ORIGINAL ARTICLE
Family Satisfaction in Critical Care Units: Does an Open Visiting Hours Policy Have an Impact? Salim Baharoon, MD,* Walid Al Yafi, MD,† Ahmad Al Qurashi, MD,* Hamdan Al Jahdali, MD,* Hani Tamim, PhD,‡ Eiman Alsafi, MD,§ and Abdullah A. Al Sayyari, MD* Objective: For critically ill patients, the interaction between health care providers and family members is essential in daily decision making. Improving this relationship has a positive impact on satisfaction with the overall care provided to patients and reduces family member symptoms of depression, anxiety, and posttraumatic stress disorder. In this study, we analyzed the impact of visitation policy (open versus restricted) on family satisfaction using the previously well-validated Critical Care Family Satisfaction Survey (CCFSS) questionnaire. Methods: This is a cross-sectional prospective observational study conducted between November 1, 2009, and January 31, 2010, in 2 critical care units with 2 different visiting policy systems, unit A (open visiting hours) and B (restricted visiting hours), comparing family satisfaction in both units using the CCFSS questionnaire. Responses were grouped in 5 satisfaction constructs, namely, the support construct, which assesses the degree of satisfaction with the support of the intensive care staff as perceived by relatives; the assurance construct, which assesses the degree of satisfaction regarding honest answers being given and the responder's confidence that the patient is receiving the best care possible; the proximity construct, which assesses the degree of satisfaction with the physical and emotional access to the patient; the information construct, which assesses the degree of satisfaction with the adequacy of information given to relatives; and the comfort construct, which assesses satisfaction with physical comfort and amenities. Results: During the study period, 115 questionnaires were distributed in each of the 2 sites. The response rates in units A and B were 92% (106) and 100% (115), respectively. The mean stay time in the intensive care unit was 3.7 days. There were more trauma cases in unit A and more cardiac patients in unit B. There was no significant difference between the 2 units in any of the 5 satisfaction constructs, the support, assurance, proximity, information, and comfort constructs, although there was a nonsignificant trend favoring the unit with the more liberal visit policy regarding amenities (unit A). Conclusions: We concluded that family satisfaction to care provided in intensive care as measured by the CCFSS questionnaire was not influenced by frequency of visitation among Saudi families. Factors other than open visiting hours may be important to evaluate. Key Words: family satisfaction, family satisfaction in ICU, open visiting hours policy, open visit policy, open visiting hours policy in ICU (J Patient Saf 2014;00: 00–00)
T
he Institute of Medicine defines quality care as safe, timely, effective, efficient, equitable, and emphasizing on patientcentered care.1 In the intensive care setting, the interaction
From the *College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; †College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; ‡Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon; and §Department of Quality Management, King Saud Chest Specialty Hospital, Riyadh, Saudi Arabia. Correspondence: Salim Baharoon, MD, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Al Shaikh Jaber Al Ahmed Al Sabah, PO Box 22490, Riyadh 11426 Kingdom of Saudi Arabia. (e‐mail: [email protected]; [email protected]). The authors disclose no conflict of interest. Copyright © 2014 by Lippincott Williams & Wilkins
J Patient Saf • Volume 00, Number 00, Month 2014
between health care providers and family members is essential in daily decision making. For critically ill patients, family members' presence has been shown to improve patient–health care provider's communication and to decrease cardiocirculatory complications, intensive care length of stay, and anxiety, without any detrimental physiological changes in heart rate, rhythm, blood pressure, intracranial pressure, or stress hormones.2–4 To our knowledge, an impact on patient mortality has not been linked to frequency of visitation. Family satisfaction is an important aspect of the overall care given to critically ill patients. Improving the relationship between health care providers and patients' family members has a positive impact on satisfaction with the overall care provided and reduces family member symptoms of depression, anxiety, and posttraumatic stress disorder.2–5 When relatives are given full and honest information in an understandable and timely manner and believe that their family member is being treated with skill and compassion, satisfaction levels rise.6–10 Measuring family satisfaction with care is an important method for assessing one critical aspect of critical care quality. The needs of critically ill patients' families are inconsistently met, which has been universally shown in many studies.9,11,12 Factors thought to improve family satisfaction in the intensive care units (ICUs) include good communication skills, ICU staff courtesy, compassion, respect, good quality of information provided to the family, and satisfactory level of health care received by the patient.6,7,10,13 There are a number of validation tools available to measure family satisfaction and needs in the critical care setting. One of the most widely used is the Critical Care Family Needs Inventory. It was first developed in 1979 and has since been successfully tested in many different institutions in various languages and societies.4,6,11,13 It is a very lengthy survey, however, with 45 need statements that respondents rate on a scale of 1 to 4. In 2001, the development of 2 shorter questionnaires was reported in the medical literature.7,10 The validity of one of these questionnaires, the Critical Care Family Satisfaction Survey (CCFSS), has been established both in the hospital where it was developed and in several other sites where it is being used on a regular basis.7,14–16 It is a self-completion questionnaire with 20 statements that respondents are asked to rate on a 5-point Likert scale. A translated Arabic version of this tool has been previously validated.17 The National Guard Health Affairs (NGHA) is a health organization in Saudi Arabia that provides advanced and tertiary care. All hospitals under the NGHA are Joint Commission International (JCI) accredited. There are 2 major medical cities under its umbrella (King Abdulaziz Medical City in central province and King Abdulaziz Medical City in western province), with total beds of 1600, as well as 3 smaller hospitals. The NGHA uses 2 different visiting hour policies in ICUs. An open door policy is used at the National Guard Hospital in Riyadh (central region, for all firstdegree relatives of patients in the adult ICU), whereas a stricter policy is applied at the National Guard Hospital in Jeddah (western region). In this study, we analyzed the impact of visitation policy (open versus restricted) on family satisfaction using the previously www.journalpatientsafety.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1
J Patient Saf • Volume 00, Number 00, Month 2014
Baharoon et al
well-validated CCFSS questionnaire. The study was approved by King Abdullah International Medical Research Center.
