Family Visitation in Greek Intensive Care Units: Nurses' Perspective Archonto Athanasiou, Elizabeth D.E. Papathanassoglou, Elisabeth Patiraki, Mary S. McCarthy and Margarita Giannakopoulou Am J Crit Care 2014;23:326-333 doi: 10.4037/ajcc2014986 © 2014 American Association of Critical-Care Nurses Published online http://www.ajcconline.org Personal use only. For copyright permission information: http://ajcc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT

Subscription Information http://ajcc.aacnjournals.org/subscriptions/ Information for authors http://ajcc.aacnjournals.org/misc/ifora.xhtml Submit a manuscript http://www.editorialmanager.com/ajcc Email alerts http://ajcc.aacnjournals.org/subscriptions/etoc.xhtml

AJCC, the American Journal of Critical Care, is the official peer-reviewed research journal of the American Association of Critical-Care Nurses (AACN), published bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2014 by AACN. All rights reserved.

Downloaded from ajcc.aacnjournals.org at MCGILL UNIVERSITY LIBRARY on October 28, 2014

Families in Critical Care

F

VISITATION IN GREEK INTENSIVE CARE UNITS: NURSES’ PERSPECTIVE AMILY

By Archonto Athanasiou, RN, MSc, Elizabeth D.E. Papathanassoglou, RN, MSc, PhD, Elisabeth Patiraki, RN, PhD, Mary S. McCarthy, RN, PhD, and Margarita Giannakopoulou, RN, PhD

©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ajcc2014986

326

Background Policies of flexible and open visiting in intensive care units benefit both patients and patients’ families. In Greek intensive care units, gaps exist between evidence and practice for family visitation, resulting in restricted visiting policies. Objectives To explore the beliefs of nurses in Greek intensive care units about the effects of visiting on patients, patients’ families, and unit staff and nurses’ attitudes toward visiting policies. Methods A descriptive correlational survey was conducted in 6 public hospitals in Athens, Greece, with a sample of 143 critical care nurses. Data were collected via an anonymous questionnaire consisting of 3 validated scales to assess the nurses’ beliefs about and attitudes toward visitation. Results Generally, nurses were resistant to family visiting and open visiting, and most (94.4%) did not want an open policy in their unit. Nurses think that open visiting policies are supportive for patients and patients families, but the overall effects of visiting depend on both the nurse and the patient (91.6%). Nurses reported that open visiting created increased physical and psychological burdens for them (87.5%) and hampered nursing care (75.5%). Years of work experience, staffing level, and number of night shifts worked by nurses per 15 days were factors predictive of nurses’ attitudes toward and beliefs about family visitation. Conclusions Nurses’ beliefs about and attitudes toward visitation are important factors in the implementation of more flexible visiting policies in Greek intensive care units. Well-staffed units with experienced nurses and fewer shifts per week may affect nurses’ negative attitude toward open visitation. (American Journal of Critical Care. 2014;23:326-333)

AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2014, Volume 23, No. 4

www.ajcconline.org

Downloaded from ajcc.aacnjournals.org at MCGILL UNIVERSITY LIBRARY on October 28, 2014

A

dmission to an intensive care unit (ICU) is a highly stressful event for both patients and patients’ family members, who feel overwhelmed by fear of the prognosis and of the patients’ deteriorated condition or even sudden death.1-9 Families form the fundamental unit of a person’s life and function as a team to support the person psychologically, ethically, socially, and spiritually.8,10-13 The burden of pain and disease of one family member will somehow overshadow the well-being of the whole family.9,14 Negative intense reactions, such as anger, irritability, shock, grief, and loss of control are often prevalent outside the ICUs, creating the need for closeness for family members to stay by the bedside of their beloved.1-9,14-19 From the perspective of family-centered care and improvement of quality, interest in finding new ways of implementing more flexible visiting hours in critical care settings has increased during the past few years.10,20-25 Several investigators8,10-13,19,26,27 whose studies focused on the satisfaction of patients and the patients’ families have pointed out the importance of meeting the families’ needs and incorporating those needs into the nursing care plan. Evidence5,8,9,12,14-18,26-30 also suggests that a flexible visiting policy increases the satisfaction of patients and patients’ families, reduces their anxiety, and helps them integrate more effectively into the complicated and hostile ICU environment.

