Discussion: identify a problem or concern that nursing can change and develop a PICOT question. Families in Critical Care N eeds of Patients’ Family Members in an Intensive Care Unit With Continuous Visitation By Mini Jacob, RN, MSN, Cynthia Horton, RN, BS, CRRN, Sharon Rance-Ashley, RN, BSN, Tera Field, RN, MSN, Robbie Patterson, RN, MSN, Claudette Johnson, RN, MSN, Holly Saunders, RN, BSN, Tracy Shelton, RN, BSN, Jessica Miller, RN, BSN, and Carmen Frobos, BS E BR Evidence-Based Review on pp 126-127 ©2016 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ajcc2016258 118 Background Although many critical care experts and national organizations support open visitation in intensive care units (ICUs), most ICU visiting policies do not allow unrestricted presence of patients’ family members. Objective To describe how well the needs of family members were met in an adult neuroscience ICU with a continuous visitation policy and an adjoining private suite for patients’ family members. Methods An exploratory, descriptive study design was used to identify the effects of continuous family visitation in the neuroscience ICU on patients’ family members and their needs and experiences during their time in the unit. A convenience sample of consenting family members completed a survey of family need items 72 hours after the patient was admitted to the unit. Results The most important needs identified by the 45 family members surveyed were items relating to information about the patient, visiting the patient, being given hope, talking with a doctor each day, and being assured that the best care is being given to the patient. Least important items were related to physical comforts for the family members. The vast majority of family members rated their needs as being met for all of the items in the survey and reported a high level of satisfaction with care. Conclusion In a neuroscience ICU with an open visitation policy and a private suite for patients’ family members, family members rated their needs as being met at a high level, unlike in prior studies in units with limitations on family visitation. The rank order of the importance of each need in the survey was similar to rankings in prior studies in a variety of critical care units. (American Journal of Critical Care. 2016;25:118-125) AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2016, Volume 25, No. 2 Jacob3_16pgs.indd 118 www.ajcconline.org 2/11/16 11:00 AM F amily members of critically ill patients experience significant psychological and physiological stress during their loved one’s stay in an intensive care unit (ICU).1,2 In descriptive research studies3-7 in the 1970s and 1980s, family members of ICU adult patients consistently identified similar high-priority needs during the time of the critical illness. Some of the highest ranked needs included the need for information about their loved one, to be geographically close to their loved one, and to know that their loved one is receiving the best care possible. In more recent descriptive studies8-14 of family needs in a variety of different critical care situations, ranking of needs was similar to the rankings in the earlier studies. In some of these studies,3,8,9,10,14 researchers also sought to determine how well family members’ needs were met during the patient’s stay in the ICU.identify a problem or concern that nursing can change and develop a PICOT question

Discussion: identify a problem or concern that nursing can change and develop a PICOT question. Several of the most important needs identified by patients’ family members were not found to be met at a high level, including needs for information and presence. On the basis of the identified needs of patients’ family members for information about their loved ones and the need for proximity to the loved ones during their ICU stay, critical care experts and professional organizations have advocated for visitation policies in critical care units that minimize restrictions on family member visitation.2,3,15-20 Despite these recommendations, surveys of critical care unit administrators indicate that most critical care units continue to have moderately restrictive policies for family visitation.21-23 Although it is not clear why such a disparity exists between the recommended visitation policy and actual practice, one likely reason is the negative attitude that many critical care nurses have toward “open” or less restrictive visitation policies.22,24-26 Since 2007, the policy for family visitation in the neuroscience intensive care unit at Emory University Hospital (Atlanta, Georgia) has allowed continuous visitation by patients’ family members. The continuous visitation policy not only allows family members to be at their loved one’s bedside 24 hours a day, but also allows family members to sleep in a family suite adjacent to the patient’s room. Patients’ rooms can accommodate 4 family members at the About the Authors Cynthia Horton, Sharon Rance-Ashley, Tera Field, Robbie Patterson, Claudette Johnson, Holly Saunders, Tracy Shelton, and Jessica Miller are staff nurses, Carmen Frobos is a family coordinator, and