key: cord-1003295-y7cbf2a8
authors: Milner, Kerry A.; Marmo, Suzanne; Goncalves, Susan
title: Implementation and sustainment strategies for open visitation in the intensive care unit: A multicentre qualitative study()
date: 2020-08-24
journal: Intensive Crit Care Nurs
DOI: 10.1016/j.iccn.2020.102927
sha: f7d66d4a020a2fec51e90c23ab1e91ca7e58495c
doc_id: 1003295
cord_uid: y7cbf2a8

OBJECTIVE: Open visitation in adult intensive care units has been associated with improved family and patient outcomes. However, worldwide adoption of this practice has been slow and reasons for this are unclear. This study documents barriers and strategies for implementing and sustaining open visitation in adult intensive care units in the United States experienced by nursing leadership. RESEARCH DESIGN: Qualitative approach using grounded theory. PARTICIPANTS: Nurse leaders in adult intensive care units with open visitation. SETTING: Magnet® or Pathway to Excellence® designated hospitals in the United States. METHODS: Semi structured interviews were conducted with 19 nurse leaders from 15 geographically dispersed hospitals. Interviews were recorded, transcribed and imported into Atlas.ti qualitative software for analysis. Grounded theory constant comparison analysis was used for coding and category development. FINDINGS: The analysis revealed three barriers; nursing attitudes and clinical and nonclinical barriers. Strategies to overcome these barriers were empathy, evidence-based practice, models of care, shared governance, nurse discretion, security and family spaces. CONCLUSION: Intensive care nursing leadership experienced distinct barriers and strategies during pre-implementation, implementation and sustainment of open visitation. Other nursing leaders interested in open visitation can use these findings as they plan this transition in their intensive care units.

Open visitation in the adult intensive care unit (ICU) where family members or designated support persons have unrestricted access to the patient has been associated with improved family (Carroll & Gonzalez, 2009; Gonzalez et al., 2004; Jacob et al., 2016; Marco et al., 2006; McAdam & Puntillo, 2013; Nassar Junior et al., 2018) and patient outcomes (da Silva Ramos et al., 2013; Fumagalli et al., 2006; Holloway & Galvin, 2016; McAdam & Puntillo, 2013; Nassar Junior et al., 2018; Rosa et al., 2017; Shulkin et al., 2014) . United States (US) national data indicate limited adoption of open visitation since it was first recommended by the Society for Critical Care Medicine (Davidson et al., 2007) and the American Association of Critical Care Nurses (AACN) (''Family presence: visitation in the adult ICU '', 2012) . In the last national study (Liu et al., 2013) , only 10.4% of adult ICUs had open visitation. Ten years later, open visitation in US hospitals recognised for nursing excellence was only 18.6% (Milner et al., 2020) . Outside the US a similar pattern of restrictive visitation has been observed (Garrouste-Orgeas et al., 2016; Giannini et al., 2008; Haghbin et al., 2011; Noordermeer et al., 2013) despite being recommended by World Federation of Critical Care Nurses (WFCCN Review Group, 2019) .

Possible barriers to implementing open visitation in the ICU have been described. Surveys of nurses who regularly provide bedside care reveal attitudes that open visitation negatively affects patient care (McAdam & Puntillo, 2013; Riley et al., 2014) , and increases workload (Coombs et al., 2017; Gershengorn & Garland, 2016) and interruptions (Monroe & Wofford, 2017) . Open visitation policies have been described as contributing to a fear of a ''free-for-all" (Kozub et al., 2017) and concerns about nurses' personal safety have been reported (Keys & Stichler, 2018; Lee et al., 2007) . Physicians identified barriers such as perceptions that open visitation violates patient rights and may place patients' safety at risk (Riley et al., 2014) . Other barriers identified in the literature include structural and architectural features of the ICU that limit space to accommodate several visitors (Cappellini et al., 2014) .