Research data12,22,31-36 on nurses’ visitation preferences and satisfaction differ among countries and facilities. Current visiting practices also vary internationally, from closed ICUs to free visiting during the day, indicating that this topic is still controversial.35,37-44 Nurses’ concerns about liberalizing visiting hours range from the disorganization of care8,22,31,34-36 and the psychological burden that nurses receive from the stressed families of patients8,22,31-35,37 to the adverse effects on patients’ physiological condition19,20,22,31,35,43,45-48 and infection control.48,49 Despite the effort to address the need for more flexible policies, most general ICUs in Athens, Greece, restrict their visiting hours, as indicated on their official websites and information sheets, a situation that leads to conflicts between health professionals and patients’ families.7 Because nurses are the final decision makers on the flexibility of visits,22,31,37,50 assessment of nurses’ beliefs about and attitudes toward liberalization of

About the Authors Archonto Athanasiou is a staff nurse in the intensive care unit, 401 Military Hospital, Athens, Greece. Elizabeth D.E. Papathanassoglou is an associate professor, Department of Nursing, Cyprus University of Technology, Nicosia, Cyprus. Elisabeth Patiraki is a professor and Margarita Giannakopoulou is an assistant professor, Faculty of Nursing, University of Athens, Athens, Greece. Mary S. McCarthy is a nurse scientist, Madigan Army Medical Center, Tacoma, Washington. Corresponding author: Mary S. McCarthy, 1611 Nisqually St, Steilacoom, WA 98388 (e-mail: mary.s.mccarthy1.civ @mail.mil).

www.ajcconline.org

visitation in the ICU would be an important step in establishing flexible and open visiting policies. The purpose of this study was to explore Greek ICU nurses’ beliefs about and attitudes toward visitation in the ICU and their beliefs about the effects of visiting on patients, patients’ families, and ICU staff.

Methods Survey Development and Testing On the basis of the literature,22 a questionnaire was developed that consisted of 3 sections and a total of 79 questions. For this survey, the term open meant that a patient’s family members were welcome to remain at the patient’s bedside at any time throughout the 24-hour day, restricted meant that family members were held to a strict visiting policy, and flexible meant flexibility in the formal visiting policy according to the needs of patients, patients’ family members, and nurses. In the first section of the questionnaire, 2 scales were used to assess nurses’ beliefs. The scales were derived from other studies22,34 and were included after obtaining the permission of their authors. The first of 4 Likert-type scales consisted of 26 items and was clustered into 3 subscales: effect of visiting and open visiting on patients’ family members, on patients, and on nurses. The second 5-point Likert-type scale

The burden of pain and disease of one member will overshadow the well-being of the whole family.

AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2014, Volume 23, No. 4

Downloaded from ajcc.aacnjournals.org at MCGILL UNIVERSITY LIBRARY on October 28, 2014

327

consisted of 20 items. It also was used to assess ICU nurses’ beliefs about the consequences of visiting and open visiting on patients, patients’ families, hospital policies, and staff. The second section of the questionnaire included a 5-point Likert-type scale with 14 items, adapted from Berti et al,34 which was used to assess the nurses’ attitudes toward visiting hours in the ICU. The third section, which consisted of 5 items and was created for this study, included questions to assess nurses’ opinions about ideal and current visiting policies. The nurses were asked to rank the perceived obstacles that lead to restriction of visits and to make suggestions that would promote easier implementation of open visitation in their ICU. The scales were translated by 2 independent translators from the original languages (Spanish and English) to Greek and then reverse translated to the original languages. The Greek scales used were approved by an expert group consisting of 3 nurses: an ICU head nurse with a master’s degree in intensive care nursing, an assistant professor in clinical nursing, and an associate professor of intensive care and emergency nursing. A pilot study was conducted with a convenience sample of 19 ICU nurses during July 2009 to evaluate the metric characteristics of the questionnaire (internal consistency reliability and validity) and the stability of the measurement (test-retest).

A convenience sample of 6 hospitals was used; 3 were military hospitals.

Design and Setting A descriptive correlational cross-sectional survey design was used to elicit ICU nurses’ beliefs about and attitudes toward visitation and the nurses’ perception of the impact of visitation on patients, patients’ families, and ICU staff. A total of 15 public secondary and tertiary care hospitals in the Athens metropolitan area, with at least 5 available beds in each ICU, were selected for submission of the protocol by using the RAND function in the Microsoft Excel computer program. Because of time constraints, the study was finally conducted with a convenience sample of 6 hospitals, of which 3 were military hospitals. Both the public hospitals and the military hospitals are under the Greek National Health system, but the 2 types have different policies regarding their function and organization. In the military hospitals, the majority of nurses and physicians are military personnel and do not take part officially in the daily duties of hospitals in Athens, a situation that limits the number of patients

