DOI: 10.1097/JPN.0000000000000055
C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins J Perinat Neonat Nurs r Volume 28 Number 4, 313–318 r Copyright
Implementing an Open Unit Policy in a Neonatal Intensive Care Unit Nurses’ and Parents’ Perceptions Kristin C. Voos, MD; Nesha Park, RN ABSTRACT Family presence is linked to reduced stress, better patient safety, and increased family satisfaction. But parental presence can increase nurses’ workload and make nurses feel uncomfortable. An open unit (OU) policy and plan for implementation was developed. An anonymous survey was given to nurses about an OU pre- and postimplementation. Responses were used to learn perceived barriers; focus groups were held to understand the concerns and develop solutions. The success of the program was measured by pre/post nursing and parent surveys. Initially, 87% (76/87) of nurses were not in favor of an OU. Most common concerns were as follows: HIPPA 71%, social issues 56%, and increased time for report 45%. Post-OU, only 17% (10/59) were not in favor. Fifty-four percent expressed no major concerns. The most common concerns were as follows: interruptions 25%, limited space 22%, HIPPA 17%. Eighty percent cited benefits for parents. Most common benefits were as follows: increased visiting 49% and improved parent emotional state 43%. Pre-OU, 78% (18/23) of parents felt they were allowed to be with their baby as much as they wanted compared to 92% (36/39) post-OU. Neonatal intensive care unit nurses had reservations toward open Author Affiliations: Pediatrics Division of Neonatology, Children’s Mercy Hospital (Dr Voos and Ms Park); and School of Medicine, University of Missouri (Dr Voos), Kansas City, Missouri. The authors thank Amy Sloan, RN, Howard Kilbride, MD, William Truog, MD, and Brian Carter, MD, for their support and expertise. Disclosure: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.
Corresponding Author: Kristin C. Voos, MD, Pediatrics Division of Neonatology, Children’s Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108 ([email protected]). Submitted for publication: July 15, 2013; accepted for publication: November 24, 2013. The Journal of Perinatal & Neonatal Nursing
visitation, but with education and a focused process for implementation, most nurses favored the change and benefits for families were recognized. Parent satisfaction increased regarding time spent with their infant. Key Words: family-centered care, neonatal intensive care unit, open unit, open visitation
amily-centered care (FCC) is an approach intended to strengthen the healthcare providerpatient-parent relationship, improve patients’ and parents’ experience of healthcare, decrease patients’ and parental stress and enhance medical decision making.1 Most of the foundational work of familycentered care rests on effective communication.2–4 It is well-established that specific healthcare provider and patient/parent communication behaviors are associated with improved patient health status, recall, treatment adherence, and satisfaction.2,3,5–8 Family-centered care recognizes the family as the constant in the infant’s life.2,9 Liberal visitation policies now are accepted as beneficial for patients and families. The AAP Policy on Family-Centered Care and the Pediatrician’s Role states that creating 24-hour open unit (OU) for families and making a commitment to information sharing are beneficial for families and staff.10 Specifically, a 24-hour OU has been shown to decrease length of stay, decrease use of the emergency department, improved parent satisfaction, and decreased parental anxiety.10,11 However, studies have shown family presence can increase nurses’ workload and can make nurses feel uncomfortable.12-15 Finding a way to balance these issues can be challenging. The purpose of this article is to describe the process involved in implementing an OU policy and the effects on staff and families.
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METHODS Part 1: Steps for OU implementation The neonatal intensive care unit (NICU) is an urban, mostly out born, 60-bed open bay, tertiary care center, which has a multidisciplinary FCC committee that includes parents, parent support partner, physicians, nurses, respiratory therapists, discharge coordinators, social workers, physical therapists, child life specialists, and pharmacists. The committee meets monthly and works regularly on FCC initiatives. The FCC committee has 1 overarching goal—to engage families to increase family presence. The committee believes that to support the role of the family, a culture change must occur first, so that the staff, not the family, are considered the “visitors” in the infant’s life. The first project that the FCC committee undertook was to revise the visitation policy, to allow parental presence 24 hours a day, making it clear to parents that they are welcome anytime and are not considered visitors. Before this change, the unit was closed during nurse change of shift in the mornings and evenings. The NICU is composed of more than 200 neonatal nurses, 50 neonatal nurse practitioners, 6 neonatal fellows, 23 neonatal attending physicians, and rotating resident physicians. Because of the large size of the unit and need for education on all levels for a sustained successful implementation of an OU, the committee saw the need to approach this policy change in a systematic and equitable manner. The following steps were included in FCC committee’s plan for an OU. 1. Gain administrative support by meeting with the hospital executive vice presidents, unit nurse managers, and NICU leadership to share the importance and plan for an OU. 2. Identify multidisciplinary unit champions to promote support among peers by requesting volunteers through the FCC committee and seeking out specific staff for this purpose. 3. Hold educational sessions and webinars for all staff to present the background rationale, benefits of an OU, and success of other institution’s OU policies. 4. Survey nursing staff to gain insight regarding OU opinions, and use this information to target further education. 5. Revise family orientation information to include verbiage that parent are not visitors and to reflect the OU policy changes. 6. Present the plan for implementation at multidisciplinary NICU staff updates. 7. Set a date for implementation. 314
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These steps for implementation were proposed over a 9-month period. Nursing updates were scheduled a year in advance and the FCC committee planned to set an implementation date soon after the staff updates. Part 2: Steps to monitor satisfaction of staff and families The FCC committee ensured the nurses concerns were heard and addressed through an anonymous survey inquiring how they felt about an OU before implementation. This was an open-ended, single-question survey to encourage response. A list of the most common concerns would be presented to nursing focus groups at a later date to request ideas for solutions. A second anonymous survey was given after implementation. This postsurvey included 3 open-ended questions: how nurses perceived the move to an OU was going; did they have any problems; and did they see any benefits for parents. The survey was distributed before and 3 months after OU implementation during 4 shifts (including day, night, and weekend shifts) over 1 week. To gauge family satisfaction, responses to the NRC Picker16 parent survey question “Did you get to spend as much time as you wanted with your baby?” pre- and post-OU were compared. The NRC Picker survey is routinely mailed to a random sample of families after discharge by the hospital.