METHODS This study is a cross-sectional observational study conducted between November 1, 2009, and January 31, 2010, in 2 critical care units under the umbrella of the National Guard Health service. Close family members (defined as parents, siblings, spouses, offspring, aunts, and uncles) of patients admitted to the ICU for more than 72 hours were surveyed prospectively using the translated Arabic version of the CCFSS. Permission to use the Arabic translated version of the survey questionnaire from its original authors was sought and granted. The institutional review board in both hospitals approved conducting the study. All patients who have been admitted in the preceding 72 hours of distributing the questionnaire were identified, and their family members were approached. The units' administrative assistant gave the family member an introductory 1-page document written in Arabic language that explains the purpose of the survey (to assess the family satisfaction regarding different aspects of care provided) and emphasized the importance of completing all the questions asked in the survey. Completed questionnaires were handled confidentially and returned in sealed envelopes to the unit assistants before patient discharge from the ICU. No consent was requested, and submission of the questionnaire back is considered an agreement of participation. Only completed questionnaires were included in the analysis. Filling in the questionnaire was optional. No ICU physicians contributed to handing, explaining, or collecting the questionnaires from family members. The 2 critical care units have distinct visiting policies. Unit A at King Abdulaziz Medical City in Riyadh has a 24-hour open visiting policy for first-degree relatives, whereas the visiting hours at unit B of King Abdulaziz Medical City in Jeddah are restricted to predetermined hours in the morning and evening. Both units function as a multidisciplinary closed unit where a team led by a North American–trained intensive care consultant assisted by intensive care staff physicians (board-certified physicians in medicine, anesthesia, or surgery with at least 2 years of intensive care experience), a critical care fellow, residents, a clinical pharmacist, a dietitian, and a physiotherapist conducts daily clinical rounds on all ICU patients. The intensive care consultant intensivist typically would be responsible for the patient for a 1-week rotation, whereas staff physicians typically do a 2-week rotation. Transfer of care occurs at discharge to medical or surgical teams depending on admission criteria. The intensive care physician may participate in follow-up after discharge for a maximum of 3 days. There are no scheduled dedicated times to discuss patient status with family members in either unit. The patient's family members will usually obtain information from residents, staff physicians, nurses, and respiratory therapists during visitation and may request to talk to the intensive care consultant in charge and typically would see him/her either on the same or the next day. Occasionally, the physician would request to see the patient's family members for an update especially for a very sick patient or to discuss code status. Although the patient's family members do obtain information from nurses, this is discouraged in both units because of potential miscommunications. Our nursing staff members are mainly coming from non–Arabic-speaking countries in Asia, Europe, and South Africa. The Arabic version of the CCFSS questionnaire consists of 2 parts. The first part collects sociodemographic information (age of the respondent, duration of patient stay in the ICU, and the relationship of the respondent to the patient). The second part includes 20 statements that the respondent is asked to grade on a
2
www.journalpatientsafety.com
5-point Likert scale according to his/her satisfaction with that statement. Responses are scored as follows: very satisfied, 5; satisfied, 4; not certain, 3; not satisfied, 2; and very dissatisfied, 1. In the validated Arabic CCFSS questionnaire, question number 20 originally asking about “Sharing in decisions regarding my family member's recovery, Information subscale” was replaced with a question on “General appearance of ICU staff, Assurance subscale.” In the current study, we used the Arabic translated version of the original questionnaire but we kept question 20 about “Sharing decisions regarding my family member's recovery, Information subscale” as is in the original version and translated it to Arabic.
Statistical Analyses The Statistical Package for the Social Sciences (version 19; SPSS Software-IBM Corporation, Armonk, NY) was used for the data management and analyses. The responses were grouped according to the following 5 constructs and subscales as follows: (1) assurance (questions 3, 4, 7, 19, and 20), (2) proximity (questions 5, 15, and 18), (3) information (questions 2, 6, 10, and 12), (4) support (questions 1, 9, 11, 13, 14, and 16), and (5) comfort (questions 17 and 8). The answers to each of these scores were transformed into a numerical scale: disagree (score of 1), undetermined (score of 2), and agree (score of 3). Moreover, a total score was calculated for each question by getting the mean and SD of the continuous scale. These subclasses were compared between the 2 units using the χ2 test or the Student t test, as appropriate. A P value of less than 0.05 was considered to indicate statistical significance. We assessed the internal consistency of the overall scale, and it was found to be very good, with a Cronbach α score of 0.843.
RESULTS During the period of the study, 115 questionnaires were distributed in each of the 2 sites, with a response rate of 92% (106) in unit A and 100% (115) in unit B. The mean stay time in ICU for both units was 3.7 days. The demographic parameters, the responder's relation to the patient, and the reason for admission to the ICU at both units are shown in Table 1. Unit A had significantly more trauma admissions, whereas unit B had more cardiac admissions. After the data were analyzed, we categorized the results according to 5 satisfaction constructs. The overall satisfaction was measured by calculating the total number of those who responded as satisfied divided by the total number of questions measuring this element. All results are shown in Tables 2 and 3. The support construct assesses the degree of satisfaction in the support by the ICU staff as perceived by the patient's family member. Most of the respondents in both units were satisfied regarding the support extended by the staff to the patient and to them. The assurance construct assesses the degree of satisfaction in honest answers being given by health care providers and the confidence that the patient is receiving the best care possible. We did not observe any significant difference between the responses of the family members in either unit. On the proximity construct, which assesses the degree of satisfaction in the physical and emotional access to the patient, questions on privacy provided during visits and participation in the care provided to their loved ones were asked. Satisfaction was comparable in both units. Similarly, the members in both units were satisfied on the flexibility of visiting hours; however, more family members in unit B answered “I don't know” as compared with unit A. The information construct assesses the degree of satisfaction in the adequacy of information given to relatives, with questions such as availability of the physician for discussion on © 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Patient Saf • Volume 00, Number 00, Month 2014
Family Satisfaction in Critical Care Units
TABLE 1. General Characteristics Unit P 0.16
0.001
0.57 0.57
Unit B
Unit A
20 (17.4%) 55 (47.8%) 20 (17.4%) 11 (9.6%) 9 (7.8%) 13 (12.4%) 7 (6.7%) 20 (19.0%) 20 (19.0%) 14 (13.3%) 14 (13.3%) 8 (7.6%) 9 (8.6%) 36.2 (11.1) 3.7 (0.8)
25 (23.6%) 35 (33.0%) 24 (22.6%) 16 (15.1%) 6 (5.7%) 27 (36.0%) 5 (6.7%) 12 (16.0%) 3 (4.0%) 10 (13.3%) 1 (1.3%) 9 (12.0%) 8 (10.7%) 37.1 (11.5) 3.7 (1.0)
No. (%) 45 (20.4) 90 (40.7) 44 (19.9) 27 (12.2) 15 (6.8) 40 (18.1) 12 (5.4) 32 (14.5) 23 (10.4) 24 (10.9) 15 (6.8) 17 (7.7) 17 (7.7) 36.6 (11.3) 3.7 (0.9)
a regular basis and clear explanation of tests, procedures, and treatments performed. The family members in unit B were more satisfied on sharing decisions with physicians, although not reaching statistical significance. The last construct was the
