AACN News—June 2001—Practice

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Vol. 18, No. 6, JUNE 2001

Research Corner: Myth vs. Reality: Visitation in Critical Care Units

By Debbie Brinker, RN, MS, CCNS, CCRN
AACN Board of Directors
Research Work Group Liaison

Consider this: A head-on collision occurs and two victims are transported to the trauma center. Both patients are admitted to ICUs in critical condition with closed head injuries, ICP bolts, endotracheal intubation and ventilation, hemodynamic lines, vasoactive infusions, sedation and analgesia.

The family of the 4-year-old victim who was admitted to the pediatric ICU is constantly at the bedside, asking questions of the intensivist and the nurse. The parents are incorporated into the patient-family care plan.

The 39-year-old was admitted to the adult ICU, where her family is allowed to visit 10 minutes on the half-hour, and informed of care decisions by the intensivist and the nurse. The night nurse allows the husband to stay at the bedside for three hours, which violates the visiting policy, angering some coworkers.

Myth: Open visitation is expected in the PICU. However, restrictive visitation in adult ICUs assists nurses in providing optimal care.

Reality: Families are demanding to be included in care decisions. How long will family members allow critical care units to exclude them from open visitation? Visitation is not a privilege granted to visitors, but a necessary component of patient and family well-being.

The PICU culture incorporates families as part of the patient unit. PICUs struggle with issues, such as whether parents can sleep at the bedside or be incorporated into rounds. Historically, adult and neonatal critical care units have had restrictive visitation policies, not only with respect to the amount of time allowed and the frequency of visits, but also regarding who can visit, often prohibiting children from being at the bedside.

The above scenario highlights the problem of restrictive visiting policies, which may not always be followed. In some cases, individual nursing staff may grant additional time to “some” family members, while others want the rules applied to everyone.

In a recent study of 201 nurses regarding visitation in critical care units, 70% said their official policies were restrictive. However, 78% of these nurses said they were nonrestrictive in applying their visitation practices. The conclusion was that most nurses base their visitation decisions on the needs of the patient and the nurse.1 These results are consistent with other studies, which found that nurses across the country are individualizing visitation.2,3

AACN has published a Protocol for Practice titled Family Visitation & Partnership in the Critical Care Unit, which discusses visitation research findings and ways they are integrated into clinical practice. Following is a summary of the areas addressed in this evidence-based protocol, as well as other curren research studies:

The Issues
Nurses’ belief that restrictive visitation is best for the patient
Because their primary role is to care for the patient, experienced nurses feel that it is easier to give the family attention and time when visitation is restricted. Although this may be true, studies have shown that more liberal visitation is optimal for the patient and more satisfying for the patient and family.3

Increased patient and family satisfaction with liberalized visitation
Restricted visitation may actually be harmful to patients and families. Units that have liberalized their visitation have documented increased satisfaction of patients and families.3,4

Lack of evidence of adverse physiological effects from visitation
Nurses justify restricted visitation as protecting the patient from adverse physiological effects. Studies have not supported this assumption. Cardiovascular responses of patients to visitors, compared to nurse-patient interactions, are not harmful to the patient.5,6 Instead of increasing, intracranial pressure (ICP) readings declined or remained unchanged during visitation.7,8

Physical environment isn’t set up to have families at the bedside
Critical care units have been designed and set up to allow nursing staff to provide physiological care.9 Because bedside space is limited, visitors can be “in the way,” making it difficult for nurses to care for their patients. The issue of providing space for families can be addressed when units are remodeled. Confidentiality and privacy are also issues that are related to physical space limitation, especially in multibed rooms. In these situations, curtains and careful communication by team members is essential.