RESULTS Part 1: Outcomes of the process of implementation of an OU: 1. Gain administrative support: After meeting with 2 of the executive vice presidents, nurse managers, and NICU leadership, the committee received full project support. To demonstrate this support, one of the executive vice presidents attended all nursing updates and introduced the topic and stated that it was fully supported by the hospital. The vice president of nursing came to all of the focus groups to champion nursing administration support of an OU. 2. Identify multidisciplinary champions: The FCC committee identified physician champions who met and provided input for ways to support the FCC committee on this endeavor, nursing champions distributed and collected the preand postimplementation surveys, and members of other disciplines (respiratory therapist, social work, neonatal nurse practitioners, and neonatal fellows) championed this project within their October/December 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
3.
4.
5.
6.
areas of expertise, bringing any concerns back to the committee. Hold educational sessions on benefits on an OU: The FCC committee reached out to other children’s hospitals and other units in the hospital to identify success stories of implementing an OU policy. The published reports on OU policies were reviewed. The FCC committee presented these findings and success stories at a regularly scheduled conference (attended by neonatal faculty, fellows, and neonatal nurse practitioners) and quarterly nursing updates before the implementation process. E-mail updates to the NICU staff with educational materials were also provided. Survey nursing staff: After review of the survey responses, 4 focus groups were held, 1 during each shift on a weekday and on a weekend, to encourage full unit participation. Because the perceptions of the nursing staff and their expressed concerns, there was a large turnout to the focus groups. Eighty percent of the unit nurses attended. The most common concerns were briefly reviewed and then possible solutions were elicited. Following all the focus groups, the unit received an update about the concerns and possible solutions. Table 1 includes most common concerns and solutions. Revise family orientation information: The parent orientation booklets and visitation guidelines were revised to reflect the changes in policy of an OU and address specific nursing concerns. The entire booklet was reviewed by the FCC committee. Family friendly language, specifically to explain that parents are not visitors and are welcome 24 hours a day, was used. Some of specific changes are listed in Table 2. Present at staff updates: The plan for implementation was shared including results of the survey and solutions. Multiple scripting scenarios were made and shared with staff during this education. Staff was also empowered with family friendly scripting provided by the FCC committee on how to
address families who had challenges adhering to the visitation guidelines. 7. An implementation date was set and shared during staff updates. Part 2: Results of staff and family satisfaction surveys Before OU implementation, 87% (76/87) of nurses were not in favor of an OU. Most common concerns included possible HIPPA violations 71%, sensitive family social issues 56%, and increased time for report 45%. Three months after implementation of an OU, only 17% (10/59) were not in favor of an OU (P > .0001). Fifty-four percent expressed no major concerns. The most common issues reported were interruptions 25%, limited space 22%, and possible HIPPA violations 17%. Perceived benefits for parents were cited by 80%; most commonly mentioned were increased visiting 49% and improved parent emotional state (decreased stress and anxiety, increased satisfaction) 43%. Specific quotes pre- and postimplementation are included in Table 3. Before going to an OU, 78% (18/23) of parents felt they were allowed to be with their baby as much as they wanted compared with 92% (36/39) postimplementation. There were no parental complaints about HIPPA violations after moving to an OU.