Evidence on facilitators for implementing and managing open visitation is limited to two single setting studies. In one study, nurses working in a medical ICU in an urban university hospital participated in focus groups to identify solutions to perceived problems and strategies to facilitate successful implementation of open visitation (Lee et al., 2007) . Solutions for protecting patient confidentiality included having a large family room for private consultations and directing visitors to a waiting room when nearby discussions involved other patients. Strategies for improving nurse and visitor communications included visitor education on the structure and flow of an ICU, staff education on the emotional needs of visitors, and social work consults to meet the visitors emotional and physical needs. Nurses also identified the need for a well-defined policy for the management of visitors that use threatening behaviour towards staff.

In a performance improvement study, nurses working in a surgical trauma ICU were surveyed about barriers to implementation of open visitation and the solutions to resolve them. The solutions included scripted prompts for staff to use with visitors to address issues of patient safety (e.g. interruptions during medication administration), the environment (e.g. overcrowding of patient room), and communication (designating a spokesperson) (Kozub et al., 2017) .

Limited adoption of open visitation in adult ICUs may be related to the lack of research on effective strategies for implementation and sustainment. A recently published review on open visitation concluded that research exploring views of ICU nurses and staff is urgently needed to understand the challenges faced during the transition to open visitation and the strategies to promote sustainment and the change in culture (Ning & Cope, 2020) .

The American Nurses Credentialing Centre is an arm of the American Nurses Association that promotes excellence in nursing and healthcare globally through its credentialing programmes (e.g. Magnet Ò and Pathway to Excellence Ò Programme). In healthcare organisations worldwide, being in the Magnet Ò programme indicates exemplary nursing professional practise and the delivery of the best patient care (''Magnet Model -Creating a Magnet Culture," n.d.). Similarly, the Pathway to Excellence Ò designation indicates healthcare organisations that have demonstrated healthy work environments for nurses while promoting high nursing professional practice standards (''Pathway to Excellence Program," n.d.). Nurses in leadership positions in Magnet Ò or Pathway to Excellence Ò Programme facilities are in a unique position to facilitate open, flexible ICU visitation policies and potentially improve patient and family outcomes. The purpose of this study was to document the barriers and strategies for implementing and sustaining open visitation in adult ICUs experienced by nurse leaders.

A grounded theory approach was chosen for this study to understand the process and practises of implementing open visitation in adult ICUs. A primary purpose of this method is to build theory and conceptual models that have immediate implications for clinical practice (Egan, 2002; Glaser & Strauss, 1967) . Grounded theory has been utilised to develop recommendations for improving practise in the ICU including nursing leaders' establishment of patient safety protocols (Häggström et al., 2017) and nurse training programmes for new graduates entering ICUs (Lewis-Pierre et al., 2017) .

Definition. Open visitation was defined as ''unrestricted access of hospitalised patients to a chosen support person (eg, family member, friend, or trusted individual) who is integral to the provision of emotional and social support 24 hours a day, according to the patient's preferences, unless the support person infringes on the rights of others and their safety, or the support person's presence is medically or therapeutically contraindicated" (''Family Visitation in the Adult Intensive Care Unit," 2016, p. 1).

Nurses working in Magnet Ò and Pathway to Excellence Ò hospitals are required to routinely translate best evidence into practise and demonstrate improved healthcare outcomes. Managing family and visitors is part of nursing practise so nurses often develop the visitor policies (Khaleghparast et al., 2015) . Therefore, it is reasonable to assume that nurse leaders of adult ICUs in Magnet Ò and Pathway to Excellence Ò hospitals are a valid and reliable source for information on barriers and strategies for implementing and sustaining open visitation. The method used to identify the 68 Magnet Ò and 32 Pathway to Excellence Ò hospitals with open visitation in their adult ICU has been previously published (Milner et al., 2020) .