Mini Jacob is the nurse educator in the neuroscience intensive care unit, Emory University Hospital, Atlanta, Georgia. Corresponding author: Mini Jacob, RN, MSN, Neuro ICU, Emory University Hospital, 1364 Clifton Rd NE, Atlanta, GA (e-mail: mini.johney.jacob@emoryhealthcare.org). www.ajcconline.org Jacob3_16pgs.indd 119 bedside during the day and 2 during the night. Family suites are equipped with 2 chairs that can convert to beds, telephone, cable television, wireless Internet access, a table, chairs, a closet, and a sink. A family coordinator for the unit is also available to provide information and logistical support to patients’ family members. Family members are provided with an identification card for unit access during the night. Family members may stay with the patient and observe any procedures that occur in the patient’s room, including placement of invasive devices. During emergency situations, a unit staff nurse and hospital chaplain stay with the family members to provide support and minute-to-minute updates on the patient’s condition. Family members are also invited to join the bedside shift report and the nursing and medical team rounds; they are also updated on the patient’s status and encouraged to create goals for the day. In the case of dying patients, all family members are allowed to be with the patient at the same time, including underage children. This level of open visitation is rare. Although approximately 50% of hospitals report “open visitation,” patients’ family members are not encouraged to stay continuously with adult patients if they desire.22 Several studies have involved surveys of nurses about visitation in ICUs with “open” visitation policies,25,27-30 but no studies have involved surveys of patients’ family members about their needs and how well those needs have been met in ICUs with visitation policies that allow unrestricted or continuous visitation. Although staff in our neuroscience ICU and national experts2,3,15-20 believe that a continuous visitation policy should ensure that family members’ needs for information about and presence with their loved one are completely met, to date, no data have validated that belief or assumption.identify a problem or concern that nursing can change and develop a PICOT question

Discussion: identify a problem or concern that nursing can change and develop a PICOT question. The purpose of this study was to determine the needs of patients’ family members, and how well those needs were met, in an adult neuroscience ICU with a policy of continuous visitation for patients’ family members. Most critical care units still have moderately restrictive visiting policies. AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2016, Volume 25, No. 2 119 2/11/16 11:00 AM Materials and Methods This study was conducted in a 27-bed neuroscience ICU at Emory University Hospital, a 571-bed academic medical center in Atlanta, Georgia. Study approval was obtained from the institution’s investigational review board before data collection. Study Design An exploratory, descriptive study design was used to identify the needs and experiences of family members of patients in a neuroscience ICU with continuous family visitation. Dependent variables were the needs and the experiences of patients’ family members. Sample Selection A convenience sample of family members was studied for 2 months. Inclusion criteria were that the individual was mentally competent and was a family member, significant other, and/or close friend of a patient who had been present in the neuroscience ICU for at least 48 hours during the preceding 3 days. Family Member Needs Survey The survey completed by family members was composed from 3 different sources: the Critical Care Needs Inventory (CCNI),2,3 the Family Satisfaction in the ICU (FS-ICU) survey,31-35 and investigator-​developed statements specific to the neuroscience ICU at the facility. Total time to complete the paper and pencil survey was less than 15 minutes. Participants were offered assistance in completing the survey, if needed. 1. The original CCNI tool was a 45-item listing of family members’ needs.2,3 The importance of each individual need is rated on a 4-level Likert scale (4 = very important, 3 = important, 2 = not important, 1 = not important at all), as is the family member’s experience with how well that need was met during the ICU stay (1 = met, 2 = partly met, 3 = not met, no score = do not remember). Space was also provided for additional comments or suggestions by the family member about each need item. The CCNI is a valid and reliable survey tool.30 For this study, the final item relating to the waiting room was deleted because the neuroscience ICU does not have a traditional waiting room. 2. Twenty-four survey items were added to the CCNI by study investigators to assess family members’ needs related to aspects of care or unit structure The neuroscience unit was designed for patients and their families to feel comfortable and welcome. 