DISCUSSION In a large tertiary NICU with the majority of nurses in opposition, an FCC committee was able to implement a policy that allowed parents to be with their infant 24 hours a day. This change was successful using a systematic approach to incorporate staff input with demonstrated support from all key stakeholders. Staff and parents both reported increased satisfaction with this policy change. Family-centered care is a philosophy often strived for in the NICU, but current practice and policies can often lag behind philosophy. Neonatal intensive care unit staff verbalize acceptance of families being
Table 1. The 3 most common concerns on surveys with solutions from the nursing focus groups Concerns HIPPA violation concerns Sensitive social information Increased time for change of shift
Solutions Revise parent orientation information to include information about HIPPA and how the NICU protects health information. Shift assignments would be starred if there was sensitive social information. If an assignment starred then the nurses would meet away from the bedside to discuss the social information and the move to the bedside for the rest of report. Revise parent orientation information to address this concern.
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Table 2. Revisions to the parent orientation booklets Parents may be with their baby any time. Parents are not considered visitors. Nursing change of shift is from 7 am to 8 am and from 7 pm to 8 pm. During this time, the NICU is closed to all visitors. Parents are not considered visitors. During the shift change, the nursing staff will be busy getting report, checking your baby, and planning your baby’s care. We ask that you wait to talk to the staff until after shift change. So, nurses can better focus on planning care for your baby. If we are discussing infants nearby, families may be asked to step away from the bedside for a short time. We try very hard to be respectful of medical information. We take many steps to keep your baby’s medical information private. Parents are welcomed at any time. You may hear private information about other infants. We ask that you respect others. Please do not repeat any private information. If you are concerned about your baby’s private medical information contact the charge nurse.
involved in care but their actions do not always reflect their words.9,12,17,18 Because of the critical status of infants in the NICU, nursing and medical staff are often focused on life-saving medical treatments, and not necessarily aware or sensitive to the needs of families.9,19 In the present report of development and implementation of an OU protocol, nurse attitudes and perceptions regarding an OU changed over time. Nurses reported that the change to an OU was much smoother than expected. Many nurses who were opposed to an OU, after implementation became in favor of it, expressing benefits for parents and staff. Parents felt greater satisfaction in the time they were able to spend with their baby after implementation.
Much has been published about the needs of families in the NICU setting. There have been reports of success when family-centered care occurs, with increased nursing and family satisfaction.10,20–24 However, little has been published on how to successfully implement FCC initiatives, especially in NICUs. This report reviews a process for creating FCC change in a large NICU setting and again confirms the benefits of an OU for nurses and families. Implementing change is challenging especially when staff may be negatively impacted. To create sustainable change, it is important to develop a plan and create buy in to successfully implement this new process and culture change. Previous efforts at accomplishing an
Table 3. Pre and postopen unit quotes from staff surveys Survey Quotes Before OU “Asking questions in front of parents . . . .Sets parents up for a great deal of distrust and would make nurse feel uncomfortable being watched . . . ” “I need time to breathe . . . get organized.” “Distracted by visitor interruptions . . . ” “Not ideal set up, we do not have private rooms” “Parents are nosy and may be listening in to other reports” “How can we explain social situations?” “Report would take longer” “I feel like parents have ample opportunity to speak to medical staff, encourage them to be on rounds more” “We need a break, we have no other place to go” “Hard to provide critical care when I have to entertain relatives” “Why are we even entertaining this idea? We are open 22 hours a day, 2 hours is not that much to ask . . . 22 out of 24 is enough” “What if RN disagrees with medical plan” “May cause parents more stress” “While these people are indeed parents and families of our pts, they are still visitors in “my house”
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Survey Quotes After OU “I think parents feel less defensive with staff because did not have to leave . . . .” “Parents are here more at night . . . stay . . . ” “Breastfeeding . . . Do not have to hurry and rush to get done before they have to leave for change of shift” “Freedom to visit when it works best for them.” “Parents feel that they are part of the team . . . ” “In this environment a lot of control is taken away from the parents, being able or feeling like they can be here all day takes a little pressure off.” “Assurance that they are not visitors is good for the family . . . ” “More comfortable and assertive at the bedside, . . . ” “Better connected or trusting of staff . . . they contribute . . . ” “They can meet the oncoming nurse . . . ” “Not as bad as we thought . . . ” “No major concerns” “Going well” “So much smoother than expected”
