Family Presence in the ICU

The stress of having a family member or loved one admitted to the hospital can be overwhelming; but when added to confusing or restrictive visitation policies, the stress can become almost unbearable.

Armed with strong evidence in support of the unrestricted presence of family members, the American Association of Critical-Care Nurses (AACN) issued a Family Visitation in the Adult ICU Practice Alert late in 2011.

The alert put forth new expectations for practice, most of which support increased and, in some cases, unlimited access of family members to their incapacitated loved ones.

“Evidence shows that the unrestricted presence and participation of a support person can enhance patient and family satisfaction, because it improves the safety of care,” reads the alert. “This is especially true in the ICU, where the patients are usually intubated and cannot speak for themselves.”

“There has been a lot of research about family participation published during the past decade,” said Karen Stutzer, MS, RN, CCRN, APN-C, executive director of nursing practice, critical care and med/surg services at Chilton Hospital, Pompton Plains, NJ. Stutzer is also a director of the AACN’s National Board.

“Clinicians asked us to develop an AACN Practice Alert on family participation in patient care,” she said.

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Reinforcing the Eveidence

The newest AACN release serves as a companion to 2010’s alert regarding family presence during resuscitation and invasive procedures.

Evidence shows the unrestricted visitation of a chosen support person (understood to be one particular individual) can improve communication, facilitate a better understanding of the patient and enhance staff satisfaction.

With that in mind, the new practice alert encourages unrestricted, 24-hour access of the chosen support person to the hospitalized patient. The document indicates the support person will be “integral to the provision of emotional and social support” and will not infringe on the rights of others.

“Family presence does not mean unrestricted open access if that family member infringes on the rights or safety of others, or when it is medically contraindicated,” clarified Nancy Curtis Molter, PhD, MN, RN, past president of AACN.

Moreover, each facility is encouraged to have a documented policy or procedure for allowing the designated individual to be at the patient’s bedside for the duration of the stay.

Evidence & Personal Impact

Stutzer pointed out the interesting contrast in attitudes toward visitation for pediatric patients and patients in the adult ICU.

“When the patient is a child, family presence is generally accepted – even expected,” she observed.

“That’s not the case when the patient is an adult, despite the considerable body of evidence built over the past decade.”

But for her colleague Molter, this practice alert goes beyond research over the past decade – it has been almost 20 years in the making.

In 1994, Molter wrote one of the initial, groundbreaking articles on this very topic following two personal experiences.

“My first experience was with a young woman who saved her fianc‚’s life because the staff made her [the fianc‚] part of the care team.”

In the second occurrence, Molter’s mother performed CPR on her father for 10 minutes – but then was prohibited from seeing him for a period of several hours once he was admitted to the hospital.

These two powerful occasions made visitation policies and family access critical issues in Molter’s career.

“The key point is family presence, not just visitation,” she emphasized. “Family members can be important members of the healthcare team. Patients and family members tell us this is a significant way for nurses and others healthcare providers to respond to a patient’s needs.

Support From Nurses 

Numbers indicate hospital staff supports these policies as well.

According to AACN, 78 percent of ICU nurses in adult critical care units prefer unrestricted policies, yet 70 percent of active hospital ICU policies place restrictions upon family visitation. This contradiction leads to conflict between nurses and confusion amongst families.

Those ICU nurses who are not in favor of unrestricted policies cite increased physiologic stress in the patient, interference with the provision of care, and added mental exhaustion for patients and families as their reasoning.

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The practice alert, however, indicated little evidence to support those opinions. What the evidence did show was that flexible visitation policies decreased patient anxiety, increased safety and shortened the length of stay in the ICU.

 

“Nurses are unanimous in their passion to respond to the needs of patients and their families,” said Stutzer.

“When we disagree about family presence, it’s usually because we have different perspectives about what family presence means – or about the best way to make it possible.”

The question of children’s visitation was also addressed in the alert, with instances of nurses restricting children from visitation due to a belief that the child could be harmed by what he or she sees, or the idea that the child’s behavior may be uncontrollable.

However, little evidence was found to support those holdings, and some studies indicated that when properly prepared for their visits to the ICU, children come away with a greater understanding, and fewer emotional changes than those kids who did not visit.

“It is recommended that [children] be allowed to visit unless they carry contagious diseases,” read the alert.

“Nurses welcome evidence-based guidance in our quest to respond to the needs of patients and families,” stated Stutzer.

Nursing Practice Impact

As mentioned, AACN encouraged each facility to ensure they follow policies and procedures in support of unrestricted visitation in the ICU while still protecting the privacy of other patients and the safety of patient and staff. To accomplish this, the onus falls on senior executives to be leaders in implementing change.

The roles of leadership in facilitating change can be as simple as removing signage and items in informational materials that allude to restrictive visitation policies. They can be as involved as the nursing leader surrounding herself with an organizational infrastructure and key stakeholders who will serve as advisers throughout the transitional process.

Other standards include supporting the patient in the right to determine whom they do (or do not) view as “family” and “partners in care” without discrimination.

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Of particular concern is the arrangement of educational programs for staff that include the benefits of unrestricted visitation, the right of family members to have access to important information, and the importance of providing written notification to both patient and their families regarding and restriction or limitations on visitation.

 

The idea of children – when accompanied by an adult – having unrestricted access was also emphasized. Mo matter how young the child, her presence at the bedside may be of invaluable importance to the patient.

The overall message of the alert – which can be viewed in its entirty here – was the importance of teamwork and collaboration between nurses, patients and family members in ensuring family visitation act as a positive, recuperative aspect of the ICU stay and experience.

Many allusions are made throughout the document to decisions and determination to be made collaboratively, as opposed to the hospitals issuing outright edicts or commands. All in all, it’s a very patient and family-friendly alert.

For Molter, it’s a triumph to see a topic so close to her heart clarified in an inclusive, mutually beneficial manner. “Success requires a unit or hospital to invest in thoughtfully developing an evidence-based policy,” she concluded.

Rob Senior

is an editor at ADVANCE.

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