120 unique to the neuroscience ICU and/or the continuous visitation policy (eg, access to CaringBridge, access to wireless Internet, presence of a convertible bed in the family studio). Ratings for each item were constructed in the same manner as for the CCNI. 3. FS-ICU survey. The original FS-ICU survey was a 34-item listing of various aspects or components of patient care in the ICU,31,32 later revised to a 24-item survey.33-35 Family members rate how well they perceived care delivery for each aspect or component on a 5-level Likert scale (1 = excellent, 2 = very good, 3 = good, 4 = fair, 5 = poor). The FS-ICU is a valid and reliable survey tool.31,33 Twelve items from the 24-item FS-ICU survey were deleted for this study because of redundancy with items on the CCNI. Neuroscience ICU’s Physical Environment and Visitation Policy The neuroscience ICU was designed for patients and their families to feel comfortable and welcome in the ICU and with a goal to better meet the needs of patients’ family members to be present with their loved one. A family waiting room outside the patient care area consists of a large waiting room, an eating area, including a refrigerator to store family members’ food, a microwave, an ice machine, a children’s corner with toys and entertainment, a quiet room, and several computers for family use. A family coordinator is also present in this area to greet and orient family members to the unit and the policies and procedures and resources available to support families during their loved one’s stay (eg, CaringBridge, dining resources, social workers, chaplains, and financial aid services). The large waiting room has sofas, chairs, a large television, wireless Internet service (also available throughout the unit), and laundry and shower facilities for family use. The patient care area of the neuroscience ICU has 20 private rooms with 2 central nurses’ stations. identify a problem or concern that nursing can change and develop a PICOT question

Discussion: identify a problem or concern that nursing can change and develop a PICOT question. Each patient’s room has an entry area for hospital staff to use medical computers with the patient easily visible. Connected to the patient’s room is the family studio, with a door to ensure privacy (see Figure). The studio has 2 reclining chairs that can be converted into beds, a table and 2 chairs, a lamp, a telephone, a large closet, a sink, a television, and wireless Internet access. Family members are encouraged to physically stay in the patient’s room or the family studio 24 hours a day. Up to 4 visitors, 12 years or older, may visit from 9 am to 9 pm, and 2 family members over the age of 18 years may stay overnight. Exceptions to the number and age of visitors are made for end-of-life situations and individual circumstances. AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2016, Volume 25, No. 2 Jacob3_16pgs.indd 120 www.ajcconline.org 2/11/16 11:00 AM Study Procedure Between 48 and 72 hours after a patient was admitted to the neuroscience ICU, informed consent was obtained from 1 eligible family member by a study investigator not involved in the direct care of the patient. The consenting family member was given the Family Member Needs survey to complete in the family studio during a quiet time. After completing the survey, family members placed the survey into a preaddressed, sealed envelope and gave it to the study investigator. Survey responses were not shared with unit personnel unless requested to do so by the family member. The study investigator was available for the family member while the family member was completing the survey to answer any questions and to assist with survey completion if requested. Data Analysis Descriptive statistics were used to summarize responses to the surveys. A rank order listing of family member needs was based on the mean Likert score for each item on the survey, with percentages calculated for how well each family need was met. Results A total of 55 family members of patients were invited to participate in the study, with 4 declining participation. Of the 51 consenting family members, 45 completed the survey during the 2-month period of the study. The family members were from 21 to 86 years old (mean [SD], 50.3 [13.8] years). Most of the participants were women (86%), spouses of the patient (40%), and either lived with the patient (62%) or saw the patient frequently (55%) before admission to the neuroscience ICU (Table 1). In the 2 days before completing the survey, 71% of the family members had spent almost all the time in the neuroscience ICU with the patient. Mean scores for the ratings of individual needs and how well those needs were met are summarized in Table 2 (available online only—www.ajcconline .org). Family member need items were arranged in rank order in the table, with the original item order in the survey tool indicated by the number in parentheses that precedes each item. Mean (SD) scores for the 43 needs items on the CCNI survey (Table 2, online only) ranged from 4.0 (0.0), which was the highest score possible, indicating that the item was very important, to 2.8 (1.1). The most important needs identified by a family member on the CCNI survey were items relating to information about the patient, visiting the patient, being given hope, talking with a doctor each day, and being assured that the best care is being provided for the patient. Least important items on the list of 43 items related to physical comforts for the www.ajcconline.org Jacob3_16pgs.indd 121 Figure View of a patient’s room and family studio from the nurses’ alcove. family members.identify a problem or concern that nursing can change and develop a PICOT question