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OU in our NICU were unsuccessful. The success of the present project was in the details of the process. The nursing and ancillary staffs were educated about potential family benefits and successes of other units with FCC, through e-mails, lectures, and staff updates. To engage staff, surveys were distributed and focus groups were held to discuss perceptions and hear concerns. These meeting were an effective way to show staff that potential problems were being addressed and provided an avenue for staff involvement in creating solutions. Then the implementation process was shared with all, including concerns with possible solutions. During the implementation process, staff witnessed family benefits, which helped altered perceptions and sustained change. One of the 4 key elements of FCC includes a critical exchange of complete and unbiased information between families and medical staff.2 Numerous studies have demonstrated that information and communication are essential needs for families of intensive care patients.25–29 Parenting in the NICU is something most families are not prepared for or expect. Finding the parental role in this situation can be difficult and taxing, especially when their infant is critically ill.30 Such challenges can have long-lasting effects on family functioning.31 Staff behaviors, as well as wording of parent handouts, help set the stage for an FCC unit and build family trust.17 In a review by Cleveland,32 one of the nursing behaviors identified to assist parents in meeting this need was a welcoming environment with supportive unit policies. Following our OU policy change, all family orientation material was revised with family-centered language. Restrictions were replaced with phrases such as, “Parents are welcome to be with their baby 24 hours a day. Parents are not considered visitors.” This approach set the tone for parent involvement and empowerment. Limitations for generalization of our process include that this implementation took place in an urban, mostly outborn, academic tertiary NICU. The process would need to be adapted to the fit specific needs of other units. The NRC Picker survey in our unit is sent to families after discharge, but the return rate is variable and may not reflect the opinion of all families. However, there were no negative family reports or expressed concerns. It will be useful to document how well this change is sustained and to identity other FCC initiatives, which could complement the OU policy in supporting our families. Measuring the impact of any implementation for staff and families is an important task. Continued monitoring with feedback will allow the unit to demonstrate which initiatives are successful from both staff and
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family points of view and will be important in promoting further change. In conclusion, before policy change, NICU nurses had reservations and skepticism toward open visitation. After the implementation process, most nurses were supportive of the OU change and reported perceived benefits for families. Parent satisfaction increased regarding time spent with their infant. Obtaining administrative support, soliciting staff attitudes, requesting involvement for solutions, and educating staff about the benefits for families can help initiate change and perceived family benefits will sustain the successful FCC practice. References 1. Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL. Through The Patient’s Eyes: Understanding and Promoting PatientCentered Care. San Francisco, CA: Jossey-Bass; 1993. 2. Ahmann E, Abraham MR, Johnson BH. Changing the Concept of Families as Visitors: Supporting Family Presence and Participation. Bethesda, MD: Institute for Family-Centered Care; 2003. 3. Rao J, Anderson L, Inui T, Frankel R. Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence. Med Care. 2007;45:340–349. 4. Stein T, Frankel R, Krupat E. Enhancing clinician communication skills in a large healthcare organization: a longitudinal case study. Patient Educ Couns. 2005;58:4–12. 5. Institute for Patient and Family-Centered Care. Principles of patient and family-centered care. http://www.ipfcc.org/faq .html. Accessed January 25, 2013. 6. Roter D, Hall J, Kern D, Barker L, Cole K, Roca R. Improving physicians’ interviewing skills and reducing patients’ emotional distress. A randomized clinical trial. Arch Intern Med. 1995;155:1877–1884. 7. Kaplan S, Greenfield S, Ware JJ. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care. 1989;27:S110–S127. 8. Lewis C, Pantell R, Sharp L. Increasing patient knowledge, satisfaction, and involvement: randomized trial of a communication intervention. Pediatrics. 1991;88:351–358. . 9. Beveridge J, Bodnaryk K, Ramachandran C. Family-centered care in the NICU. Can Nurs. 2001;97(3):14. 10. American Academy of Pediatrics, Committee on Hospital Care. Family-Centered care and the pediatrician’s role. Pediatrics. 2003;112:69. 11. Forsythe P. New Practices in the transitional care center improve outcomes for outcomes for babies and their families. J Perinatol. 1998;18(6 part 2 suppl):S13–S17. 12. Brown J, Ritchie JA. Nurses’ perceptions of parent and nurse roles in caring for hospitalized children. Child Health Care. 1990;19(1):28–36. 13. Griffin T. Visitation Patterns: The Parents who visit too much. Neonatal Netw. 1998;17(7):67–68. 14. Lust BL. The patient in the intensive care unit: a family experience. Crit Care Q. 1984;6(4):449–457. 15. Dunkel J, Eisendrath S. Families in the intensive care unit: their effect on staff. Heart Lung. 1983;12(3):258–261. 16. National Research Corporation (NRC). NRC picker pediatric inpatient experience survey (4 point). Proprietary instrument. http://www.nationalresearch.com. Accessed November 24, 2013.
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17. Griffin T. A family-centered “Visitation” policy in the neonatal intensive care unit that a welcomes parents as partners. J Perinat Neonatal Nurs. 2013;27(2):160–165. 18. Berman H. Nurses’ belief about family involvement in children’s hospital. 1991;14:141–153. 19. Hazinski MF. Nursing care of the critically ill child: a sevenpoint check. Pediatr Nurs. 1985;11(6):453–461. 20. Griffin T. Family-centered care in the NICU. J Perinat Neonatal Nurs. 2006;20(1):98–102. 21. Cypress BS. Family presence on rounds a systematic review of the literature. Dimens Crit Care Nurs. 2012;31(1): 53–64. 22. Griffin T. Bringing change of shift to the bedside: a patient and family-centered approach. J Perinat Neonatal Nurs. 2010;24(4):348–353. 23. Tidwell T, Edwards J, Snider E, et al. A nursing pilot study on bedside reporting to promote best practice and patient/family-centered care. J Neurosci Nurs. 2011;43(4): E1–E5. 24. Garrouste-Orgaes 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.