For this study, the researchers searched LinkedIn and hospital websites to obtain email addresses of nurses in leadership positions (e.g. Magnet Ò or Pathway to Excellence Ò programme director, nurse manager, senior nurse manager, clinical/patient care director) in the ICU of the 68 Magnet Ò and 32 Pathway to Excellence Ò hospitals. This method yielded 29 email addresses. Next, the researchers obtained the direct phone numbers for 26 of the hospitals' c-suites by calling the hospital operator and then made calls to obtain the contact information of nurses in leadership positions associated with ICU. This method yielded 11 additional contacts. Email invitations were then sent to these nurses (n = 40) inviting them to participate in a semi-structured phone interview. These recruitment methods yielded a total of 19 nurse leaders from 15 hospitals who agreed to be interviewed.

For hospital characteristics the researchers used public data available from the American Hospital Directory website (https://www.ahd.com). These data included geographic location, median number of specialty care beds, and trauma level designation. The number of years with open visitation and nurse leader position was collected from the participants at the start of the interview.

A semi-structured interview discussion guide, summarised in Table 1 , was developed by the authors to elicit nurse leaders' perspectives about barriers and strategies for implementing and sustaining open visitation in their adult ICU. The discussion guide was reviewed by a nurse scholar in critical care. The first author (KM, critical care nurse) served as the interviewer for all interviews and used comprehensive probes to obtain and clarify responses from participants. On average, the interviews lasted 30 minutes, took place over the phone, and were audio-recorded. Recruitment was continued until no new information emerged during the interviews (e.g. data saturation).

The audio files were transcribed verbatim into Microsoft Word by a professional transcription service. The Microsoft Word files containing the transcripts were imported into ATLAS.ti version 8.4.0 (Friese, 2019) for data management. An ''open coding" process (Strauss & Corbin, 1990) was used by two of the researchers (SG, nurse manager/supervisor and acute care nurse; SM, medical and critical care social worker) to develop a preliminary codebook with the discussion guide as an initial framework. When new ideas or concepts related to the study purpose were identified, they were assigned a semantic code (Strauss & Corbin, 1990) . To check for consistency, these researchers independently coded two randomly selected transcript excerpts to establish intercoder agreement of the textual codes for the codebook (Campbell et al., 2013) . Initial intercoder agreement was 77.8%. After reconciliation, intercoder agreement was 85.7%. Remaining transcripts were coded using the codebook and new codes were added as needed. The coded data were printed out by code type, reviewed for accuracy, and examined for links to other codes. This ''axial coding" process (Strauss & Corbin, 1990 ) was performed to connect code categories, and to look for relationships that could reasonably be taken to represent common core categories. As a part of the ongoing interpretive process, the constant comparison method (Glaser & Strauss, 1967 ) was used to compare and contrast core categories within and across groups, which allowed for the discovery of similarities and differences in the data. Similarities and differences in perceived barriers and strategies for implementing and sustaining open visitation were identified within and between interviews (Boeije, 2002) .

Several steps were taken to enhance the research credibility and transferability. First, a standardised codebook, and intercoder agreement cheques were used to reduce potential researcher bias and subjectivity (Onwuegbuzie & Leech, 2007) . The researchers also provide a detailed description of the data collection and analysis procedures as an ''audit trail" for other researchers interested in replicating the study (Bloomberg & Volpe, 2008) . Finally, to increase the opportunity for transferability (Bloomberg & Volpe, 2008) , the researchers provide details about the study participants and recruitment and study context.

This study was approved by the Institutional Review Board (IRB) at the authors' university (IRB# 180112A). This study conformed to the principles outlined in the Declaration of Helsinki (World Medical Association, 2013) . Participants were informed of the study purpose and participation was voluntary in an email invite. Prior to the start of the phone interview, the interviewer obtained verbal consent for study participation and audiotaping. Participants were also informed about the confidentiality in presenting the results. Participant and hospital names were not used when presenting participant data. This report adheres to the Consolidated Criteria for Reporting Qualitative (COREQ) research guidelines (Tong et al., 2007) . Table 2 displays the participant and hospital characteristics. The nurse leaders were mostly female, director or nurse manager of critical care or patient care services in geographically dispersed Magnet hospitals. Nearly half the hospitals had a trauma designation of level 1. The median number of specialty care beds was 85 and the median number of years with open visitation was 6.