Variables Mother/father Son/daughter Brother/sister Husband/wife Other Trauma Malignancy Respiratory diseases Neuromuscular Postoperative/surgery Cardiac Septic shock Other Mean (SD) Mean (SD)
Relation to patients
Reason for admission to ICU
Age Length of stay
comfort construct, which assesses the satisfaction in physical comfort and amenities. The questions asked addressed cleanliness, appearance, and peacefulness of the waiting room. Although the overall score did not show any statistical difference, more
TABLE 2. Satisfaction Domain Mean Scores Unit B P
Unit A
Mean (SD) Mean (SD)
0.87 2.3 (0.8) 2.3 (0.8) 0.92 2.4 (0.8) 2.4 (0.8) 0.81 2.4 (0.8) 2.4 (0.8) 0.52 2.3 (0.8) 2.4 (0.8) 0.51 2.3 (0.7) 2.2 (0.6) 0.69 2.37 (0.48) 2.39 (0.51) 0.47 2.3 (0.8) 2.4 (0.8) 0.17 2.3 (0.8) 2.5 (0.8) 0.67 2.3 (0.8) 2.4 (0.8) 0.24 2.3 (0.5) 2.4 (0.6) 0.43 2.4 (0.8) 2.3 (0.9) 1.00 2.3 (0.8) 2.3 (0.8) 0.70 2.4 (0.8) 2.4 (0.8) 0.16 2.5 (0.8) 2.3 (0.8) 0.53 2.38 (0.40) 2.31 (0.48) 0.95 2.5 (0.8) 2.5 (0.8) 0.86 2.4 (0.8) 2.5 (0.8) 0.62 2.6 (0.8) 2.6 (0.7) 0.27 2.4 (0.8) 2.3 (0.8) 0.61 2.4 (0.8) 2.5 (0.8) 0.84 2.5 (0.8) 2.5 (0.7) 0.97 2.5 (0.5) 2.5 (0.5) 0.52 2.5 (0.7) 2.6 (0.7) 0.03 2.2 (0.9) 2.4 (0.8) 0.07 2.3 (0.6) 2.5 (0.7) 0.73 2.4 (0.3) 2.4 (0.5)
Variables Waiting time for results of tests and x-rays Assurance Peace of mind in knowing my family member's nurse(s) Promptness of staff in responding to alarms and requests for assistance Noise in the critical care unit Sharing in decisions regarding my family member's recovery Assurance score Ability to share in the care of my family member Proximity Privacy provided for me and my family member during our visits Flexibility of visiting hours Proximity score Availability of the physician to speak with me on a regular basis Information Clear explanation of tests, procedures, and treatments Clear answers to my questions Sharing in decisions regarding my family member's care on a regular basis Information score Honesty of the staff about my family member's condition Support Support and encouragement given to me during my family member's stay in the critical care unit Quality of care given to my family member Availability of nurses to speak with me every day about my family member's care Sensitivity of the physician(s) to my family member's needs Preparation for my family member's transfer from critical care Support score Cleanliness and appearance of the waiting room Comfort Peacefulness of the waiting room Comfort score Overall score
© 2014 Lippincott Williams & Wilkins
www.journalpatientsafety.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
3
J Patient Saf • Volume 00, Number 00, Month 2014
Baharoon et al
TABLE 3. Participants' Detailed Responses Unit B
Unit A
Agree, Mean (%)
Undetermined, Mean (%)
Disagree, Mean (%)
Agree, Mean (%)
Undetermined, Mean (%)
Disagree, Mean (%)
0.89
57 (49.6)
37 (32.2)
21 (18.3)
55 (51.9)
31 (29.2)
20 (18.9)
0.94
68 (59.1)
29 (25.2)
18 (15.7)
63 (59.4)
25 (23.6)
18 (17.0)
0.92
70 (60.9)
23 (20.0)
22 (19.1)
67 (63.2)
19 (17.9)
20 (18.9)
0.73
63 (54.8)
23 (20.0)
29 (25.2)
61 (57.5)
23 (21.7)
22 (20.8)
0.25
50 (43.5)
49 (42.6)
16 (13.9)
37 (34.9)
57 (53.8)
12 (11.3)
0.77 0.37
62 (53.9) 64 (55.7)
30 (26.1) 23 (20.0)
23 (20.0) 28 (24.3)
62 (58.5) 67 (63.2)
26 (24.5) 21 (19.8)
18 (17.0) 18 (17.0)
0.82
65 (56.5)
24 (20.9)
26 (22.6)
64 (60.4)
19 (17.9)
23 (21.7)
0.31
69 (60.0)
24 (20.9)
22 (19.1)
62 (58.5)
16 (15.1)
28 (26.4)
0.44
61 (53.0)
31 (27.0)
23 (20.0)
60 (56.6)
21 (19.8)
25 (23.6)
0.89
68 (59.1)
24 (20.9)
23 (20.0)
61 (57.5)
21 (19.8)
24 (22.6)
0.37
71 (61.7)
25 (21.7)
19 (16.5)
57 (53.8)
24 (22.6)
25 (23.6)
0.98 0.98
77 (67.0) 74 (64.3)
15 (13.0) 18 (15.7)
23 (20.0) 23 (20.0)
71 (67.0) 69 (65.1)
13 (12.3) 17 (16.0)
22 (20.8) 20 (18.9)
0.73 0.50
84 (73.0) 74 (64.3)
13 (11.3) 18 (15.7)
18 (15.7) 23 (20.0)
79 (74.5) 60 (56.6)
14 (13.2) 20 (18.9)
13 (12.3) 26 (24.5)
0.85
72 (62.6)
20 (17.4)
23 (20.0)
69 (65.1)
19 (17.9)
18 (17.0)
0.65
75 (65.2)
19 (16.5)
21 (18.3)
68 (64.2)
22 (20.8)
16 (15.1)
0.32
78 (67.8)
20 (17.4)
17 (14.8)
79 (74.5)
11 (10.4)
16 (15.1)
0.09
54 (47.0)
25 (21.7)
36 (31.3)
64 (60.4)
21 (19.8)
21 (19.8)
P
dissatisfied members were present in unit B when asked about the peacefulness of the waiting room. Units B's family waiting room is much smaller than unit A's.
DISCUSSION Restricted hospital visiting hours began in the late 1800s in an attempt to establish order in general wards.18 Although this restriction was originally applied only to nonpaying patients, in the 1960s, hospitals broadly restricted visiting hours to all patents in the ICU and general wards.18 The rationale used at that time was that they were “protecting patients and their families from exhaustion caused by too many visitors” (K. Ludmerer, MD, Washington University, oral communication, April 23, 2004). Other reasons included interference with the delivery of care and intense physiological stress to the patient.18
4
www.journalpatientsafety.com
Variables Assurance: time spent awaiting laboratory result and radiological results Assurance: knowing the attending staff nurse Assurance: quick response to emergency situation Assurance: noise level in ICU units Assurance: sharing in decisions regarding my family member's recovery Proximity: sharing in patient care Proximity: privacy given to you and families during visits in unit Proximity: flexibility of visiting time Information: availability of physicians periodically Information: clear explanation of all results, procedures, and treatment Information: clear answers to questions Information: sharing in treatment decision for patients periodically Support: honesty of physicians Support: support of staff to patients and family members Support: quality of care to patients Support: availability of nursing staff to talk every day about patients Support: physicians' response to patients' needs Support: preparation of transfer of patient from ICU unit Comfort: cleanliness and appearance of waiting room Comfort: quiet atmosphere in waiting room
In 2004, Berwick and Kotagal18 wrote that “restricting visiting in ICUs is neither caring, compassionate, nor necessary.” Liberal visiting hours in both wards and ICUs was found beneficial for patients. Patients in critical care units experience fewer hallucinations and have less anxiety when their families are at their bedside.19–22 Contrary to unsubstantiated claims, visits of family and friends to ill patients do not usually increase patients' stress levels, as measured by blood pressure, heart rate, and intracranial pressure, but rather may actually lower them.23,24 Evidence also suggests that families may serve as a helpful support structure, increasing opportunities for patient and family education as well as facilitating communication between the patient and clinicians.23 They may also be able to provide feedback to nurses and physicians more effectively than the critically ill patient can, creating a better working relationship for everyone involved.23 The presence of family members during a critically ill patient's hospitalization helps him/her cope better with overwhelming © 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Patient Saf • Volume 00, Number 00, Month 2014