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25. Perlman N, Freedman J, Abramovitch R, Whyte H, Kirpalani H, Perlman M. Informational needs of parents of sick neonates. Pediatrics. 1991;88(3):512–518. 26. Kasper J, Nyamathi A. Parents of children in the pediatric intensive care unit: what are their needs? Heart Lung. 1988;17(5):574–581. 27. Fisher M. Identified needs of parents in a pediatric intensive care unit. Crit Care Nurse. 1994;14(3):82–90. 28. Daley L. The perceived immediate needs of families with relatives in the intensive care setting. Heart Lung. 1984;13(3):231–237. 29. Shellabarger S, Thompson T. The critical times: meeting parental communication needs throughout the NICU experience. Neonatal Netw. 1993;12(2):39–45. 30. Fenwick J, Barclay L, Schmied V. Struggling to mother: a consequence of inhibitive nursing interactions in the neonatal nursery. J Perinat Neonatal Nurs. 2001;15(2):49–64. 31. Talmi A, Harmon RJ. Relationships between preterm infants and their parent: disruption and development. Zero to Three. 2003;24(2):13–20. 32. Cleveland L. Parenting in the neonatal intensive care unit. J Obstet Gynecol Neonatal Nurs. 2008;37(6):666–691.
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C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins J Perinat Neonat Nurs r Volume 28 Number 4, 313–318 r Copyright
Implementing an Open Unit Policy in a Neonatal Intensive Care Unit Nurses’ and Parents’ Perceptions Kristin C. Voos, MD; Nesha Park, RN ABSTRACT Family presence is linked to reduced stress, better patient safety, and increased family satisfaction. But parental presence can increase nurses’ workload and make nurses feel uncomfortable. An open unit (OU) policy and plan for implementation was developed. An anonymous survey was given to nurses about an OU pre- and postimplementation. Responses were used to learn perceived barriers; focus groups were held to understand the concerns and develop solutions. The success of the program was measured by pre/post nursing and parent surveys. Initially, 87% (76/87) of nurses were not in favor of an OU. Most common concerns were as follows: HIPPA 71%, social issues 56%, and increased time for report 45%. Post-OU, only 17% (10/59) were not in favor. Fifty-four percent expressed no major concerns. The most common concerns were as follows: interruptions 25%, limited space 22%, HIPPA 17%. Eighty percent cited benefits for parents. Most common benefits were as follows: increased visiting 49% and improved parent emotional state 43%. Pre-OU, 78% (18/23) of parents felt they were allowed to be with their baby as much as they wanted compared to 92% (36/39) post-OU. Neonatal intensive care unit nurses had reservations toward open Author Affiliations: Pediatrics Division of Neonatology, Children’s Mercy Hospital (Dr Voos and Ms Park); and School of Medicine, University of Missouri (Dr Voos), Kansas City, Missouri. The authors thank Amy Sloan, RN, Howard Kilbride, MD, William Truog, MD, and Brian Carter, MD, for their support and expertise. Disclosure: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.
Corresponding Author: Kristin C. Voos, MD, Pediatrics Division of Neonatology, Children’s Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108 ([email protected]). Submitted for publication: July 15, 2013; accepted for publication: November 24, 2013. The Journal of Perinatal & Neonatal Nursing
visitation, but with education and a focused process for implementation, most nurses favored the change and benefits for families were recognized. Parent satisfaction increased regarding time spent with their infant. Key Words: family-centered care, neonatal intensive care unit, open unit, open visitation
amily-centered care (FCC) is an approach intended to strengthen the healthcare providerpatient-parent relationship, improve patients’ and parents’ experience of healthcare, decrease patients’ and parental stress and enhance medical decision making.1 Most of the foundational work of familycentered care rests on effective communication.2–4 It is well-established that specific healthcare provider and patient/parent communication behaviors are associated with improved patient health status, recall, treatment adherence, and satisfaction.2,3,5–8 Family-centered care recognizes the family as the constant in the infant’s life.2,9 Liberal visitation policies now are accepted as beneficial for patients and families. The AAP Policy on Family-Centered Care and the Pediatrician’s Role states that creating 24-hour open unit (OU) for families and making a commitment to information sharing are beneficial for families and staff.10 Specifically, a 24-hour OU has been shown to decrease length of stay, decrease use of the emergency department, improved parent satisfaction, and decreased parental anxiety.10,11 However, studies have shown family presence can increase nurses’ workload and can make nurses feel uncomfortable.12-15 Finding a way to balance these issues can be challenging. The purpose of this article is to describe the process involved in implementing an OU policy and the effects on staff and families.