Discussion: identify a problem or concern that nursing can change and develop a PICOT question. Mean scores for how well needs were met during the hospitalization ranged from 1.0 (0.2), where a score of 1 meant that the need was met and a score of 3 meant that the need was not met at all, to 2.2 (1.4). Mean (SD) scores for the 24 needs items specific to the visiting situation in the neuroscience ICU and developed by the study investigators (Table 2, online only) ranged from 3.9 (0.3), where a score of 4 meant very important, to 2.8 (1.2). The most important needs identified by family members from these items related to information about the patient, being close to or present with the patient, and being able to sleep when staying overnight. Least important items related to physical comforts for the family members and being included on physician rounds. Mean (SD) scores on how well needs were met on the investigator-developed items ranged from 1.0 (0.2), where a score of 1 meant that the need was met, to 2.0 (1.0), where a score of 2 meant that the need was partially met. Mean (SD) scores for the 12 satisfaction items on the survey (Table 3) ranged from 1.2 (0.5), where a score of 1.0 meant excellent, to 1.8 (1.1). Highest satisfaction scores were for the care provided by nurses and doctors and for courtesy and respect given to the patient and family. The lowest satisfaction score was for frequency of physician communication with the patient’s family. Fifteen of the 45 family members provided specific suggestions for care improvements, and 18 provided other comments on the survey tool Family members noted that getting information about the patient, visiting, and being given hope were most important. AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2016, Volume 25, No. 2 121 2/11/16 11:00 AM Table 1 Characteristics of family members of patients in the neuroscience intensive care unit (N = 45) No. (%) of family members Characteristic Sex Male Female 6 (14) 37 (86) Relationship to patient Parent Spouse Significant other Child Friend Other 9 (18) 18 (40) 3 (6) 10 (22) 0 (0) 1 (2) Lived with patient before admission Yes No 28 (62) 17 (38) How often did you see patient before hospitalization? > Once a week Once a week Once a month Once every 6 months Once every year Not even every year 25 (55) 11 (24) 6 (13) 1 (2) 0 (0) 2 (4) Ethnicity White Hispanic African American Asian Other 20 (44) 3 (7) 20 (44) 1 (2) 0 (0) Educational level completed Grade school High school Community college College Graduate school 2 (4) 11 (24) 14 (31) 8 (18) 10 (22) Time spent with patient last 2 days Almost all the time At least 24 hours At least 12 hours At least 6 hours < 6 hours 32 (71) 10 (22) 1 (2) 1 (2) 1 (2) (summarized in Table 4). Specific compliments about the care provided by the unit staff far exceeded the number of negative comments about either the staff care or the physical environment of the neuroscience ICU. Discussion The most important needs identified by family members on the CCNI survey were items relating to information about the patient, visiting the patient, being given hope, talking with a doctor each day, and being assured that the best care is being provided for the patient. Least important items were related to physical comforts for themselves. According to responses to how well individual needs were 122 met on the CCNI, the vast majority of family members rated their needs as being met for all of the items in the survey. According to the survey results, family members’ satisfaction with care was very high. Compared with prior studies3-10,12,14 of the needs of adult family members of ICU patients, family members’ most and least important needs have not changed. Prior studies included family members whose loved ones were cared for in a variety of different types of adult ICUs, including medical, surgical, neuroscience, mixed medical-surgical, and coronary care units. The consistency in how family members ranked their needs, particularly the most and least important needs, despite the type of ICU and diagnosis, supports the universal nature of what is important to patients’ family members during a critical illness. Of the 43 CCNI need statements in our survey, family members had all of their needs met at a very high level. In prior studies, although some needs were met at a high level, some needs identified as very important in the survey were met less than 50% of the time. In Molter’s original research, family members identified needs related to talking with a doctor at least once a day, having knowledge of chaplain services, needing to have a place to be alone in the hospital, and needing to have someone help w …