Nurses have difficulty incorporating families into care
Experienced nurses may have difficulty changing their care routine to include families when the time isn’t structured. Novice nurses, who are gaining competence in assessment, management and technical skills, may have difficulty juggling their time to include families when time isn’t structured and limited. They may also feel “scrutinized” by family members who stay at the bedside.10

Concerns regarding children as visitors
Studies have suggested that children who are screened for communicable diseases before visiting are no more likely than adults to spread infection.11,12 This applies to special care nurseries, as well as adult ICUs. However, children need special preparation for visitation, and the family needs assistance in determining when it is appropriate for children to visit. Sibling visitation in neonatal ICUs can be safe and provide benefits for the family.13

Pets may provide psychosocial and emotional benefits
Pet visitation programs include both family pets and licensed, trained animals and owners. Studies related to this issue have primarily centered around psychosocial and the emotional benefits for patients and the epidemiological safety of having pets at the bedside.14,15 Twelve studies are documented in the AACN Protocol for Practice titled “Family Pet Visiting, Animal-assisted Activities, and Animal-assisted Therapy in Critical Care.”16

Potential Solutions
Options to restrictive visiting policies
Movement to less restricted, individualized visiting practices is recommended. An ideal approach considers patient and family visitation preferences, assesses patient and family needs on admission and incorporates these into the plan of care. The AACN Practice Protocol outlines practice guidelines, as opposed to a policy.9 (Table)

Changing to visitation guidelines
Change in culture doesn’t happen overnight. Visitation policies should become visitation “guidelines” to allow for a shift in patient- and family-centered care that incorporates their needs. The goal is to assist nurses to become comfortable with providing care with families at the bedside.9

Planning and implementation are key
It is important to involve the multidisciplinary team in brainstorming possible implications of proposed changes to liberalize visitation and in designing an implementation plan. Give staff members time to adjust to the idea of having family members in the unit 24 hours a day and support them in adapting to the changes. Successfully setting up a change to more liberalized visitation may include mentoring by staff of units that have implemented these changes, learning their processes as well as outcomes.4

To become comfortable incorporating family and other visitors into the care routine, nurses must have the opportunity to:9,17
• Learn the research-based knowledge on visiting.
• Clarify their values regarding incorporation of family members into care delivery.
• Have discussions with their peers, other disciplines and patients and family members who have undergone a critical care experience to arrive at consensus of what the visiting practice guidelines will be for their unit.
• Disseminate the practice guidelines to appropriate multidisciplinary colleagues.
• Post environmental cues and signs that are congruent with the guidelines.
• Receive ongoing administrative support for making research-based practice changes.

Educating and mentoring nurses regarding communication strategies
Nurses have a valid concern about how to provide optimal care to patients while taking time to answer family questions, including them in care and providing support for visitors at the bedside. They need to work with members of the team who are comfortable communicating with and incorporating families at the bedside, including trained staff nurses, social workers, child life specialists and chaplains. Following are some of the keys to success:9
• Mentor staff and model ways to include the family in the care.
• Know how to ask family to take a break so that the nurse can focus totally on patient assessment and management when needed.
• Find ways to include family in care, such as providing massage, helping with skin care, reading to the patient at the bedside or quietly holding the patient’s hand.
• Know when and how to use other team members to assist with the family.

Development of family and visitor orientation and resource program
Research ways that other units have developed orientation resources and incorporate strategies to help prepare families to visit at the bedside, as well as resources and support for families in the institution. PICUs, which already have incorporated a family-centered care philosophy, may be of assistance in providing ideas for family orientation and resources.

The Family Intervention Research Team at the University of Iowa, Iowa City, has tested a Facilitated Child Visitation Intervention (FCVI) with children over the age of 5 visiting in adult and NICUs.18 This program, as well as guidelines for adult family members as visitors in adult critical care units, are highlighted in the appendix of AACN’s Protocol for Practice.9 The strategies include the previsit phase and preparation (written information, CD-ROM, videotapes, photos, one-on-one counseling, pretouring of the unit for presurgical admissions), role-modeling for family members as to what they can touch or do, referral of family members to others on the team (social worker, chaplain) for assistance in developing coping strategies and to potentially be with them during the visits, and providing ongoing monitoring and evaluation of family visitation to assess their needs, as well as patient responses.

Other creative resource ideas have been identified in the literature, such as the multimedia computer program for “ICU information” at the University of California at San Francisco Stanford Hospital, which gives visitors and family members a visual and audio introduction of the ICU environment and hospital support services.19

Family-centered care resources may also be found on the Institute of Family-Centered Care Web site at www.familycenteredcare.org.