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METHODS Part 1: Steps for OU implementation The neonatal intensive care unit (NICU) is an urban, mostly out born, 60-bed open bay, tertiary care center, which has a multidisciplinary FCC committee that includes parents, parent support partner, physicians, nurses, respiratory therapists, discharge coordinators, social workers, physical therapists, child life specialists, and pharmacists. The committee meets monthly and works regularly on FCC initiatives. The FCC committee has 1 overarching goal—to engage families to increase family presence. The committee believes that to support the role of the family, a culture change must occur first, so that the staff, not the family, are considered the “visitors” in the infant’s life. The first project that the FCC committee undertook was to revise the visitation policy, to allow parental presence 24 hours a day, making it clear to parents that they are welcome anytime and are not considered visitors. Before this change, the unit was closed during nurse change of shift in the mornings and evenings. The NICU is composed of more than 200 neonatal nurses, 50 neonatal nurse practitioners, 6 neonatal fellows, 23 neonatal attending physicians, and rotating resident physicians. Because of the large size of the unit and need for education on all levels for a sustained successful implementation of an OU, the committee saw the need to approach this policy change in a systematic and equitable manner. The following steps were included in FCC committee’s plan for an OU. 1. Gain administrative support by meeting with the hospital executive vice presidents, unit nurse managers, and NICU leadership to share the importance and plan for an OU. 2. Identify multidisciplinary unit champions to promote support among peers by requesting volunteers through the FCC committee and seeking out specific staff for this purpose. 3. Hold educational sessions and webinars for all staff to present the background rationale, benefits of an OU, and success of other institution’s OU policies. 4. Survey nursing staff to gain insight regarding OU opinions, and use this information to target further education. 5. Revise family orientation information to include verbiage that parent are not visitors and to reflect the OU policy changes. 6. Present the plan for implementation at multidisciplinary NICU staff updates. 7. Set a date for implementation. 314
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These steps for implementation were proposed over a 9-month period. Nursing updates were scheduled a year in advance and the FCC committee planned to set an implementation date soon after the staff updates. Part 2: Steps to monitor satisfaction of staff and families The FCC committee ensured the nurses concerns were heard and addressed through an anonymous survey inquiring how they felt about an OU before implementation. This was an open-ended, single-question survey to encourage response. A list of the most common concerns would be presented to nursing focus groups at a later date to request ideas for solutions. A second anonymous survey was given after implementation. This postsurvey included 3 open-ended questions: how nurses perceived the move to an OU was going; did they have any problems; and did they see any benefits for parents. The survey was distributed before and 3 months after OU implementation during 4 shifts (including day, night, and weekend shifts) over 1 week. To gauge family satisfaction, responses to the NRC Picker16 parent survey question “Did you get to spend as much time as you wanted with your baby?” pre- and post-OU were compared. The NRC Picker survey is routinely mailed to a random sample of families after discharge by the hospital.
RESULTS Part 1: Outcomes of the process of implementation of an OU: 1. Gain administrative support: After meeting with 2 of the executive vice presidents, nurse managers, and NICU leadership, the committee received full project support. To demonstrate this support, one of the executive vice presidents attended all nursing updates and introduced the topic and stated that it was fully supported by the hospital. The vice president of nursing came to all of the focus groups to champion nursing administration support of an OU. 2. Identify multidisciplinary champions: The FCC committee identified physician champions who met and provided input for ways to support the FCC committee on this endeavor, nursing champions distributed and collected the preand postimplementation surveys, and members of other disciplines (respiratory therapist, social work, neonatal nurse practitioners, and neonatal fellows) championed this project within their October/December 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
3.
4.
5.
6.
areas of expertise, bringing any concerns back to the committee. Hold educational sessions on benefits on an OU: The FCC committee reached out to other children’s hospitals and other units in the hospital to identify success stories of implementing an OU policy. The published reports on OU policies were reviewed. The FCC committee presented these findings and success stories at a regularly scheduled conference (attended by neonatal faculty, fellows, and neonatal nurse practitioners) and quarterly nursing updates before the implementation process. E-mail updates to the NICU staff with educational materials were also provided. Survey nursing staff: After review of the survey responses, 4 focus groups were held, 1 during each shift on a weekday and on a weekend, to encourage full unit participation. Because the perceptions of the nursing staff and their expressed concerns, there was a large turnout to the focus groups. Eighty percent of the unit nurses attended. The most common concerns were briefly reviewed and then possible solutions were elicited. Following all the focus groups, the unit received an update about the concerns and possible solutions. Table 1 includes most common concerns and solutions. Revise family orientation information: The parent orientation booklets and visitation guidelines were revised to reflect the changes in policy of an OU and address specific nursing concerns. The entire booklet was reviewed by the FCC committee. Family friendly language, specifically to explain that parents are not visitors and are welcome 24 hours a day, was used. Some of specific changes are listed in Table 2. Present at staff updates: The plan for implementation was shared including results of the survey and solutions. Multiple scripting scenarios were made and shared with staff during this education. Staff was also empowered with family friendly scripting provided by the FCC committee on how to
address families who had challenges adhering to the visitation guidelines. 7. An implementation date was set and shared during staff updates. Part 2: Results of staff and family satisfaction surveys Before OU implementation, 87% (76/87) of nurses were not in favor of an OU. Most common concerns included possible HIPPA violations 71%, sensitive family social issues 56%, and increased time for report 45%. Three months after implementation of an OU, only 17% (10/59) were not in favor of an OU (P > .0001). Fifty-four percent expressed no major concerns. The most common issues reported were interruptions 25%, limited space 22%, and possible HIPPA violations 17%. Perceived benefits for parents were cited by 80%; most commonly mentioned were increased visiting 49% and improved parent emotional state (decreased stress and anxiety, increased satisfaction) 43%. Specific quotes pre- and postimplementation are included in Table 3. Before going to an OU, 78% (18/23) of parents felt they were allowed to be with their baby as much as they wanted compared with 92% (36/39) postimplementation. There were no parental complaints about HIPPA violations after moving to an OU.