stress factors.24 The literature has identified the following needs of families during a critical illness or injury: reassurance, proximity, information, convenience, and support. Reassurance is the need for honest answers to questions and the confidence that the patient is receiving the best care possible. Proximity refers to physical and emotional access to the patient, which brings comfort to the family and also enables the family to accurately assess the patient's situation. Families require frequent updates in information concerning a patient's plan of care, any changes, and the patient's overall progress. They want to know specifically what is being done for their loved one and why. Information grounds family members by letting them know what can be reasonably expected, thereby decreasing stress and anxiety.25 A principal fear of family members is that they might miss a vital piece of information concerning the patient's condition.26 Convenience takes into consideration privacy and comfort, with amenities readily available such as a telephone, comfortable furniture, and refreshments. Support includes extended family members, friends, clergy, and the health care staff. Nursing support for the family engenders an atmosphere of mutual trust.25 Family members are better able to cope with the patient's illness when these identified needs are met. Increasing family access to their loved one in the critical care environment is a way to fulfill these needs.26,27 Open visiting hours may not be suitable in all clinical settings and cultures. Benefits to patients in the more liberal visitation and more involvement of patients' families in the care of their loved ones are undeniably evidence based. Patients and their family members should actively participate in setting the appropriate model of visitation in the ICU. Physicians, nurses, respiratory therapists, patient relations officers, and hospital administrators should engage in this discussion, and the target should be encouraging more frequent presence of family members and more patient interaction with their loved ones during their critical illness. The goal is to provide patient- and family-centered care for those patients who are most in need of such care. A trail evaluation of liberal visitation in ICUs with restricted policies may reveal so many advantages to decision makers. Obstacles may be encountered and balanced easement of the gains and losses will likely result in a better model of visitation that is suitable for different patient populations. The current study examined family members' satisfaction in 2 ICUs that have similar operating systems but different visiting hour policies. The results suggest that both models of visiting hours policy may achieve significant family satisfaction, and the data do not support the superiority of 1 model over the other in our patient population. It is likely that the content of information provided during encounters with the health care provider may be a more important factor than the visitation frequency. Culture variations may also play a factor in overall satisfaction. The initiation of the more liberal visiting hours policy that was initiated because of increasing dissatisfaction among family members in 1 ICU resulted in higher patient and family satisfaction as well as a marked decrease in formal complaints. However, this may be secondary to the feeling among family members that something was done to address their concern.28 There are several limitations to this study, including a small sample size and the fact that the families surveyed were from 2 different geographical areas of the country. Sociocultural factors influencing expectations and satisfaction in these 2 geographical regions can be an important factor. The internal characteristics of the units, including the manner in which families are approached, may also have influenced the results. There was no consistent pattern of delivering information in either unit. Time dedicated to families per day by the physician in charge may be © 2014 Lippincott Williams & Wilkins
Family Satisfaction in Critical Care Units
another factor that affects satisfaction. Time of delivery of the questionnaire to the family members was consistently early in both units. Overall satisfaction may vary if this was done at different time intervals after admission. Despite these limitations, we think that this study may indicate that the frequency of visitation per se may not be the main factor to determine satisfaction of patients' family members but rather a combination of factors that include sociocultural characteristics of families, time per family for discussion, and direct communication through physicians in charge versus commendation through nurses and residents. Designing a follow-up study to evaluate all these factors is crucial. Despite a strong push from the intensive care community toward liberating visiting hours in the ICU, compliance with this recommendation is still approximately 40%.29 Most ICUs in Saudi Arabia do not have open visiting policies. Claims that family members' presence interferes with patient care and triggers complaints are common in Saudi hospitals. Analyzing the elements that affect family satisfaction may permit development of a model that provides proximity of those 2 approaches.
REFERENCES 1. Institute of Medicine Committee on Quality of Health in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001:1–337. 2. Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med. 2007;356:469–478. 3. Pochard F, Azoulay E, Chevret S, et al. Symptoms of anxiety and depression in family members of intensive care unit patients: ethical hypothesis regarding decision-making capacity. Crit Care Med. 2001;29: 1893–1897. 4. Azoulay E, Pochard F, Kentish-Barnes N, et al. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med. 2005;171:987–994. 5. Dowling J, Wang B. Impact on family satisfaction: the critical care family assistance program. Chest. 2005;128(suppl):76S–80S. 6. Malacrida R, Bettelini CM, Degrate A, et al. Reasons for dissatisfaction: a survey of relatives of intensive care patients who died. Crit Care Med. 1998:26:1187–1193. 7. Azouly E, Pochard F, Chevret S, et al. Meeting the needs of intensive care unit patient families: a multicentre study. Am J Respir Crit Care Med. 2001;163:135–139. 8. Molter NC. Needs of relatives of critically ill patients. Heart Lung. 1979;8:332–339. 9. Heyland DK, Rocker GM, Dodek PM, et al. Family satisfaction with care in the intensive care unit: results of a multiple center study. Crit Care Med. 2002;30:1413–1418. 10. Heyland DK, Rocker GM, O'Callaghan CJ, et al. Dying in the ICU: perspectives of family members. Chest. 2003;124:392–397. 11. Azoulay E, Chevret S, Leleu G, et al. Half the families of intensive care unit patients experience inadequate communication with physicians. Crit Care Med. 2000;28:3044–3049. 12. Johnson D, Wilson M, Cavanaugh B, et al. Measuring the ability to meet family needs in an intensive care unit. Crit Care Med. 1998;26:266–271. 13. Hanson LC, Danis M, Garrett J. What is wrong with end of life care? Opinions of bereaved family members. J Am Geriatr Soc. 1997;45:1339–1344. 14. Wasser T, Pasquale MA, Matchett SC, et al. Establishing reliability and validity of the Critical Care Family Satisfaction Survey. Crit Care Med. 2001;29:192–196.
www.journalpatientsafety.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
5
J Patient Saf • Volume 00, Number 00, Month 2014
Baharoon et al
15. Wasser T, Matchett S, Ray D, et al. Validation of a total score for the Critical Care Family Satisfaction Survey. J Clin Outcomes Manag. 2004;11:502–507.
23. Krapohl GL. Visiting hours in the adult intensive care unit: using research to develop a system that works. Dimens Crit Care Nurs. 1995;14:245–258.
16. Ray D, Wasser TE, Ahrens TM, et al. Validation of the Critical Care Family Satisfaction Survey by use of Internet data entry: 116-S. Crit Care Med. 2005;33(suppl):A29.
24. Gonzalez CE, Carroll DL, Elliott JS, et al. Visiting preferences of patients in the intensive care unit and in a complex care medical unit. Am J Crit Care. 2004;13:194–198.
17. Brown A, Hijazi M. Arabic translation and adaptation of Critical Care Family Satisfaction Survey. Int J Qual Health Care. 2008;20:291–296.
25. Hallgrimsdottir EM. Accident and emergency nurses' perceptions and experiences of caring for families. J Clin Nurs. 2000;9:611–619.
18. Berwick DM, Kotagal M. Restricted visiting hours in ICUs time to change. JAMA. 2004;292:736–737. doi:10.1001/jama.292.6.736. 19. Takman CA, Severinsson EI. The needs of significant others within intensive care: the perspectives of Swedish nurses and physicians. Intensive Crit Care Nurs. 2004;20:22–31. 20. Sullivan EE. Family visitation in PACU. J Perianesth Nurs. 2001;16:29–30. 21. Simon SK, Phillips K, Badalamenti S, et al. Current practices regarding visitation policies in critical care units. Am J Crit Care. 1997;6:210–217. 22. Gurley MJ. Determining ICU visitation hours. Medsurg Nurs. 1995;4:40–43.
6
www.journalpatientsafety.com
26. Wagner JM. Lived experience of critically ill patients' family members during cardiopulmonary resuscitation. Am J Crit Care. 2004;13:416–420. 27. Marfell JA, Garcia JS. Contracted visiting hours in the coronary care unit. A patient-centered quality improvement project. Nurs Clin North Am. 1995;30:87–96. 28. Roland P, Russell J, Richards KC, et al. Visitation in critical care: processes and outcomes of a performance improvement initiative. J Nurs Care Qual. 2001;15:18–26. 29. Kirchhoff KT, Dahl N. American Association of Critical-Care Nurses' national survey of facilities and units providing critical care. Am J Crit Care. 2006;15:13–27.