Incorporating children and pets into a visitation program
Strategies to incorporate children and pets include working with infection control committees to design screening criteria for epidemiological safety. Other strategies included in the AACN Protocol for Practice include:16
• Developmentally appropriate education for children prior to visiting
• Evaluation of the child’s and patient’s response to the visitation and assistance with the child’s coping
• Assisting the parents to decide whether a child should visit
• Developing strategies to help the child who doesn’t visit, such as suggesting that they make and send artwork to the patient
• Physical planning for pet visitation, such as entrance, and instructions for the owner of the pet regarding care of the animal and required health certificates

Family members must be incorporated as part of the patient unit. Visitation policies should be changed to visitation guidelines, and must include anyone the patient considers to be “family.” Nurses need to be assisted in shifting their attitudes and beliefs, and be given education regarding dispelling myths and basing visitation practices on research. Other team members, including charge nurses, supervisors, social workers, child life specialists and chaplains, must be used appropriately to assist with the family, so that the bedside nurse can focus on the patient.

The cultural shift to liberal visitation must be set up for success, learning from institutions or units that have the practice in place, using a team approach in designing, implementing and evaluating the new practice, and not expecting that everyone will change their attitudes and practice overnight. Incorporating patients and families in critical care units is a challenge worth undertaking. As L.E. Fuller said: Nobody cares how much you know until they know how much you care.

1. Simon SK, Phillips K, Badalamenti S, Ohlert J, Krumberger J. Current practices regarding visitation policies in critical care units. Am J Crit Care. 1997;6:210-217.
2. Carlson B, Riegel B, Thomason T. Visitation: policy versus practice. Dimens Crit Care Nurs. 1998;17(1):40-47.
3. Ramsey P, Cathelyn J, Gugliotta B, Glenn LL. Visitor and nurse satisfaction with a visitation policy change in critical care units. Dimens Crit Care Nurs. 1999;18:(5)42-48.
4. Giuliano KK, Giuliano AJ, Bloniasz E, Quirk PA, Wood J. Families first: Liberal visitation policies may be in patient's best interest. Nurs Manage. May 2000:46-50.
5. Schulte DA, Burrell LO, Gueldner SH. Pilot study of the relationship between heart rate and ectopy and unrestricted vs restricted visiting hours in the coronary care unit. Am J Crit Care. 1993;2:134-136.
6. Kleman M, Bickert A, Karpinski A, et al. Physiologic responses of coronary care patients to visiting. J Cardiovasc Nurs. 1993;7:(3)52-62.
7. Hendrickson SL. Intracranial pressure changes and family presence. J Neurosci Nurs. 1987;19:14-17.
8. Prins MM. The effect of family visits on intracranial pressure. West J Nurs Res. 1989;11:281-297.
9. Titler MG. Family Visitation and Partnership in the Critical Care Unit. In: Protocols for Practice: Creating a Healing Environment. Aliso Viejo, Calif: AACN. 1997.
10. Titler MG, Bombei C, Schutte DL. Developing family-focused care units. Crit Care Nurs Clin North Am. 1995;7:375-386.
11. Kowba MD, Schwirian PM. Direct sibling contact and bacterial colonization in newborns. J Obstet Gynecol Neonatal Nurs. 1985;14:,412-417.
12. Solheim K, Spellacy C. Sibling visitation: effects on newborn infection rates. J Obstet Gynecol Neonatal Nurs. 1988;18:43-48.
13. Newman CB, McSweeney MA. A descriptive study of sibling visitation. Neonatal Netw. 1990; 9:(4)27-31.
14. Cole, KM, Gawlinski A. Animal-assisted therapy in the intensive care unit: a staff nurse’s dream comes true. Nurs Clin North Am. 1995; 30: 529-537.
15. Baun MM, Bergstrom N, Langston NF, Thomas L. Physiological effects of human/companion animal bonding. Nurs Res. 1984;33:126-129.
16. Titler MG, Drahozal R. Family Pet Visiting, Animal-assisted Activities, and Animal-assisted Therapy in Critical Care. In: Family Visitation and Partnership in the Critical Care Unit. In: Protocols for Practice: Creating a Healing Environment. Aliso Viejo, Calif; AACN. 1997.
17. Chesla CA. Reconciling technologic and family care in critical-care nursing. Image J Nurs Sch. 28: 199-204.
18. Nicholson AC, Titler MG, Montgomery LA, et al. Effects of child visitation in adult critical care units: a pilot study. Heart Lung. 1993;22:36-45.
19. Petterson M. Visitors have information and insight at their fingertips. Crit Care Nurse. 2000;20(2):136.