DISCUSSION In a large tertiary NICU with the majority of nurses in opposition, an FCC committee was able to implement a policy that allowed parents to be with their infant 24 hours a day. This change was successful using a systematic approach to incorporate staff input with demonstrated support from all key stakeholders. Staff and parents both reported increased satisfaction with this policy change. Family-centered care is a philosophy often strived for in the NICU, but current practice and policies can often lag behind philosophy. Neonatal intensive care unit staff verbalize acceptance of families being
Table 1. The 3 most common concerns on surveys with solutions from the nursing focus groups Concerns HIPPA violation concerns Sensitive social information Increased time for change of shift
Solutions Revise parent orientation information to include information about HIPPA and how the NICU protects health information. Shift assignments would be starred if there was sensitive social information. If an assignment starred then the nurses would meet away from the bedside to discuss the social information and the move to the bedside for the rest of report. Revise parent orientation information to address this concern.
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Table 2. Revisions to the parent orientation booklets Parents may be with their baby any time. Parents are not considered visitors. Nursing change of shift is from 7 am to 8 am and from 7 pm to 8 pm. During this time, the NICU is closed to all visitors. Parents are not considered visitors. During the shift change, the nursing staff will be busy getting report, checking your baby, and planning your baby’s care. We ask that you wait to talk to the staff until after shift change. So, nurses can better focus on planning care for your baby. If we are discussing infants nearby, families may be asked to step away from the bedside for a short time. We try very hard to be respectful of medical information. We take many steps to keep your baby’s medical information private. Parents are welcomed at any time. You may hear private information about other infants. We ask that you respect others. Please do not repeat any private information. If you are concerned about your baby’s private medical information contact the charge nurse.
involved in care but their actions do not always reflect their words.9,12,17,18 Because of the critical status of infants in the NICU, nursing and medical staff are often focused on life-saving medical treatments, and not necessarily aware or sensitive to the needs of families.9,19 In the present report of development and implementation of an OU protocol, nurse attitudes and perceptions regarding an OU changed over time. Nurses reported that the change to an OU was much smoother than expected. Many nurses who were opposed to an OU, after implementation became in favor of it, expressing benefits for parents and staff. Parents felt greater satisfaction in the time they were able to spend with their baby after implementation.
Much has been published about the needs of families in the NICU setting. There have been reports of success when family-centered care occurs, with increased nursing and family satisfaction.10,20–24 However, little has been published on how to successfully implement FCC initiatives, especially in NICUs. This report reviews a process for creating FCC change in a large NICU setting and again confirms the benefits of an OU for nurses and families. Implementing change is challenging especially when staff may be negatively impacted. To create sustainable change, it is important to develop a plan and create buy in to successfully implement this new process and culture change. Previous efforts at accomplishing an
Table 3. Pre and postopen unit quotes from staff surveys Survey Quotes Before OU “Asking questions in front of parents . . . .Sets parents up for a great deal of distrust and would make nurse feel uncomfortable being watched . . . ” “I need time to breathe . . . get organized.” “Distracted by visitor interruptions . . . ” “Not ideal set up, we do not have private rooms” “Parents are nosy and may be listening in to other reports” “How can we explain social situations?” “Report would take longer” “I feel like parents have ample opportunity to speak to medical staff, encourage them to be on rounds more” “We need a break, we have no other place to go” “Hard to provide critical care when I have to entertain relatives” “Why are we even entertaining this idea? We are open 22 hours a day, 2 hours is not that much to ask . . . 22 out of 24 is enough” “What if RN disagrees with medical plan” “May cause parents more stress” “While these people are indeed parents and families of our pts, they are still visitors in “my house”
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Survey Quotes After OU “I think parents feel less defensive with staff because did not have to leave . . . .” “Parents are here more at night . . . stay . . . ” “Breastfeeding . . . Do not have to hurry and rush to get done before they have to leave for change of shift” “Freedom to visit when it works best for them.” “Parents feel that they are part of the team . . . ” “In this environment a lot of control is taken away from the parents, being able or feeling like they can be here all day takes a little pressure off.” “Assurance that they are not visitors is good for the family . . . ” “More comfortable and assertive at the bedside, . . . ” “Better connected or trusting of staff . . . they contribute . . . ” “They can meet the oncoming nurse . . . ” “Not as bad as we thought . . . ” “No major concerns” “Going well” “So much smoother than expected”