During the axial coding phase of data analysis, it was determined that unique core categories emerged during preimplementation, implementation and sustainment phases of open visitation. Data analysis revealed that participants communicated barriers and facilitators for these three distinct phases. Fig. 1 illustrates this framework for the phases of implementating open visitation conceptualised during data analysis.

During the pre-implementation phase, the open coding process yielded the major categories of nursing attitudes, empathy and evidence-based practice (EBP). Empathy and EBP and were identified as strategies to overcome the barrier of nursing attitudes. In this context EBP represents a problem solving approach to clinical practise that integrates best available evidence, clinical expertise, and patient/family preferences and values (Melnyk and Fineout-Overholt, 2015) Table 3 displays the participant quotes for each barrier and strategy identified during the pre-implementation phase.

Negative nursing attitudes. The nursing attitude of resistance was the most often expressed barrier in the pre-implementation phase. As participants were exploring or planning the transition to open visitation in their ICU, they described resistance from experienced nurses who were socialised to ICU nursing through provider centric models of care. Nurses were described as questioning how they could manage to provide high quality care to critically ill patients with visitors, including children, being allowed at any time.

Using empathy. Empathy was identified as a key strategy in the pre-implementation phase. Specifically, nurses reflected on personal feelings and professional experiences associated with open visitation, and participants drew on these positive feelings to change their own perceptions and to foster buy-in to open visitation. Examples of both personal and patient empathy were identified. Personal empathy related to the nurses' own experience with open visitation. Patient empathy related to nurses who witnessed patients who got better or had a good day when they has a visit from someone special.

Advocating EBP. EBP was another key strategy for gaining nurse buy-in during the pre-implementation phase. Participants appealed to the professional practice expectation of aligning practise with available evidence, clinical expertise and patient preferences. Specifically, participants referred nurses to the AACN practise guidelines (''Family presence: visitation in the adult ICU," 2012; ''Family Visitation in the Adult Intensive Care Unit," 2016) and challenged nurses to review the best available evidence on open visitation. Participants suggested consulting with child life specialists and social work to use their expertise and evidence to address nurse concerns about allowing young children to visit the ICU.

During the implementation phase, the open coding process yielded the major categories of nursing attitudes, EBP and shared governance. Nursing attitudes were a barrier to implementation, and EBP and shared governance were facilitators. Table 3 displays the participant quotes for each barrier and strategy identified during the implementation phase.

Negative nursing attitudes. The most often reported barrier in the implementation phase was negative nursing attitudes related to the role of family and visitors while in the ICU. Participants expressed that nurses were concerned about family and visitors interfering with their ability to provide care to their critically ill patients. We believe that patient rooms have a clinician zone, a patient zone, and a family zone. So, we encourage families to stay and participate in care -participant 6 Our redesign of our space has helped a lot to make it more comfortable for all to be present, and we do have definitely lots of family members present in our unit. We also have two big family lounges. . .and there is also coffee, ice machine with water, and a refrigerator and microwave in that space, and some tables for eating -participant 10A I think we've created a culture that it's not even an expectation it's just something that we do. . .we understand that the integral parts that patients' families and loved ones are whoever they define as 'family members,' the important role that they play in the healing process, and how they advocate for their loved one, and are truly part of our interdisciplinary team. -participant 10B

Advocating EBP. A strategy that contributed to success in the implementation phase was nurse-to-nurse education on evidence-based best practises. Several participants suggested seeking out EBP champions within nursing to help disseminate this information among the nurses.

Shared governance. Shared governance emerged as a strategy for the implementation phase. Participants identified the importance and value of a shared governance structure where nurse input and ownership of the process facilitated the implementation of open visitation. Participants also reported the need to include patients in advisory councils to support the implementation of open visitation.