Practice guidelines for family visitation

Flexible visiting—mutual understanding between staff and family regarding who visits and length of time for visits

Contract—written agreement between patient, family and staff regarding who visits and length of time for visits

Patient-controlled visitation—sign on door for when patient wants visitors or a red light indicator for no visitors and a green light indicating ready for visitors

Structured—periodic visitation by two people for a longer period of time, such as 30 minutes

Inclusive—visitation open except for times specified and agreed upon by staff, such as during a change of shift report

Open visitation—no restrictions placed on frequency, time or length of visits; number and type of visitors may be restricted

CNS Practice Standards and Enhanced APN Resources Result From Group’s Work

Julie Marcum, RN, MSN, CCRN, CS
Advanced Practice Work Group

Developing a scope and standards of practice for clinical nurse specialists in acute and critical care and enhancing resources and networking opportunities for advanced practice nurses were among the important accomplishments of the AACN Advanced Practice Work Group during the past year.

The national volunteer group is currently wrapping up the rather full agenda that made up its charge. During the year, the group met on two different weekends—once in Southern California and again in Atlanta, Ga.—to define and refine its work.

The meetings, where the group interacted with the AACN national leadership team and discussed AACN’s Strategic Plan, provided members with an opportunity to network, learn, collaborate and develop friendships.

A substantial part of its efforts was directed at developing the Scope of Practice for the Acute and Critical Care Clinical Nurse Specialist. This document will serve not only as a reference for graduate nursing programs, but also as a guide for novice and experienced acute and critical care CNSs to enhance their practice. The Advanced Practice Work Group also developed the Standards of Practice and Standards of Professional Performance for the CNS in Critical Care. Both documents are expected to be available by the end of year.

Members of the Advanced Practice Work Group contributed several articles for publication in AACN News. The topics addressed such areas as how APNs utilize clinical practice guidelines, the curriculum for the Advanced Practice Institute, entrepreneurship opportunities for APNs and successful outcome measures to guide APNs in their practice.

After reviewing the preliminary API curriculum, the group suggested additional topics and expert speakers to balance content and meet the unique needs of advanced practice nurses. Members also analyzed the “Advanced Practice” area of the AACN Web site (www.aacn.org) and offered suggestions for enhancing links and adding topics of interest to APNs.

The work group also discussed networking relationships between APNs and other national organizations such as the Society of Critical Care Medicine, the American College of Nurse Practitioners, Sigma Theta Tau International and the Nursing Organization Leadership Forum.
In addition to the face-to-face meetings, the group dialogued with each other via the Internet and the Advanced Practice Work Group discussion area of the
AACN Web site.

The group’s proposed agenda for the next year is equally challenging. Agenda items include additional articles for AACN News, development of the curriculum for API 2002, enhancing networking opportunities and reviewing resources for supporting the advanced practice roles of AACN members.

Practice Resource Network: Frequently Asked Questions

QHow can I handle an abusive, hostile physician who constantly uses foul language in my presence. I love my new job, but this physician is making my life miserable. The other nurses simply ignore his behavior. Having a good working environment doesn’t seem possible when he is around. I am so upset by his behavior that I can’t concentrate for hours after he leaves and am afraid I will make a serious error as a result. I have considered complaining to my supervisor. However, one nurse who did, suffered even more abuse and eventually left for another unit. I love everything else about my job and don’t want to leave. What can I do?