© 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Family Satisfaction in Critical Care Units: Does an Open Visiting Hours Policy Have an Impact? Salim Baharoon, MD,* Walid Al Yafi, MD,† Ahmad Al Qurashi, MD,* Hamdan Al Jahdali, MD,* Hani Tamim, PhD,‡ Eiman Alsafi, MD,§ and Abdullah A. Al Sayyari, MD* Objective: For critically ill patients, the interaction between health care providers and family members is essential in daily decision making. Improving this relationship has a positive impact on satisfaction with the overall care provided to patients and reduces family member symptoms of depression, anxiety, and posttraumatic stress disorder. In this study, we analyzed the impact of visitation policy (open versus restricted) on family satisfaction using the previously well-validated Critical Care Family Satisfaction Survey (CCFSS) questionnaire. Methods: This is a cross-sectional prospective observational study conducted between November 1, 2009, and January 31, 2010, in 2 critical care units with 2 different visiting policy systems, unit A (open visiting hours) and B (restricted visiting hours), comparing family satisfaction in both units using the CCFSS questionnaire. Responses were grouped in 5 satisfaction constructs, namely, the support construct, which assesses the degree of satisfaction with the support of the intensive care staff as perceived by relatives; the assurance construct, which assesses the degree of satisfaction regarding honest answers being given and the responder's confidence that the patient is receiving the best care possible; the proximity construct, which assesses the degree of satisfaction with the physical and emotional access to the patient; the information construct, which assesses the degree of satisfaction with the adequacy of information given to relatives; and the comfort construct, which assesses satisfaction with physical comfort and amenities. Results: During the study period, 115 questionnaires were distributed in each of the 2 sites. The response rates in units A and B were 92% (106) and 100% (115), respectively. The mean stay time in the intensive care unit was 3.7 days. There were more trauma cases in unit A and more cardiac patients in unit B. There was no significant difference between the 2 units in any of the 5 satisfaction constructs, the support, assurance, proximity, information, and comfort constructs, although there was a nonsignificant trend favoring the unit with the more liberal visit policy regarding amenities (unit A). Conclusions: We concluded that family satisfaction to care provided in intensive care as measured by the CCFSS questionnaire was not influenced by frequency of visitation among Saudi families. Factors other than open visiting hours may be important to evaluate. Key Words: family satisfaction, family satisfaction in ICU, open visiting hours policy, open visit policy, open visiting hours policy in ICU (J Patient Saf 2014;00: 00–00)
T
he Institute of Medicine defines quality care as safe, timely, effective, efficient, equitable, and emphasizing on patientcentered care.1 In the intensive care setting, the interaction
From the *College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; †College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; ‡Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon; and §Department of Quality Management, King Saud Chest Specialty Hospital, Riyadh, Saudi Arabia. Correspondence: Salim Baharoon, MD, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Al Shaikh Jaber Al Ahmed Al Sabah, PO Box 22490, Riyadh 11426 Kingdom of Saudi Arabia. (e‐mail: [email protected]; [email protected]). The authors disclose no conflict of interest. Copyright © 2014 by Lippincott Williams & Wilkins
J Patient Saf • Volume 00, Number 00, Month 2014
between health care providers and family members is essential in daily decision making. For critically ill patients, family members' presence has been shown to improve patient–health care provider's communication and to decrease cardiocirculatory complications, intensive care length of stay, and anxiety, without any detrimental physiological changes in heart rate, rhythm, blood pressure, intracranial pressure, or stress hormones.2–4 To our knowledge, an impact on patient mortality has not been linked to frequency of visitation. Family satisfaction is an important aspect of the overall care given to critically ill patients. Improving the relationship between health care providers and patients' family members has a positive impact on satisfaction with the overall care provided and reduces family member symptoms of depression, anxiety, and posttraumatic stress disorder.2–5 When relatives are given full and honest information in an understandable and timely manner and believe that their family member is being treated with skill and compassion, satisfaction levels rise.6–10 Measuring family satisfaction with care is an important method for assessing one critical aspect of critical care quality. The needs of critically ill patients' families are inconsistently met, which has been universally shown in many studies.9,11,12 Factors thought to improve family satisfaction in the intensive care units (ICUs) include good communication skills, ICU staff courtesy, compassion, respect, good quality of information provided to the family, and satisfactory level of health care received by the patient.6,7,10,13 There are a number of validation tools available to measure family satisfaction and needs in the critical care setting. One of the most widely used is the Critical Care Family Needs Inventory. It was first developed in 1979 and has since been successfully tested in many different institutions in various languages and societies.4,6,11,13 It is a very lengthy survey, however, with 45 need statements that respondents rate on a scale of 1 to 4. In 2001, the development of 2 shorter questionnaires was reported in the medical literature.7,10 The validity of one of these questionnaires, the Critical Care Family Satisfaction Survey (CCFSS), has been established both in the hospital where it was developed and in several other sites where it is being used on a regular basis.7,14–16 It is a self-completion questionnaire with 20 statements that respondents are asked to rate on a 5-point Likert scale. A translated Arabic version of this tool has been previously validated.17 The National Guard Health Affairs (NGHA) is a health organization in Saudi Arabia that provides advanced and tertiary care. All hospitals under the NGHA are Joint Commission International (JCI) accredited. There are 2 major medical cities under its umbrella (King Abdulaziz Medical City in central province and King Abdulaziz Medical City in western province), with total beds of 1600, as well as 3 smaller hospitals. The NGHA uses 2 different visiting hour policies in ICUs. An open door policy is used at the National Guard Hospital in Riyadh (central region, for all firstdegree relatives of patients in the adult ICU), whereas a stricter policy is applied at the National Guard Hospital in Jeddah (western region). In this study, we analyzed the impact of visitation policy (open versus restricted) on family satisfaction using the previously www.journalpatientsafety.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1
J Patient Saf • Volume 00, Number 00, Month 2014
Baharoon et al
well-validated CCFSS questionnaire. The study was approved by King Abdullah International Medical Research Center.