During the sustainment phase the open coding process yielded the major categories of clinical and non-clinical barriers, nurse discretion, security, family spaces and culture. Nurse discretion, security and family spaces were facilitators. Table 3 displays the participant quotes for each barrier and strategy identified during the sustainment phase.

Clinical barriers. Clinical barriers were identified as accepted clinical situations where open visitation is suspended. For example, during flu season protection of fragile patients was identified as a major concern by nearly every participant and open visitation may be suspended. Participants were also concerned about maintaining isolation precautions. In some cases, visitors may be asked to leave if they do not follow isolation precautions after being educated.

Non-clinical barriers. Nonclinical barriers were identified as changes to the ICU environment in response to situations that jeopardise staff safety. Changes included keeping ICU doors closed or locked in certain hospitals or at certain times or suspending open visitation for disruptive visitors.

Nurse discretion. While open visitation is the policy, participants supported nurse discretion as a way for nurses to set parameters of safety while maintaining a partnership between the nurse, patient and visitor. Participants described that including nurse discretion in visitation policies facilitated nurse empowerment and autonomy to act if visitors were being disruptive.

Security. Participants acknowledged that having a security presence facilitated sustainment of open visitation. Security presence ranged from the capability to lock ICU doors or press a panic button if there was an imminent secruity threat to security at the entrance of the ICU at night. Nurses were encourage to do what they needed, to maintain safety for themselves and their patients with strategies such as calling local police if secruity wasn't responding.

Family spaces. Family spaces encompassed physical space that belonged to the family. These were dedicated spaces within the ICU where family felt welcomed to relax and participate in caring for the patient. Participants recognised that physical structures may not be changeable, however, newer physical structures with ICU rooms having larger family space and a family common area on the ICU made this process easier to sustain. For those facilities with older structures, nurses would partner with the family to carve out family, patient and nurse ''zones" in the room.

Family space also included a culture where families were able to communicate freely and feel welcomed as a member of the ICU team. Providing space for family and visitors on the care team helped family and staff understand the role in the patient's healing process.

This multi-centre qualitative study documents nurse leaders' perceptions about barriers and strategies to implementing and sustaining open visitation in adult ICUs within Magnet Ò and Pathway to Excellence Ò hospitals of different sizes and trauma designation, in urban areas across the US. New findings to advance the process of implementing and sustaining open visitation that did not appear in previous studies (Lee et al., 2007; Liu et al., 2013) were empathy, EBP, nurse discretion, security and family spaces.

To ensure nurse buy-in during the pre-implementation phase, nurse leaders appealed to nurses' empathy using personal or professional storeys of nurses who experienced open visitation as a family member or saw the patient's condition improve after family visits. Previous research suggests that empathy represents an intellectual form of knowing that inspires nursing innovation and change (Zuber & Moody, 2018) . Nurse leaders also reported using the EBP process to disseminate evidence to get nurse buy-in. Previous research supports that EBP models drive sustainable organisational change (Fineout-Overholt et al., 2010) .

Allowing children to visit the ICU was a concern of nurses in this study as well as our previous study where nearly 60% of adult ICUs claiming to have open visitation did not allow children to visit (Milner et al., 2020) . In a sample of AACN members, 27.4% of nurses working in an adult ICU reported no policy for child visitation and 67.9% thought children were at risk for psychological trauma when visiting an adult in the ICU (Desai et al., 2020) . The literature suggests that there is little evidence to support restricting children from visiting the ICU, and that restriction may be harmful to children's coping process (Hanley & Piazza, 2012) . Collaborating with social workers and childlife specialists to support nurses in preparing children for patient visits was suggested in the current study and supported by other research (Desai et al., 2020; Hanley & Piazza, 2012) .