328

admitted. Overall, nurses from 13 ICUs participated in the study: 5 general ICUs , 4 coronary, 1 infection, 1 cardiosurgical, 1 respiratory, and 1 surgical. Sample and Recruitment Process The target population consisted of the entire nursing staff of the 13 participating ICUs (226 nurses) regardless of educational background and working experience. Each nurse received a participant information sheet and a copy of the questionnaire, enclosed in an envelope. The head nurse of each ICU was responsible for distributing the questionnaires to the staff. Return of a completed questionnaire anonymously in a sealed envelope was considered equivalent to the respondent’s consent to have the data included in the study. A total of 143 questionnaires were returned completed and were available for analysis. Survey Implementation The study was approved by the scientific review board of the selected hospitals and the University of Athens, Faculty of Nursing. Demographic data collected included age, sex, educational level, type of ICU, work experience, number of shifts in a 15day period in ICU setting, staff adequacy, and job satisfaction. Survey data were prospectively collected from September 2009 until November 2009. After a 3-week period for each hospital, the completed and uncompleted questionnaires were collected by the primary researcher (A.A.). Data Analysis Data were analyzed by using SPSS software, version 17.0 (SPSS IBM Corp). The Cronbach  and test-retest reliability were evaluated during both the pilot study and the main study. All the scores were greater than the acceptable values and were considered sufficient. Descriptive statistics were used and variable values were expressed as mean and standard deviation or frequency and interquartile range. Values of variables were examined for normal distribution, and t tests, analysis of variance, and the Pearson correlation were used for analysis. If marked departure from normality criteria occurred, the Wilcoxon signed rank test was performed, and the Spearman
was estimated. Finally, stepwise linear regression analysis was used to identify the predictive validity of any personal and professional factors on the scores of the scales. A nominal significance level of  = .05 was used, and Bonferroni adjustment was made for multiple bivariate comparisons.

AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2014, Volume 23, No. 4

www.ajcconline.org

Downloaded from ajcc.aacnjournals.org at MCGILL UNIVERSITY LIBRARY on October 28, 2014

40

Nurses’ Beliefs About Visitation The estimated Cronbach  values were 0.72, 0.82, and 0.83 for the first, second, and third scales, respectively. Respondents’ total scores were 2.40 (range 1-4; SD, 0.67) on the first scale of beliefs about visiting and open visiting and 2.78 (range, 1-5; SD, 1.00) on the second scale (Table 1). Nurses thought that patients’ relatives are more satisfied with open visitation (84.6%) but at the same time feel obliged to stay longer at the bedside, a situation that leads to the relatives’ exhaustion. Two-thirds of the nurses also stated that open visiting does not provide more information or reassurance to a patient’s family about the patient’s condition. The results from the patients’ subscale revealed that nurses think that patients are emotionally supported by family visitation (89.5%). Moreover, nurses reported that patients’ boredom is reduced (84.6%) and that family visitation increases patients’ will to live (80.4%). Twothirds of the nurses thought that, in general, family visits increased a patient’s blood pressure and heart rate, but without causing marked destabilization in the patient’s condition. Half of the nurses thought that visiting keeps patients from resting, and 91.6% stated that the overall effect of visiting depends on both the personality and the relationship of the patients and families before the admission in the ICU. As far as the organization of care in the ICU is concerned, nurses thought that visiting and open visiting hampered the planning of nursing care (75.5%), that in many instances nurses spent more time providing information than in taking care of the patients (61.6%). More

www.ajcconline.org

30 25 20 15 10 5 0 Understaffed

Moderately staffed

Fairly staffed

Satisfyingly staffed

Well-staffed

Figure 1 Nurses’ beliefs about the staffing level and the adequacy in nurse to patient ratio in their intensive care unit.

40 35 Percentage of nurses

Nurses’ Background and Demographic Data The highest percentage of the respondents were female (78.3%) registered nurses; 54.5% had a university bachelor’s degree in nursing. Most respondents were single (54.5%), and 70.6% did not have children. The nurses had a mean of 6 (SD, 5.2) years of working experience in intensive care and worked a mean of 6 (SD, 2.8) shifts per 15-day period. A total of 36.4% of the nurses thought that their ICU was understaffed; only 4.8% reported that they worked in a well-staffed ICU (Figure 1). Nearly three-quarters of the nurses were satisfied (39.2%), fairly satisfied (19.5%), or very satisfied (16.1%) with their job (Figure 2). All hospitals that participated in the study had a scheduled visiting policy that restricted the number of visits (1 or 2 per day) and the duration of each visit (30 or 60 minutes).

Percentage of nurses

35

Results

30 25 20 15 10 5 0 Unsatisfied

Moderately satisfied

Satisfied

Fairly satisfied

Very satisfied

Figure 2 Job satisfaction level among nurses in Greek intensive care units.