METHODS This study is a cross-sectional observational study conducted between November 1, 2009, and January 31, 2010, in 2 critical care units under the umbrella of the National Guard Health service. Close family members (defined as parents, siblings, spouses, offspring, aunts, and uncles) of patients admitted to the ICU for more than 72 hours were surveyed prospectively using the translated Arabic version of the CCFSS. Permission to use the Arabic translated version of the survey questionnaire from its original authors was sought and granted. The institutional review board in both hospitals approved conducting the study. All patients who have been admitted in the preceding 72 hours of distributing the questionnaire were identified, and their family members were approached. The units' administrative assistant gave the family member an introductory 1-page document written in Arabic language that explains the purpose of the survey (to assess the family satisfaction regarding different aspects of care provided) and emphasized the importance of completing all the questions asked in the survey. Completed questionnaires were handled confidentially and returned in sealed envelopes to the unit assistants before patient discharge from the ICU. No consent was requested, and submission of the questionnaire back is considered an agreement of participation. Only completed questionnaires were included in the analysis. Filling in the questionnaire was optional. No ICU physicians contributed to handing, explaining, or collecting the questionnaires from family members. The 2 critical care units have distinct visiting policies. Unit A at King Abdulaziz Medical City in Riyadh has a 24-hour open visiting policy for first-degree relatives, whereas the visiting hours at unit B of King Abdulaziz Medical City in Jeddah are restricted to predetermined hours in the morning and evening. Both units function as a multidisciplinary closed unit where a team led by a North American–trained intensive care consultant assisted by intensive care staff physicians (board-certified physicians in medicine, anesthesia, or surgery with at least 2 years of intensive care experience), a critical care fellow, residents, a clinical pharmacist, a dietitian, and a physiotherapist conducts daily clinical rounds on all ICU patients. The intensive care consultant intensivist typically would be responsible for the patient for a 1-week rotation, whereas staff physicians typically do a 2-week rotation. Transfer of care occurs at discharge to medical or surgical teams depending on admission criteria. The intensive care physician may participate in follow-up after discharge for a maximum of 3 days. There are no scheduled dedicated times to discuss patient status with family members in either unit. The patient's family members will usually obtain information from residents, staff physicians, nurses, and respiratory therapists during visitation and may request to talk to the intensive care consultant in charge and typically would see him/her either on the same or the next day. Occasionally, the physician would request to see the patient's family members for an update especially for a very sick patient or to discuss code status. Although the patient's family members do obtain information from nurses, this is discouraged in both units because of potential miscommunications. Our nursing staff members are mainly coming from non–Arabic-speaking countries in Asia, Europe, and South Africa. The Arabic version of the CCFSS questionnaire consists of 2 parts. The first part collects sociodemographic information (age of the respondent, duration of patient stay in the ICU, and the relationship of the respondent to the patient). The second part includes 20 statements that the respondent is asked to grade on a
2
www.journalpatientsafety.com
5-point Likert scale according to his/her satisfaction with that statement. Responses are scored as follows: very satisfied, 5; satisfied, 4; not certain, 3; not satisfied, 2; and very dissatisfied, 1. In the validated Arabic CCFSS questionnaire, question number 20 originally asking about “Sharing in decisions regarding my family member's recovery, Information subscale” was replaced with a question on “General appearance of ICU staff, Assurance subscale.” In the current study, we used the Arabic translated version of the original questionnaire but we kept question 20 about “Sharing decisions regarding my family member's recovery, Information subscale” as is in the original version and translated it to Arabic.
Statistical Analyses The Statistical Package for the Social Sciences (version 19; SPSS Software-IBM Corporation, Armonk, NY) was used for the data management and analyses. The responses were grouped according to the following 5 constructs and subscales as follows: (1) assurance (questions 3, 4, 7, 19, and 20), (2) proximity (questions 5, 15, and 18), (3) information (questions 2, 6, 10, and 12), (4) support (questions 1, 9, 11, 13, 14, and 16), and (5) comfort (questions 17 and 8). The answers to each of these scores were transformed into a numerical scale: disagree (score of 1), undetermined (score of 2), and agree (score of 3). Moreover, a total score was calculated for each question by getting the mean and SD of the continuous scale. These subclasses were compared between the 2 units using the χ2 test or the Student t test, as appropriate. A P value of less than 0.05 was considered to indicate statistical significance. We assessed the internal consistency of the overall scale, and it was found to be very good, with a Cronbach α score of 0.843.
RESULTS During the period of the study, 115 questionnaires were distributed in each of the 2 sites, with a response rate of 92% (106) in unit A and 100% (115) in unit B. The mean stay time in ICU for both units was 3.7 days. The demographic parameters, the responder's relation to the patient, and the reason for admission to the ICU at both units are shown in Table 1. Unit A had significantly more trauma admissions, whereas unit B had more cardiac admissions. After the data were analyzed, we categorized the results according to 5 satisfaction constructs. The overall satisfaction was measured by calculating the total number of those who responded as satisfied divided by the total number of questions measuring this element. All results are shown in Tables 2 and 3. The support construct assesses the degree of satisfaction in the support by the ICU staff as perceived by the patient's family member. Most of the respondents in both units were satisfied regarding the support extended by the staff to the patient and to them. The assurance construct assesses the degree of satisfaction in honest answers being given by health care providers and the confidence that the patient is receiving the best care possible. We did not observe any significant difference between the responses of the family members in either unit. On the proximity construct, which assesses the degree of satisfaction in the physical and emotional access to the patient, questions on privacy provided during visits and participation in the care provided to their loved ones were asked. Satisfaction was comparable in both units. Similarly, the members in both units were satisfied on the flexibility of visiting hours; however, more family members in unit B answered “I don't know” as compared with unit A. The information construct assesses the degree of satisfaction in the adequacy of information given to relatives, with questions such as availability of the physician for discussion on © 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Patient Saf • Volume 00, Number 00, Month 2014
Family Satisfaction in Critical Care Units
TABLE 1. General Characteristics Unit P 0.16
0.001
0.57 0.57
Unit B
Unit A
20 (17.4%) 55 (47.8%) 20 (17.4%) 11 (9.6%) 9 (7.8%) 13 (12.4%) 7 (6.7%) 20 (19.0%) 20 (19.0%) 14 (13.3%) 14 (13.3%) 8 (7.6%) 9 (8.6%) 36.2 (11.1) 3.7 (0.8)
25 (23.6%) 35 (33.0%) 24 (22.6%) 16 (15.1%) 6 (5.7%) 27 (36.0%) 5 (6.7%) 12 (16.0%) 3 (4.0%) 10 (13.3%) 1 (1.3%) 9 (12.0%) 8 (10.7%) 37.1 (11.5) 3.7 (1.0)
No. (%) 45 (20.4) 90 (40.7) 44 (19.9) 27 (12.2) 15 (6.8) 40 (18.1) 12 (5.4) 32 (14.5) 23 (10.4) 24 (10.9) 15 (6.8) 17 (7.7) 17 (7.7) 36.6 (11.3) 3.7 (0.9)
a regular basis and clear explanation of tests, procedures, and treatments performed. The family members in unit B were more satisfied on sharing decisions with physicians, although not reaching statistical significance. The last construct was the