AFirst, learn about and develop your conflict resolution skills and build your confidence. Try talking directly with the physician about his unacceptable behavior. You are the best one to try to solve this problem.

There are several good books on conflict resolution, many of which can be found in a local library or at a bookstore. A quick search on amazon.com revealed more than 1,000 topics that deal with conflict management. Here are just a few:
• How to Deal With Difficult People (Successful Office Skills Series), by Donald H. Weiss, Bobbi Linkemer. June 1987
• Getting to Peace: Transforming Conflict at Home, at Work, and in the World, by William L. Ury. October 1999
• The Magic of Dialogue: Transforming Conflict into Cooperation, by Daniel Yankelovich. September 1999
• The Peacemaker: A Biblical Guide to Resolving Personal Conflict, by Ken Sande. February 1997
• The Magic of Conflict Workbook: Your Personal Guidance System, by Thomas F. Crum. June 1993
• Conflict Resolution, by Daniel Dana. December 2000
• Emotional Vampires: Dealing With People Who Drain You Dry,by Albert J. Bernstein. August 2000
• The Briles Report on Women in Healthcare: Changing Conflict to Collaboration in a Toxic Workplace, by Judith Briles. July 1994

Following are some approaches that can help successfully guide you through a resolution to this problem:

1. If possible, confront the physician immediately after he has used the offensive language, but not during times of high stress and anxiety, such as when his patient is failing. Try to find a time when he is not rushed and you can pull him aside for a few minutes of private discussion. You might invite him to join you for a cup of coffee, telling him that you want to discuss something with him. Regardless, make sure you talk to him in private and not in front of other staff or patients. Embarrassing him in front of others could make him more abusive and reflect poorly on you as a professional.

2. Do not place blame or attack the physician for his behavior. He may not realize that his behavior is annoying or hurtful. Some people use offensive language without even thinking and simply need to be reminded this is offensive to others. And, remember that some people simply have poor people skills. We should try to help them succeed at the difficult task of interacting with others, just as we would do for our nurse colleagues.

3. In talking with the physician, use “I” statements, such as: “Doctor X, when you talk in those terms and use that kind of language, I find it very offensive and upsetting. I know you don't mean to hurt me, but it makes me feel demeaned and angry, and I know that is not your intention. I know you have only the best of intentions and want to work with me as a professional colleague. I want the same kind of relationship with you. Therefore, I really wish you would try to tone down your language and use a more professional approach. I know we both want to provide our patients with the most nurturing, healing and professional environment possible. I really think this will help achieve that goal.”

4. Stay friendly and positive, and try to understand the stress this physician may be experiencing. When he seems particularly uptight, you may be able to avert unacceptable behavior by asking if you can be of assistance in anyway. Stay positive, focus on building collegial relationships, set appropriate behavior limits for both of you and avoid being swayed by your anger and feelings of resentment.

5. Rehearse what you are going to say, and try to anticipate this physician’s reaction and how you will handle it. Be prepared for the worst, but hope for the best. He may surprise you and apologize profusely.

6. Finally, talk to your department supervisor about developing a set of “Behavior Norms” for your unit. This document should reflect how you want everyone on the unit to interact and treat one another. Once the draft is completed by staff with physician input and approved by management require that everyone sign it and agree to conform to these norms. As a contract on how everyone will treat each other, it provides a standard to measure people who stray from the norms. If this physician continues to act out, the manager, in conjunction with other proactive physicians, can talk to him and set limits on and consequences for his behavior.

Q:I am very interested in reducing stress, increasing morale and changing the atmosphere in our very busy cardiac surgery unit. Recently, I developed a “Good News Forum” center, where staff can post pleasant, positive comments about the unit and their coworkers. A weekly quote is also posted on the board. I am seeking other easy and quick ways to help reduce stress and increase team support in this highly technical workplace. Can you also point me to resources on subjects such as stress reduction and team building?