Table 1 Mean scores on the scales Score Mean

Rangea

First beliefs scale (effect of open visiting) On patients On patients’ families On nurses

2.40 2.40 2.68 2.09

1-4 1-4 1-4 1-4

Second beliefs scale (effects of visiting and open visiting on patients, patients’ families, hospital policies, and staff)

2.78

1-5

Attitudes scale (nurses’ attitudes toward visiting hours)

2.74

1-5

Instrument

a

A score of 1 corresponded to strongly disagree, and a score of 4 or 5 corresponded to strongly agree.

than half of the nurses stated that during visiting they felt controlled and nervous and they could not behave as they normally would in the ICU.

AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2014, Volume 23, No. 4

Downloaded from ajcc.aacnjournals.org at MCGILL UNIVERSITY LIBRARY on October 28, 2014

329

Table 2 Nurses’ perceived obstacles in liberalizing visiting hours Median (25th-75th percentile [interquartile range])

Identified obstacles Patient’s condition unstable

1 (1-3)

Nursing workload

2 (1-2)

Psychological burden for nurses

3 (2-4)

Communication problems with patient’s family

3 (2-5)

Other obstacles (bacterial dispersion)

3 (2-8)

Space problems in intensive care units

4 (2-5)

Nurses’ attitudes

5 (2-6)

Physicians’ attitudes

6 (2-7)

Percentage of nurses

90 80 70 60 50 40 30 20 10 0 Ideal visiting policy for patients Restricted visitation

Ideal visiting policy Ideal visiting policy for patients’ families for nurses Flexible visitation

Open visitation

Figure 3 Nurses’ beliefs about ideal visiting policies for patients, patients’ families, and nursing staff.

Additionally, 55.2% of the nurses claimed they do not feel qualified to interact with patients’ family members and that overall, visiting increases nurses’ physical and psychological burden (87.5%). Nurses’ Attitudes Toward Visiting Hours in the ICU Nurses’ mean score on the scale for attitudes toward visiting and visiting hours was 2.74 (range, 1-5; SD, 0.99; Table 1). Nurses reported that they would make exceptions to the existing schedule only for patients who were emotionally weak (60.2%) or dying (70.2%) and also for families who had practical problems visiting the patient within the scheduled visiting policy of the ICU (60%). Nurses were also negative about the flexibility of the number of visitors for each patient, supporting a maximum of 2 persons per visit, and about allowing the patient to control the visitation, even if the patient was capable (65%). Almost all nurses (94.4%) did not want an open visiting policy in their ICU.

330

Nurses’ Opinions About Ideal and Current Visiting Policies Instability of the patient’s condition and nursing workload were the leading obstacles to unrestricted family access in the ICU (Table 2). To the question “What kind of policy do you think is ideal for the patient, family, and staff?” nurses were in favor of flexible visitation for the benefit of patients (61.4%) and patients’ families (65.7%) and were in favor of restricted visitation for the benefit of nurses (80%). None voted for open visiting (Figure 3). Relationships Between Beliefs, Attitudes, and Experience No significant correlations were found between variables having children, education level, or other personal data and total scores on the scales. Positive correlations were found for the variable work experience and the first belief scale (r = 0.19; P = .02) and for ICU work experience and the second belief scale (r = 0.19; P = .02). Negative correlations to the first and the second belief scales were found only for the variable number of shifts (r = -0.20; P = .02) and (r = -0.16, P = .05). The variables work experience and ICU work experience were positively correlated to the attitudes scale (r = 0.21; P = .01) and (r = 0.31; P = .001), respectively. In contrast, the variable number of shifts was negatively correlated (r = -0.25; P = .003). Therefore, nurses who had extensive working experience and had a more relaxed work schedule in a 15-day period tended to have more positive responses toward flexible visiting hours. The correlation between the belief scales and the attitude scales was also positive: r = 0.42;P < .001 for the first scale and r = 0.45; P < .001 for the second scale, accounting for the content reliability of the questionnaire. Predictors of Nurses’ Beliefs About and Attitudes Toward Decisions on Visiting Multiple regression analysis revealed that the social-demographic factors work experience, adequate staffing, and number of shifts were independently correlated and were predictive of nurses’ scores on the beliefs and attitudes scales (Table 3). Hence, the more shifts a nurse had in a 15-day period, the more negative beliefs and attitudes he or she tended to have toward visitation. Additionally, the more experience a nurse had, and providing that the ICU was well staffed, the more positive beliefs and attitudes he or she tended to have toward family visitation.

Discussion We explored ICU nurses’ beliefs about and attitudes toward visitation and open visitation.

AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2014, Volume 23, No. 4

www.ajcconline.org

Downloaded from ajcc.aacnjournals.org at MCGILL UNIVERSITY LIBRARY on October 28, 2014

Table 3 Predictors of nurses’ beliefs and attitudes Social-demographic factors

β

SE

P

Number of shifts per 15-day period How well is the intensive care unit (ICU) staffed

-0.41 0.92

0.20 0.46

.04 .048

Second beliefs scale (effects of visiting and open visiting on Years of experience as an ICU nurse patients, patients’ families, hospital policies, and staff) How well is the ICU staffed

0.32 1.63

0.15 0.66

.04 .01

Attitudes scale (nurses’ attitudes toward visiting hours)

0.25 -0.46

0.11 0.20

.02 .02

Instrument First beliefs scale (effect of open visiting on patients, patients’ families, and nurses)

From the 226 questionnaires distributed, 143 participants responded and were enrolled, yielding a response rate of 63%, which is acceptable for long questionnaires.51 Several guidelines21,25,52-54 suggest that advocating for patients’ right to visitation and embracing patients’ families should be expected practices in the stressful critical care setting. In the United States, the Institute for Patient- and Family-Centered Care25 and the American Association of Critical-Care Nurses54 have already incorporated these standards of care into several recommendations to facilitate unrestricted visiting models. In the ICUs that participated in our study, the hospitals’ official websites and information sheets indicated that restricted visiting was the official visiting policy. Numerous investigators have explored the needs of family members when one member is critically ill, and some researchers have compared relatives’ perceptions with nurses’ perceptions regarding family needs. The most important needs are summarized into 5 categories: comfort, information, assurance, support, and ability to be near the patient.8,15-17,29,55,56 In our study, the overall score on the beliefs scale indicates that nurses tend to recognize the emotional benefit of visiting and open visiting for patients and patients’ families, a finding also reported by other researchers.12,22,31,33-37 Despite these results, the needs of information, reassurance, and closeness, which are highly ranked by patients’ relatives, are perceived differently by nurses, causing conflicts in the ICUs.8,15-16,55-57 Nurses’ scores on their beliefs about the effect of visiting on the organization of care and on staff were moderately low, results that are almost unanimous in all studies. Some investigators8,22,31,34-36 accept these negative perceptions that patients’ families can cause chaos and are physical obstacles to nurses. Nevertheless, others disagree,32,33,44 explaining that when ICUs become overcrowded, patients’ families are simply asked to leave the rooms. Nurses also reported a change in their behavior during visits by patients’ families, interestingly combined with the feeling of being controlled by visitors but without the fear of making mistakes, a result similar to the findings of

www.ajcconline.org

Years of experience as an ICU nurse Number of shifts per 15-day period

other studies.34 Moreover, we found a high percentage of agreement with the belief that open visiting is physically and psychologically exhausting for nurses, as also suggested in other studies,8,22,31-35,37 a finding that accounts for setting aside the needs of patients’ families. Consequently, Greek nurses seem to be more concerned about the negative effects of visiting on the standard nursing care routine and on the nurses themselves. The scores on the attitudes scales reveal that nurses are resistant toward liberalizing the number and length of visits, even during the first 24 hours of admission. They reported being lenient only with dying and emotionally weak patients and for families who cannot visit within the schedule. This result is similar to the results of other studies,34,36 but contradicts other reports32,33,35 that identify space and communication problems as leading challenges in ICUs with open visiting. An interesting finding was that the nurses in our study recognize the right of a patient to request visitation; however, they do not agree with giving patients control of the visit, a result similar to that of other studies.34,36 According to Kirchhoff et al,31 nurses tend to use visitation as an authority tool to keep control over the nurses’ domain of activities; this tendency is one reason patients’ relatives feel like strangers in an ICU.58 In our study, the social-demographic factors work experience, adequacy in nurse to patient ratio, and number of shifts had predictive value. Thus, adjustments to institutional management that would provide well-staffed ICUs with experienced nurses and fewer shifts per week, combined with educational support, might have a positive effect on nurses’ resistance toward open visitation. Moreover, the comments at the end of the questionnaire underscore the need for support of Greek nurses to cope with the psychological burden, to receive education about family dynamics, and to target their efforts at providing adequate information to patients’ relatives.

Nurses recognize the emotional benefit of open visiting for patients and patients’ families.

AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2014, Volume 23, No. 4

Downloaded from ajcc.aacnjournals.org at MCGILL UNIVERSITY LIBRARY on October 28, 2014

331

Limitations Despite the initially higher sample estimate, 6 hospitals made up the final sample. The response rate to the questionnaire was 63%, acceptable for long questionnaires in general, but moderately low in comparison with the rate of 70% suggested in the literature. The difficulty in informing all nurses of each ICU about the study and the length of the questionnaire could account for this response rate. Finally, 3 of the 6 participating hospitals were military hospitals, which have better working conditions and fewer shifts for nurses than do other public hospitals.

Conclusions and Implications Visitation in Greece remains a controversial issue. The opposing needs of patients’ families, patients, and nurses, result in keeping the doors of the ICUs closed. Apparently no agreement exists for the ideal visiting policy. In our study, Greek nurses were resistant toward open visiting in their ICUs. Thus, they need support to overcome the perceived barriers of imposing new policies. Attempts toward an open ICU should include better working conditions for nurses; that is, experienced nurses, fewer shifts, and well-staffed ICUs. We think that if such conditions were implemented, a change could occur. Perhaps future researchers could examine the perceptions of patients, patients’ families, or physicians toward visiting and more flexible visiting policies in the ICUs, in an attempt to find a balance among everyone’s needs. More research is needed to explore how emotions and self-efficacy could influence nurses’ decisions and compliance regarding new protocols and visiting policies. New approaches that include role-play exercises related to challenging visitation scenarios, adequate in-hospital training on communication skills, and specific assessment forms could lead to a well-designed strategy for interacting with patients’ relatives who exhibit negative behavior. Support for nurses with physical and psychological burdens, incentives for the promotion of flexible visitation, and frequent updates of best evidence on family visitation might also contribute to behavioral changes and the adoption of new visiting policies.15,28,35,43,46-47,50,53-54,59 ACKNOWLEDGMENTS This research was performed at 401 General Military Hospital of Athens, 251 General Air Force Hospital of Athens, Navy Hospital of Athens, Attiko University Hospital of Athens, Konstantinopouleio-Agia Olga General Hospital of Nea Ionia/Athens, and Sotiria General Hospital of Chest Diseases of Athens, Athens, Greece. We thank all study participants and ICU head nurses for their contributions to the study. We also thank Zikos Dimitrios, RN, MSc, PhD, for his assistance with the formatting of tables and figures.

332

FINANCIAL DISCLOSURES None reported.

eLetters Now that you’ve read the article, create or contribute to an online discussion on this topic. Visit www.ajcconline.org and click “Responses” in the second column of either the full-text or PDF view of the article.

REFERENCES 1. Van Horn E, Hesh A. The effect of critical care hospitalization on family members: stress and responses. Dimens Crit Care Nurs. 2000;19(4):40-49. 2. 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(10):1893-1897. 3. Pochard F, Darmon M, Fassier T, et al; French FAMIREA study group. Symptoms of anxiety and depression in family members of intensive care unit patients before discharge or death: a prospective multicenter study. J Crit Care. 2005;20(1):90-96. 4. Auerbach SM, Kiesler DJ, Wartella J, Rausch S, Ward KR, Ivatury R. Optimism, satisfaction with needs met, interpersonal perceptions of the healthcare team, and emotional distress in patients’ family members during critical care hospitalization. Am J Crit Care. 2005;14:202-210. 5. Azoulay E, Pochard F, Kentish-Barnes N, et al; FAMIREA study group. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med. 2005;171(9):987-994. 6. Paparrigopoulos T, Melissaki A, Efthymiou A, et al. Shortterm psychological impact on family members of intensive care unit patients. J Psychosom Res. 2006;61(5):719-722. 7. Plakas S, Cant B, Taket A. The experiences of families of critically ill patients in Greece: a social constructionist grounded theory study. Intensive Crit Care Nurs. 2008;25(1):10-20. 8. Garrouste-Orgeas M, Philippart F, Timsit JF et al. Perceptions of a 24-hour visiting policy in the intensive care unit. Crit Care Med. 2008;36(1):30-35. 9. McAdam JL, Puntillo K. Symptoms experienced by family members of patients in intensive care units. Am J Crit Care. 2009;18(3):200-210. 10. Damboise C, Cardin S. Family-centered critical care: how one unit implemented a plan. Am J Nurs. 2003;103(6):56AA-56EE. 11. Simpson T, Wilson D, Mucken N, Martin S, West E, Guinn N. Implementation and evaluation of a liberalized visiting policy. Am J Crit Care. 1996;5(6):420-426. 12. Roland P, Russell J, Richards KC, Sullivan SC. Visitation in critical care: process and outcomes of a performance improvement initiative. J Nurs Care Qual. 2001;15(2):18-26. 13. McAdam JL, Arai S, Puntillo KA. Unrecognized contributions of families in the intensive care unit. Intensive Care Med. 2008;34(6):1097-1101. 14. McKiernan M, McCarthy G. Family members’ lived experience in the intensive care unit: a phenomenological study. Intensive Crit Care Nurs. 2010;26(5):254-261. 15. Quinn S, Redmond K, Begley C. The needs of relatives visiting adult critical care settings as perceived by relatives and nurses: part 2. Intensive Crit Care Nurs. 1996;12:239-245. 16. Hinkle JL, Fitzpatrick E, Oskrochi GR. Identifying the perception of needs of family members visiting and nurses working in the intensive care unit. J Neurosci Nurs. 2009;41(2):85-91. 17. Lee LYK, Lau YL. Immediate needs of adult family members of adult intensive care patients in Hong Kong. J Clin Nurs. 2003;12:490-500. 18. McKinley S, Nagy S, Stein-Parbury J, Bramwell M, Hudson J. Vulnerability and security in seriously ill patients in intensive care. Intensive Crit Care Nurs. 2002;18(1):27-36. 19. Horn E, Kautz D. Promotion of family integrity in the acute care setting. Dimens Crit Care Nurs. 2007;26(3):101-107. 20. Gibson V, Plowright C, Collins T, et al. Position statement on visiting in adult critical care units in the UK. Nurs Crit Care. 2012;17(4):213-218. 21. Davidson JE, Powers K, Hedayat KM, et al; American College of Critical Care Medicine Task Force 2004-2005, Society of

AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2014, Volume 23, No. 4

www.ajcconline.org

Downloaded from ajcc.aacnjournals.org at MCGILL UNIVERSITY LIBRARY on October 28, 2014

22.

23. 24.

25.

26.

27. 28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

Critical Care Medicine. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 20042005. Crit Care Med. 2007;35(2):605-622. Marco L, Bermejillo I, Garayalde N, et al. Intensive care nurses’ beliefs and attitudes towards the effect of open visiting on patients, family and nurses. Nurs Crit Care. 2006;11:33-41. Levy MM. A view from the other side. Crit Care Med. 2007; 35(2):603-604. Latour JM, Haines C. Families in the ICU: do we truly consider their needs, experiences and satisfaction? Nurs Crit Care. 2007;12(4):173-174. Institute for Patient- and Family-Centered Care. Changing hospital “visiting” and policies and practices: supporting family presence and participation. http://www.ipfcc.org/visiting.pdf. Published October 2010. Accessed April 16, 2014. Gonzalez CE, Carroll DL, Elliott JS, Fitzgerald PA, Vallent JH. Visiting preferences of patients in the intensive care unit and in a complex medical unit. Am J Crit Care. 2004;13(3):194-197. Carroll DL, Gonzalez CE. Visiting preferences of cardiovascular patients. Prog Cardiovasc Nurs. 2009;24(4):149-154. Delva D, Vanoost S, Bijttebier P, Lauwers P, Wilmer A. Needs and feelings of anxiety of relatives of patients hospitalized in intensive care units: implications for social work. Soc Work Health Care. 2002;35(4):21-40. Karlsson C, Tisell A, Engström A, Andershed B. Family members’ satisfaction with critical care: a pilot study. Nurs Crit Care. 2011;16(1):11-18. Olsen KD, Dysvik E, Hansen BS. The meaning of family members’ presence during intensive care stay: a qualitative study. Intensive Crit Care Nurs. 2009;25(4):190-198. Kirchhoff KT, Pugh E, Calame RM, Reynolds N. Nurses’ beliefs and attitudes toward visiting in adult critical care settings. Am J Crit Care. 1993;2(3):238-245. Plowright CI. Intensive therapy unit nurses’ beliefs about and attitudes towards visiting in three district general hospitals. Intensive Crit Care Nurs. 1998;14:262-270. Livesay S, Gilliam A, Mokracek M, Sebastian S, Hickey JV. Nurses’ perceptions of open visiting hours in neuroscience intensive care unit. J Nurs Care Qual. 2005;20(2):182-189. Berti D, Ferdinande P, Moons P. Beliefs and attitudes of intensive care nurses toward visits and open visiting policy. Intensive Care Med. 2007;33:1060-1065. Lee MD, Friedenberg AS, Mukpo DH, Conray K, Palmisciano A, Levy MM. Visiting hours policies in New England intensive care units: strategies for improvement. Crit Care Med. 2007;35(2):497-501. Biancofiore G, Bindi L, Barsotti E, Menichini S, Baldini S. Open intensive care units: a regional survey about the beliefs and attitudes of healthcare professionals. Minerva Anestesiol. 2010;76 (2):93-99. Farrell ME, Joseph DH, Schwartz-Barcott D. Visiting hours in the ICU: finding the balance among patient, visitor and staff needs. Nurs Forum. 2005;40(1):18-28. Quinio P, Savry C, Deghelt A, Guilloux M, Catineau J, de Tinténiac A. A multicenter survey of visiting policies in French intensive care units. Intensive Care Med. 2002;28(10):1389-1394. Anzoletti AB, Buja A, Bortolusso V, Zampieron A. Access to intensive care units: a survey in North-East Italy. Intensive Crit Care Nurs. 2008;24(6):366-374. Giannini A, Miccinesi G, Leoncino S. Visiting policies in Italian intensive care units: a nationwide survey. Intensive Care Med. 2008;34(7):1256-1262. Hunter JD, Goddard C, Rothwell M, Ketharaju S, Cooper H. A survey of intensive care unit visiting policies in the

