the wider culture of the PICU. The potential for role confusion, the management of information and the physical environment of the PICU further contributed to variability in nurses' working with families.

RELEVANCE TO CLINICAL PRACTICE

The results highlighted a need for education for both nurses and medical staff who work with families of critically ill children. Additionally, the need for each PICU to have a written policy on family presence and participation is crucial to guide practice and maintain continuity of care.

Involving relatives in ICU patient care: critical care nursing challenges

AIMS AND OBJECTIVES

To identify the barriers critical care nurses experience to relative involvement in intensive care unit patient care.

BACKGROUND

Previous studies have discussed the experiences of relatives visiting an intensive care unit, the needs of relatives in the intensive care environment, critical care nurse and relative interaction, intensive care unit visiting policies and the benefits of including relatives in patient care. The barriers that critical care nurses experience to relative involvement in patient care have received minimal exploration.

DESIGN

Critical care nurses were recruited for a mixed methods study. An explanatory mixed method design was used, with two phases. Phase 1 was Quantitative and Phase 2 was Qualitative.

METHODS

Data collection occurred over five months in 2012-2013. Phase 1 used an online questionnaire (n = 70), and semi-structured interviews (n = 6) were conducted in Phase 2. Phase 1 participants were 70 critical care nurses working in Australian intensive care units and six critical care nurses were recruited from a single Sydney intensive care unit for Phase 2. Through sequential data collection, Phase 1 results formed the development of Phase 2 interview questions.

RESULTS

Participants reported various barriers to relative involvement in critically ill patient care. Factors related to the intensive care unit patient, the intensive care unit relative, the critical care nurse and the intensive care environment contributed to difficulties encompassing relative involvement.

CONCLUSIONS

This study has identified that when considering relative involvement in patient care, critical care nurses take on a paternalistic role. The barriers experienced to relative involvement result in the individual critical care nurse deciding to include or exclude relatives from patient care.

RELEVANCE TO CLINICAL PRACTICE

Knowledge of the barriers to relative involvement in critically ill patient care may provide a basis for improving discussion on this topic and may assist intensive care units to implement strategies to reduce barriers.

Family visitation in greek intensive care units: nurses' perspective

BACKGROUND

Policies of flexible and open visiting in intensive care units benefit both patients and patients' families. In Greek intensive care units, gaps exist between evidence and practice for family visitation, resulting in restricted visiting policies.

OBJECTIVES

To explore the beliefs of nurses in Greek intensive care units about the effects of visiting on patients, patients' families, and unit staff and nurses' attitudes toward visiting policies.

METHODS

A descriptive correlational survey was conducted in 6 public hospitals in Athens, Greece, with a sample of 143 critical care nurses. Data were collected via an anonymous questionnaire consisting of 3 validated scales to assess the nurses' beliefs about and attitudes toward visitation.

RESULTS

Generally, nurses were resistant to family visiting and open visiting, and most (94.4%) did not want an open policy in their unit. Nurses think that open visiting policies are supportive for patients and patients families, but the overall effects of visiting depend on both the nurse and the patient (91.6%). Nurses reported that open visiting created increased physical and psychological burdens for them (87.5%) and hampered nursing care (75.5%). Years of work experience, staffing level, and number of night shifts worked by nurses per 15 days were factors predictive of nurses' attitudes toward and beliefs about family visitation.

CONCLUSIONS

Nurses' beliefs about and attitudes toward visitation are important factors in the implementation of more flexible visiting policies in Greek intensive care units. Well-staffed units with experienced nurses and fewer shifts per week may affect nurses' negative attitude toward open visitation.

Family-centred care in the paediatric intensive care unit: an integrative review of the literature

AIMS AND OBJECTIVES

To review extant research on family-centred care in a paediatric intensive care environment and identify gaps in the literature.

BACKGROUND

Family-centred care is currently a core concept in paediatric nursing, focusing on the premise that families are central to a child's well-being, and as such, should be included as equal members of the child's healthcare team. Due to the nature of critical care, family-centred care may be challenging to implement and maintain.

DESIGN

An integrative literature review.

METHODS

The review was conducted using the Cumulative Index to Nursing and Allied Health Literature, PubMed, OVID MEDLINE and Google Scholar databases, from 1990 to present. The search focused on the following terms: 'p(a)ediatric critical care', 'paediatric intensive care unit', 'family cent(e)red care', 'parental needs', 'family presence' and 'family/nurse roles'. Additionally, the search was limited to studies conducted in a developed country and published in English.

RESULTS

Eighteen studies were included in the review. The results demonstrated that implementing family-centred care into a paediatric intensive care environment posed several challenges. The discrepancy between nurses' and parents' perception of their roles, the reluctance of medical staff to share potentially negative or rapidly changing information, restrictive family presence and poor understanding of family needs emerged as the key difficulties. No studies evaluated strategies to improve family-centred care practice.

CONCLUSIONS

Family-centred care presents many challenges in a paediatric intensive care environment; however, nurses are uniquely positioned to foster relationships with families, encourage accurate and honest information sharing and advocate for families to be present when they choose.