Variables Mother/father Son/daughter Brother/sister Husband/wife Other Trauma Malignancy Respiratory diseases Neuromuscular Postoperative/surgery Cardiac Septic shock Other Mean (SD) Mean (SD)
Relation to patients
Reason for admission to ICU
Age Length of stay
comfort construct, which assesses the satisfaction in physical comfort and amenities. The questions asked addressed cleanliness, appearance, and peacefulness of the waiting room. Although the overall score did not show any statistical difference, more
TABLE 2. Satisfaction Domain Mean Scores Unit B P
Unit A
Mean (SD) Mean (SD)
0.87 2.3 (0.8) 2.3 (0.8) 0.92 2.4 (0.8) 2.4 (0.8) 0.81 2.4 (0.8) 2.4 (0.8) 0.52 2.3 (0.8) 2.4 (0.8) 0.51 2.3 (0.7) 2.2 (0.6) 0.69 2.37 (0.48) 2.39 (0.51) 0.47 2.3 (0.8) 2.4 (0.8) 0.17 2.3 (0.8) 2.5 (0.8) 0.67 2.3 (0.8) 2.4 (0.8) 0.24 2.3 (0.5) 2.4 (0.6) 0.43 2.4 (0.8) 2.3 (0.9) 1.00 2.3 (0.8) 2.3 (0.8) 0.70 2.4 (0.8) 2.4 (0.8) 0.16 2.5 (0.8) 2.3 (0.8) 0.53 2.38 (0.40) 2.31 (0.48) 0.95 2.5 (0.8) 2.5 (0.8) 0.86 2.4 (0.8) 2.5 (0.8) 0.62 2.6 (0.8) 2.6 (0.7) 0.27 2.4 (0.8) 2.3 (0.8) 0.61 2.4 (0.8) 2.5 (0.8) 0.84 2.5 (0.8) 2.5 (0.7) 0.97 2.5 (0.5) 2.5 (0.5) 0.52 2.5 (0.7) 2.6 (0.7) 0.03 2.2 (0.9) 2.4 (0.8) 0.07 2.3 (0.6) 2.5 (0.7) 0.73 2.4 (0.3) 2.4 (0.5)
Variables Waiting time for results of tests and x-rays Assurance Peace of mind in knowing my family member's nurse(s) Promptness of staff in responding to alarms and requests for assistance Noise in the critical care unit Sharing in decisions regarding my family member's recovery Assurance score Ability to share in the care of my family member Proximity Privacy provided for me and my family member during our visits Flexibility of visiting hours Proximity score Availability of the physician to speak with me on a regular basis Information Clear explanation of tests, procedures, and treatments Clear answers to my questions Sharing in decisions regarding my family member's care on a regular basis Information score Honesty of the staff about my family member's condition Support Support and encouragement given to me during my family member's stay in the critical care unit Quality of care given to my family member Availability of nurses to speak with me every day about my family member's care Sensitivity of the physician(s) to my family member's needs Preparation for my family member's transfer from critical care Support score Cleanliness and appearance of the waiting room Comfort Peacefulness of the waiting room Comfort score Overall score
© 2014 Lippincott Williams & Wilkins
www.journalpatientsafety.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
3
J Patient Saf • Volume 00, Number 00, Month 2014
Baharoon et al
TABLE 3. Participants' Detailed Responses Unit B
Unit A
Agree, Mean (%)
Undetermined, Mean (%)
Disagree, Mean (%)
Agree, Mean (%)
Undetermined, Mean (%)
Disagree, Mean (%)
0.89
57 (49.6)
37 (32.2)
21 (18.3)
55 (51.9)
31 (29.2)
20 (18.9)
0.94
68 (59.1)
29 (25.2)
18 (15.7)
63 (59.4)
25 (23.6)
18 (17.0)
0.92
70 (60.9)
23 (20.0)
22 (19.1)
67 (63.2)
19 (17.9)
20 (18.9)
0.73
63 (54.8)
23 (20.0)
29 (25.2)
61 (57.5)
23 (21.7)
22 (20.8)
0.25
50 (43.5)
49 (42.6)
16 (13.9)
37 (34.9)
57 (53.8)
12 (11.3)
0.77 0.37
62 (53.9) 64 (55.7)
30 (26.1) 23 (20.0)
23 (20.0) 28 (24.3)
62 (58.5) 67 (63.2)
26 (24.5) 21 (19.8)
18 (17.0) 18 (17.0)
0.82
65 (56.5)
24 (20.9)
26 (22.6)
64 (60.4)
19 (17.9)
23 (21.7)
0.31
69 (60.0)
24 (20.9)
22 (19.1)
62 (58.5)
16 (15.1)
28 (26.4)
0.44
61 (53.0)
31 (27.0)
23 (20.0)
60 (56.6)
21 (19.8)
25 (23.6)
0.89
68 (59.1)
24 (20.9)
23 (20.0)
61 (57.5)
21 (19.8)
24 (22.6)
0.37
71 (61.7)
25 (21.7)
19 (16.5)
57 (53.8)
24 (22.6)
25 (23.6)
0.98 0.98
77 (67.0) 74 (64.3)
15 (13.0) 18 (15.7)
23 (20.0) 23 (20.0)
71 (67.0) 69 (65.1)
13 (12.3) 17 (16.0)
22 (20.8) 20 (18.9)
0.73 0.50
84 (73.0) 74 (64.3)
13 (11.3) 18 (15.7)
18 (15.7) 23 (20.0)
79 (74.5) 60 (56.6)
14 (13.2) 20 (18.9)
13 (12.3) 26 (24.5)
0.85
72 (62.6)
20 (17.4)
23 (20.0)
69 (65.1)
19 (17.9)
18 (17.0)
0.65
75 (65.2)
19 (16.5)
21 (18.3)
68 (64.2)
22 (20.8)
16 (15.1)
0.32
78 (67.8)
20 (17.4)
17 (14.8)
79 (74.5)
11 (10.4)
16 (15.1)
0.09
54 (47.0)
25 (21.7)
36 (31.3)
64 (60.4)
21 (19.8)
21 (19.8)
P
dissatisfied members were present in unit B when asked about the peacefulness of the waiting room. Units B's family waiting room is much smaller than unit A's.
DISCUSSION Restricted hospital visiting hours began in the late 1800s in an attempt to establish order in general wards.18 Although this restriction was originally applied only to nonpaying patients, in the 1960s, hospitals broadly restricted visiting hours to all patents in the ICU and general wards.18 The rationale used at that time was that they were “protecting patients and their families from exhaustion caused by too many visitors” (K. Ludmerer, MD, Washington University, oral communication, April 23, 2004). Other reasons included interference with the delivery of care and intense physiological stress to the patient.18
4
www.journalpatientsafety.com
Variables Assurance: time spent awaiting laboratory result and radiological results Assurance: knowing the attending staff nurse Assurance: quick response to emergency situation Assurance: noise level in ICU units Assurance: sharing in decisions regarding my family member's recovery Proximity: sharing in patient care Proximity: privacy given to you and families during visits in unit Proximity: flexibility of visiting time Information: availability of physicians periodically Information: clear explanation of all results, procedures, and treatment Information: clear answers to questions Information: sharing in treatment decision for patients periodically Support: honesty of physicians Support: support of staff to patients and family members Support: quality of care to patients Support: availability of nursing staff to talk every day about patients Support: physicians' response to patients' needs Support: preparation of transfer of patient from ICU unit Comfort: cleanliness and appearance of waiting room Comfort: quiet atmosphere in waiting room
In 2004, Berwick and Kotagal18 wrote that “restricting visiting in ICUs is neither caring, compassionate, nor necessary.” Liberal visiting hours in both wards and ICUs was found beneficial for patients. Patients in critical care units experience fewer hallucinations and have less anxiety when their families are at their bedside.19–22 Contrary to unsubstantiated claims, visits of family and friends to ill patients do not usually increase patients' stress levels, as measured by blood pressure, heart rate, and intracranial pressure, but rather may actually lower them.23,24 Evidence also suggests that families may serve as a helpful support structure, increasing opportunities for patient and family education as well as facilitating communication between the patient and clinicians.23 They may also be able to provide feedback to nurses and physicians more effectively than the critically ill patient can, creating a better working relationship for everyone involved.23 The presence of family members during a critically ill patient's hospitalization helps him/her cope better with overwhelming © 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Patient Saf • Volume 00, Number 00, Month 2014
stress factors.24 The literature has identified the following needs of families during a critical illness or injury: reassurance, proximity, information, convenience, and support. Reassurance is the need for honest answers to questions and the confidence that the patient is receiving the best care possible. Proximity refers to physical and emotional access to the patient, which brings comfort to the family and also enables the family to accurately assess the patient's situation. Families require frequent updates in information concerning a patient's plan of care, any changes, and the patient's overall progress. They want to know specifically what is being done for their loved one and why. Information grounds family members by letting them know what can be reasonably expected, thereby decreasing stress and anxiety.25 A principal fear of family members is that they might miss a vital piece of information concerning the patient's condition.26 Convenience takes into consideration privacy and comfort, with amenities readily available such as a telephone, comfortable furniture, and refreshments. Support includes extended family members, friends, clergy, and the health care staff. Nursing support for the family engenders an atmosphere of mutual trust.25 Family members are better