A:Congratulations on your positive efforts to build morale and avoid stress. You obviously understand “an ounce of prevention is worth a pound of cure.” This is especially true in these high-stress, resource-restricted times. AACN has several tools that may interest you:
• DiSC Leadership Self-Assessment Tool—designed to help nurses identify their behavioral tendencies in the workplace, such as what motivates, excites, bores, inspires or demotivates individuals. Item #121750; Price, $75 for members ($90 for nonmembers). Group discounts are available
• Staffing Blueprint: Constructing Your Staffing Solutions—provides excellent ideas for building a healthy staff environment. Item #300117, Price, $26 for members ($35 for nonmembers)
• Reinventing your Nursing Career: A Handbook for Success in the Age of Managed Care—includes chapters on empowerment, time management and personal transitions. Item #128285. Price, $29.95 for members ($32 for nonmembers)
• AACN Practice Protocol titled “Creating a Healing Environment—Alternative and Complementary Modalities for Managing Stress and Anxiety in Acute and Critical Care”—includes a number of annotated bibliographies on the topic of ICU nurses and stress and health. Item #CC170710. Price, $52 for members ($64 for nonmembers)

These resources can be ordered by calling (800) 899-2226 or online in the “Bookstore” area of the AACN Web site at www.aacn.org.

Another interesting publication, Getting Excited Again About Nursing: How to Make it Contagious, can be ordered by calling (800) 373-2952. Request Item #CE132-50-00. The price, is $13 for audiotape and $15 for audio CD. Orders can also be faxed to (303) 292-5629.

You might also conduct an online search using keywords, such as “nursing humor” or “nursing stress.” There are multiple, wonderful sites with some great jokes, ideas and fun exercises. You can also search for book topics such as “team building,” “conflict resolution” and “stress management” on www.amazon.com. Combining the topics with the word healthcare should bring up some great results.

One last thought, remember to smile and to say a genuine “thank you” as often as possible. Although celebrations such as the recent National Nurses’ Week and Critical Care Awareness and Recognition Month are nice, the thanks that really count are the ones that come from the heart and are personal, one-on-one interactions. Human beings have an amazing capacity to withstand almost any stress, as long as they feel supported and appreciated. Try to share this feeling with your staff and it will be returned in kind, leading to a healthy, happy and healing environment for both your staff and patients.

Suggested Reading
Tsele N. Muller M. Clinical accompaniment: the critical care nursing students’ experiences in a private hospital. Curationis. 2000 June; 23(2): 32-6
Luczun ME. Stress management techniques for ICU practitioners. Curr Rev Respir Crit Care. 1988 Oct 27; 11(4):27-32
Crickmore R. A review of stress in the intensive care unit. Intensive Care Nurs. 1987; 3(1):19-27 (36 ref).
Friedman EH. Stress and intensive care nursing: a ten-year reappraisal. Heart Lung. 1982 Jan-Feb; 11:26-8.
Ehrenfeld M. Bar-Tal Y. Identifying the coping behaviours used by nurses in intensive care. Nurs Stand. 1995 May 3-9; 9(32):27-30 (36 ref).

Deadlines Near to Apply for 2 Nursing Research Grants

The deadlines to submit proposals for two AACN nursing research grants are approaching. Following is brief information about each of these grants:

Medtronic Physio-Control-AACN Small Grants Program

Cosponsored by Medtronic Physio-Control, this program awards up to $1,500 to qualified individuals carrying out projects that focus on aspects of acute myocardial infarction resuscitation. Proposals must be received by July 1, 2001.

AACN Clinical Inquiry Grants
These grants provide awards of up to $250 to qualified AACN members who are carrying out clinical research projects that will directly benefit patients or their families. Applications must be received by July 1, 2001.

To obtain an application for either of these grants, all (800) 899-2226 (request Item #1013), or visit the AACN Web site at www.aacn.org. Click on “Clinical Practice,” then “Research,” then “Grants.”

Online Quick Poll

Does your hospital conduct a CCRN Review Course for staff certification or recertification?

No 84%
Yes 16%

Number of Responses: 685

The AACN Online Quick Poll is a voluntary, nonscientific survey on a variety of topics. AACN presents these surveys to give our users an opportunity to share their opinions on particular topics. Participate by visiting the AACN Web site at www.aacn.org.
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