RELEVANCE TO CLINICAL PRACTICE

This review outlines the extant research to enhance awareness of the unique state of family-centred care in paediatric intensive care and makes recommendations for future research.

Factors affecting stress experienced by surrogate decision makers for critically ill patients: implications for nursing practice

OBJECTIVES

This study explores surrogate decision-makers' (SDMs) challenges making decisions related to the care of patients in critical care, to (1) characterise the SDM stress, (2) identify personal, social, care-related factors influencing stress and (3) consider implications of findings to improving critical care practice.

METHODOLOGY

Semi-structured interviews were conducted with SDMs of critically ill patients receiving care in two tertiary care institutions. Transcripts were analysed using a grounded theory approach. Domains explored were: stress characteristics, stress mitigators, coping strategies, social networks, SDM decision-making role, decision-making concordance, knowledge of patient's preferences, experience with provider team, SDM-provider communication, patient outcome certainty.

MAIN OUTCOMES

We interviewed 34 SDMs. Most were female and described long-term relationships with patients. SDMs described the strain of uncertain outcomes and decision-making without clear, consistent information from providers. Decision-making anxiety was buffered by SDMs' active engagement of social networks, faith and access to clear communication from providers.

CONCLUSION

Stress is a very real factor influencing SDMs confidence and comfort making decisions. These findings suggest that stress can be minimised by improving communication between SDMs and medical providers. Nurses' central role in the ICU makes them uniquely poised to spearhead interventions to improve provider-SDM communication and reduce SDM decision-making anxiety.

Perceptions of an open visitation policy by intensive care unit workers

BACKGROUND

An intensive care unit (ICU) admission is a stressful event for the patient and the patient's family. Several studies demonstrated symptoms of anxiety, depression, and posttraumatic stress disorder in family members of patients admitted to ICU. Some studies recognize that the open visitation policy (OVP) is related to a reduction in symptoms of anxiety and depression for the patient and an improvement in family satisfaction. However, some issues have been presented as barriers for the adoption of that strategy. This study was designed to evaluate perceptions of physicians, nurses, and respiratory therapists (RTs) of an OVP and to quantify visiting times in a Brazilian private intensive care unit (ICU).

METHODS

This observational and descriptive study was performed in the medical-surgical (22 beds) and neurologic ICU (8 beds) of Sírio-Libanês Hospital (HSL), São Paulo, Brazil. All physicians, nurses, and RTs from ICU were invited to participate in the study. A questionnaire was applied to all ICU workers who accepted to participate in the study. The questionnaire consisted of 22 questions about the visiting policy. During five consecutive days, we evaluated the time that the visitors stayed in the patient room, as well as the type of visitor.

RESULTS

A total of 106 ICU workers participated in this study (42 physicians, 39 nurses, and 25 RTs). Only three of the questions exposed a negative perception of the visiting policy: 53.3% of the participants do not think that the OVP consistently increases family satisfaction with patient's care; 59.4% of ICU workers think that the OVP impairs the organization of the patient's care; 72.7% of participants believe that their work suffers more interruptions because of the OVP. The median visiting time per day was 11.5 hours.

CONCLUSIONS

According to physicians, nurses, and respiratory therapists, the greatest impact of OVP is the benefit to the patients rather than to the family or to the staff. Furthermore, they feel that they need communication training to better interact with family members who are present in the ICU 24 hours per day.

Visitation policies and practices in US ICUs

INTRODUCTION

Prior reports suggest that restrictive ICU visitation policies can negatively impact patients and their loved ones. However, visitation practices in US ICUs, and the hospital factors associated with them, are not well described.

METHODS

A telephone survey was made of ICUs, stratified by US region and hospital type (community, federal, or university), between 2008 and 2009. Hospital characteristics were self-reported and included the hospitals' bed number, critical care unit number, and presence of ICU leadership. Hospital and ICU visitation restrictions were based on five criteria: visiting hours; visit duration; number of visitors; age of visitors; and membership in the patient's immediate family. Hospitals or ICUs without restrictions had open visitation policies; those with any restriction had restrictive policies.

RESULTS

The study surveyed 606 hospitals in the Northeast (17.0%), Midwest (26.2%), South (36.6%), and West (20.1%) regions; most were community hospitals (n = 401, 66.2%). The mean hospital size was 239 ± 217 beds; the mean percentage of ICU beds was 11.6% ± 13.4%. Hospitals often had restrictive hospital (n = 463, 76.4%) and ICU (n = 543, 89.6%) visitation policies. Many ICUs had ≥ 3 restrictions (n = 375; 61.9%), most commonly related to visiting hours and visitor number or age. Nearly all ICUs allowed visitation exceptions (n = 474; 94.8%). ICUs with open policies were more common in hospitals with < 150 beds. Among restrictive ICUs, the bed size, hospital type, number of critical care units, and ICU leadership were not associated with the number of restrictions. On average, hospitals in the Midwest had the least restrictive policies, while those in the Northeast had the most restrictive.

CONCLUSION

In 2008 the overwhelming majority of US ICUs in this study had restrictive visitation policies. Wide variability in visitation policies suggests that further study into the impact of ICU visitations on care and outcomes remains necessary to standardize practice.