able to cope with the patient's illness when these identified needs are met. Increasing family access to their loved one in the critical care environment is a way to fulfill these needs.26,27 Open visiting hours may not be suitable in all clinical settings and cultures. Benefits to patients in the more liberal visitation and more involvement of patients' families in the care of their loved ones are undeniably evidence based. Patients and their family members should actively participate in setting the appropriate model of visitation in the ICU. Physicians, nurses, respiratory therapists, patient relations officers, and hospital administrators should engage in this discussion, and the target should be encouraging more frequent presence of family members and more patient interaction with their loved ones during their critical illness. The goal is to provide patient- and family-centered care for those patients who are most in need of such care. A trail evaluation of liberal visitation in ICUs with restricted policies may reveal so many advantages to decision makers. Obstacles may be encountered and balanced easement of the gains and losses will likely result in a better model of visitation that is suitable for different patient populations. The current study examined family members' satisfaction in 2 ICUs that have similar operating systems but different visiting hour policies. The results suggest that both models of visiting hours policy may achieve significant family satisfaction, and the data do not support the superiority of 1 model over the other in our patient population. It is likely that the content of information provided during encounters with the health care provider may be a more important factor than the visitation frequency. Culture variations may also play a factor in overall satisfaction. The initiation of the more liberal visiting hours policy that was initiated because of increasing dissatisfaction among family members in 1 ICU resulted in higher patient and family satisfaction as well as a marked decrease in formal complaints. However, this may be secondary to the feeling among family members that something was done to address their concern.28 There are several limitations to this study, including a small sample size and the fact that the families surveyed were from 2 different geographical areas of the country. Sociocultural factors influencing expectations and satisfaction in these 2 geographical regions can be an important factor. The internal characteristics of the units, including the manner in which families are approached, may also have influenced the results. There was no consistent pattern of delivering information in either unit. Time dedicated to families per day by the physician in charge may be © 2014 Lippincott Williams & Wilkins
Family Satisfaction in Critical Care Units
another factor that affects satisfaction. Time of delivery of the questionnaire to the family members was consistently early in both units. Overall satisfaction may vary if this was done at different time intervals after admission. Despite these limitations, we think that this study may indicate that the frequency of visitation per se may not be the main factor to determine satisfaction of patients' family members but rather a combination of factors that include sociocultural characteristics of families, time per family for discussion, and direct communication through physicians in charge versus commendation through nurses and residents. Designing a follow-up study to evaluate all these factors is crucial. Despite a strong push from the intensive care community toward liberating visiting hours in the ICU, compliance with this recommendation is still approximately 40%.29 Most ICUs in Saudi Arabia do not have open visiting policies. Claims that family members' presence interferes with patient care and triggers complaints are common in Saudi hospitals. Analyzing the elements that affect family satisfaction may permit development of a model that provides proximity of those 2 approaches.
REFERENCES 1. Institute of Medicine Committee on Quality of Health in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001:1–337. 2. Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med. 2007;356:469–478. 3. Pochard F, Azoulay E, Chevret S, et al. Symptoms of anxiety and depression in family members of intensive care unit patients: ethical hypothesis regarding decision-making capacity. Crit Care Med. 2001;29: 1893–1897. 4. Azoulay E, Pochard F, Kentish-Barnes N, et al. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med. 2005;171:987–994. 5. Dowling J, Wang B. Impact on family satisfaction: the critical care family assistance program. Chest. 2005;128(suppl):76S–80S. 6. Malacrida R, Bettelini CM, Degrate A, et al. Reasons for dissatisfaction: a survey of relatives of intensive care patients who died. Crit Care Med. 1998:26:1187–1193. 7. Azouly E, Pochard F, Chevret S, et al. Meeting the needs of intensive care unit patient families: a multicentre study. Am J Respir Crit Care Med. 2001;163:135–139. 8. Molter NC. Needs of relatives of critically ill patients. Heart Lung. 1979;8:332–339. 9. Heyland DK, Rocker GM, Dodek PM, et al. Family satisfaction with care in the intensive care unit: results of a multiple center study. Crit Care Med. 2002;30:1413–1418. 10. Heyland DK, Rocker GM, O'Callaghan CJ, et al. Dying in the ICU: perspectives of family members. Chest. 2003;124:392–397. 11. Azoulay E, Chevret S, Leleu G, et al. Half the families of intensive care unit patients experience inadequate communication with physicians. Crit Care Med. 2000;28:3044–3049. 12. Johnson D, Wilson M, Cavanaugh B, et al. Measuring the ability to meet family needs in an intensive care unit. Crit Care Med. 1998;26:266–271. 13. Hanson LC, Danis M, Garrett J. What is wrong with end of life care? Opinions of bereaved family members. J Am Geriatr Soc. 1997;45:1339–1344. 14. Wasser T, Pasquale MA, Matchett SC, et al. Establishing reliability and validity of the Critical Care Family Satisfaction Survey. Crit Care Med. 2001;29:192–196.
www.journalpatientsafety.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
5
J Patient Saf • Volume 00, Number 00, Month 2014
Baharoon et al
15. Wasser T, Matchett S, Ray D, et al. Validation of a total score for the Critical Care Family Satisfaction Survey. J Clin Outcomes Manag. 2004;11:502–507.
23. Krapohl GL. Visiting hours in the adult intensive care unit: using research to develop a system that works. Dimens Crit Care Nurs. 1995;14:245–258.
16. Ray D, Wasser TE, Ahrens TM, et al. Validation of the Critical Care Family Satisfaction Survey by use of Internet data entry: 116-S. Crit Care Med. 2005;33(suppl):A29.
24. Gonzalez CE, Carroll DL, Elliott JS, et al. Visiting preferences of patients in the intensive care unit and in a complex care medical unit. Am J Crit Care. 2004;13:194–198.
17. Brown A, Hijazi M. Arabic translation and adaptation of Critical Care Family Satisfaction Survey. Int J Qual Health Care. 2008;20:291–296.
25. Hallgrimsdottir EM. Accident and emergency nurses' perceptions and experiences of caring for families. J Clin Nurs. 2000;9:611–619.
18. Berwick DM, Kotagal M. Restricted visiting hours in ICUs time to change. JAMA. 2004;292:736–737. doi:10.1001/jama.292.6.736. 19. Takman CA, Severinsson EI. The needs of significant others within intensive care: the perspectives of Swedish nurses and physicians. Intensive Crit Care Nurs. 2004;20:22–31. 20. Sullivan EE. Family visitation in PACU. J Perianesth Nurs. 2001;16:29–30. 21. Simon SK, Phillips K, Badalamenti S, et al. Current practices regarding visitation policies in critical care units. Am J Crit Care. 1997;6:210–217. 22. Gurley MJ. Determining ICU visitation hours. Medsurg Nurs. 1995;4:40–43.
6
www.journalpatientsafety.com
26. Wagner JM. Lived experience of critically ill patients' family members during cardiopulmonary resuscitation. Am J Crit Care. 2004;13:416–420. 27. Marfell JA, Garcia JS. Contracted visiting hours in the coronary care unit. A patient-centered quality improvement project. Nurs Clin North Am. 1995;30:87–96. 28. Roland P, Russell J, Richards KC, et al. Visitation in critical care: processes and outcomes of a performance improvement initiative. J Nurs Care Qual. 2001;15:18–26. 29. Kirchhoff KT, Dahl N. American Association of Critical-Care Nurses' national survey of facilities and units providing critical care. Am J Crit Care. 2006;15:13–27.
© 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