During the implementation phase of open visitation, nurse leaders identified champions to disseminate information about the positive effects of open visitation on patient outcomes (e.g. EBP). Use of champions has been associated with increases in evidence-based practises (Parker et al., 2019) . Shared governance councils were also an effective implementation strategy that is consistent with previous reports where organisations have leveraged shared governance to advance EBP, improve quality of care, safety and work life (Gallagher-Ford, 2015) .

In the sustainment phase, nurse discretion was a key strategy. Nurses expressed the need to be able to set parameters for open visitation that keeps the patient, family, nurse and healthcare team safe while maintaining patient-nurse-family partnerships. Lessons learned from a nurse-led quality improvement project in the surgical ICU indicated that nurses should have the ability to customise open visitation in order to best meet the patient's condition and that the need for nurse discretion should be communicated often to families, patients and staff (Kozub et al., 2017) . Each participant stressed the importance of empowering nurses to assess patients care needs, and incorporate the assessment findings as parameters for visitation. Visitors and staff need to understand that open visitation does not permit unrestricted access to patients, rather it is should be a professional and individualised visitation plan, based on patient and family needs (McAdam et al., 2008) .

Security presence in the ICU emerged as a strategy for sustainment of open visitation. In this study, nurse leaders expressed the need for a security presence to maintain safe open visitation and provide support for when open visitation needed to be suspended. In the US gun violence in hospitals is rising with 88 shootings occurring in 86 hospitals resulting in 121 deaths between 2012 and 2016 (Wax et al., 2019) . A recent qualitative study revealed that nurses in the US want a security presence in the ICU and waiting area, metal detectors and bag inspections by security guards at access points, and centrally monitored security cameras throughout the ICU (Keys & Stichler, 2018) . Outside the US, reasons for and the type of security presence in the ICU may look different, but is still necessary. For example, the coronavirus pandemic has created a global need for increased administrative controls for health security like recording all persons entering a patient's ICU room and keeping non-essential staff and visitors to a minimum (Jansson et al., 2020) . A security presence as described by the nurse leaders in this study may help to address these tasks.

In the sustainment phase, nurse leaders perceived that family spaces, both physical and emotional, were important for open visitation. Inadequate physical space for families has been reported as a barrier to family involvement in care (Hetland et al., 2018) . Attention to family's emotional space is achieved by honouring family involvement and sense of belonging. Research supports involvement of the family and patients in the plan of care to decrease risk of post-intensive care syndrome for family (Davidson et al., 2012) .

There are several limitations to our study. The researchers did not interview bedside nurses whose views may be different than the nurse leaders. The researchers had a good response rate of 47.5%. However, potential participants for which there was no contact information or did not respond to the study invitation may have a different perspective on barriers and strategies for implementing and sustaining open visitation. The researchers conducted phone interviews and could not assess participants' non-verbal communication cues.

Strengths of this study include a proposed framework for implementing and sustaining open visitation. The multicenter sample allowed for a broader range of perspectives that may make the framework more widely applicable. The researchers used rigorous qualitative methods including standardised codebook, intercoder agreement cheques, audit trail and details about the ICU, participants and recruitment. The research team included individuals from social work and nursing. Researchers with multiple perspectives can provide a richness of theoretical approaches and an unbiased perspective when investigating complex processes (Bindler et al., 2012) like implementing and sustaining open visitation in the adult ICU. Lastly, to address positionality (Bryant & Charmaz, 2007) that may influence data collection and analysis the authors disclose their professional experience in clinical settings in the methods.

In this multicentre qualitative study, barriers and strategies were identified by nurse leaders for different phases of implementing and sustaining open visitation. As noted in this study, the transformative experience of implementing open visitation contributed to a critical care culture shift away from provider centric models of care to one of patient and family centred care. Future research should include comparison studies to evaluate if open visitation improves patient, visitor, and staff outcomes when compared to adult ICU's with restrictive visitation. Implementation and evaluation studies should also be encouraged to shed further light on best practises for this type of organisational change.

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The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.