www.ajcconline.org

United Kingdom. Anaesthesia. 2010;65(11):1101-1105. 42. Spreen AE, Schuurmans MJ. Visiting policies in the adult intensive care units: a complete survey of Dutch ICUs. Intensive Crit Care Nurs. 2011;27(1):27-30. 43. Sims JM, Miracle VA. A look at critical care visitation: the case for flexible visitation. Dimens Crit Care Nurs. 2006; 25(4):175-180. 44. Soury-Lavergne A, Hauchard I, Dray S, et al; Société de Réanimation de Langue Française (SRLF). Survey of caregiver opinions on the practicalities of family-centred care in intensive care units. J Clin Nurs. 2012;21(7-8):1060-1067. 45. Berwick DM, Kotagal M. Restricted visiting hours in ICUs: time to change. JAMA. 2004;292:736-737. 46. Slota M, Shearn D, Potersnak K, Haas L. Perspectives on family-centered, flexible visitation in the intensive care unit setting. Crit Care Med. 2003;31(5)(suppl): S362-S366. 47. Whitton S, Pittiglio LI. Critical care open visiting hours. Crit Care Nurs Q. 2011;34(4):361-366. 48. Fumagalli S, Boncinelli L, Lo Nostro A, et al. Reduced cardiocirculatory complications with unrestrictive visiting policy in an intensive care unit: results from a pilot, randomized trial. Circulation. 2006;113 (7):946-952. 49. Adams S, Herrera A, Miller L. Visitation in the intensive care unit: impact on infection prevention and control. Crit Care Nurs Q. 2011;34(1):3-10. 50. Agård AS, Lomborg K. Flexible family visitation in the intensive care unit: nurses’ decision-making. J Clin Nurs. 2011; 20(7-8):1106-1114. 51. Burns N, Grove SK. The Practice of Nursing Research: Conduct, Critique and Utilization. 4th ed. Philadelphia, PA: WB Saunders Co; 2001:430-431. 52. Obama B. Presidential memorandum: hospital visitation. http://www.whitehouse.gov/the-press-office/presidentialmemorandum-hospital-visitation. Published April 15, 2010. Accessed April 17, 2014. 53. The Joint Commission. Patient-centered communication standards for hospitals. R3 Report: Requirement, Rationale, Reference. February 9, 2011:1-4. 54. Bell L. Family presence: visitation in the adult ICU. American Association of Critical-Care Nurses practice alert. http://www.aacn.org/wd/practice/content/practicealerts/familyvisitation-icu-practice-alert.pcms?menu=practice. Published November 20, 2011. Accessed April 17, 2014. 55. Hinkle JL, Fitzpatrick E. Needs of American relatives of intensive care patients: perceptions of relatives, physicians and nurses. Intensive Crit Care Nurs. 2011;27(4):218-225. 56. Maxwell KE, Stuenkel D, Saylor C. Needs of family members of critically ill patients: a comparison of nurse and family perceptions. Heart Lung. 2007;36(5):367-376. 57. Buckley P, Andrews T. Intensive care nurses’ knowledge of critical care family needs. Intensive Crit Care Nurs. 2011; 27(5):263-272. 58. Latour J. Is family-centred care in critical care that difficult? A view from Europe. Nurs Crit Care. 2005;10:51-52. 59. Chien W-T, Chiu YL, Lam L-W, Ip W-Y. Effects of a needsbased education programme for family carers with a relative in an intensive care unit: a quasi-experimental study. Int J Nurs Stud. 2006;43(1):39-50.

To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected].

AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2014, Volume 23, No. 4

Downloaded from ajcc.aacnjournals.org at MCGILL UNIVERSITY LIBRARY on October 28, 2014

333