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OU in our NICU were unsuccessful. The success of the present project was in the details of the process. The nursing and ancillary staffs were educated about potential family benefits and successes of other units with FCC, through e-mails, lectures, and staff updates. To engage staff, surveys were distributed and focus groups were held to discuss perceptions and hear concerns. These meeting were an effective way to show staff that potential problems were being addressed and provided an avenue for staff involvement in creating solutions. Then the implementation process was shared with all, including concerns with possible solutions. During the implementation process, staff witnessed family benefits, which helped altered perceptions and sustained change. One of the 4 key elements of FCC includes a critical exchange of complete and unbiased information between families and medical staff.2 Numerous studies have demonstrated that information and communication are essential needs for families of intensive care patients.25–29 Parenting in the NICU is something most families are not prepared for or expect. Finding the parental role in this situation can be difficult and taxing, especially when their infant is critically ill.30 Such challenges can have long-lasting effects on family functioning.31 Staff behaviors, as well as wording of parent handouts, help set the stage for an FCC unit and build family trust.17 In a review by Cleveland,32 one of the nursing behaviors identified to assist parents in meeting this need was a welcoming environment with supportive unit policies. Following our OU policy change, all family orientation material was revised with family-centered language. Restrictions were replaced with phrases such as, “Parents are welcome to be with their baby 24 hours a day. Parents are not considered visitors.” This approach set the tone for parent involvement and empowerment. Limitations for generalization of our process include that this implementation took place in an urban, mostly outborn, academic tertiary NICU. The process would need to be adapted to the fit specific needs of other units. The NRC Picker survey in our unit is sent to families after discharge, but the return rate is variable and may not reflect the opinion of all families. However, there were no negative family reports or expressed concerns. It will be useful to document how well this change is sustained and to identity other FCC initiatives, which could complement the OU policy in supporting our families. Measuring the impact of any implementation for staff and families is an important task. Continued monitoring with feedback will allow the unit to demonstrate which initiatives are successful from both staff and
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family points of view and will be important in promoting further change. In conclusion, before policy change, NICU nurses had reservations and skepticism toward open visitation. After the implementation process, most nurses were supportive of the OU change and reported perceived benefits for families. Parent satisfaction increased regarding time spent with their infant. Obtaining administrative support, soliciting staff attitudes, requesting involvement for solutions, and educating staff about the benefits for families can help initiate change and perceived family benefits will sustain the successful FCC practice. References 1. Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL. Through The Patient’s Eyes: Understanding and Promoting PatientCentered Care. San Francisco, CA: Jossey-Bass; 1993. 2. Ahmann E, Abraham MR, Johnson BH. Changing the Concept of Families as Visitors: Supporting Family Presence and Participation. Bethesda, MD: Institute for Family-Centered Care; 2003. 3. Rao J, Anderson L, Inui T, Frankel R. Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence. Med Care. 2007;45:340–349. 4. Stein T, Frankel R, Krupat E. Enhancing clinician communication skills in a large healthcare organization: a longitudinal case study. Patient Educ Couns. 2005;58:4–12. 5. Institute for Patient and Family-Centered Care. Principles of patient and family-centered care. http://www.ipfcc.org/faq .html. Accessed January 25, 2013. 6. Roter D, Hall J, Kern D, Barker L, Cole K, Roca R. Improving physicians’ interviewing skills and reducing patients’ emotional distress. A randomized clinical trial. Arch Intern Med. 1995;155:1877–1884. 7. Kaplan S, Greenfield S, Ware JJ. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care. 1989;27:S110–S127. 8. Lewis C, Pantell R, Sharp L. Increasing patient knowledge, satisfaction, and involvement: randomized trial of a communication intervention. Pediatrics. 1991;88:351–358. . 9. Beveridge J, Bodnaryk K, Ramachandran C. Family-centered care in the NICU. Can Nurs. 2001;97(3):14. 10. American Academy of Pediatrics, Committee on Hospital Care. Family-Centered care and the pediatrician’s role. Pediatrics. 2003;112:69. 11. Forsythe P. New Practices in the transitional care center improve outcomes for outcomes for babies and their families. J Perinatol. 1998;18(6 part 2 suppl):S13–S17. 12. Brown J, Ritchie JA. Nurses’ perceptions of parent and nurse roles in caring for hospitalized children. Child Health Care. 1990;19(1):28–36. 13. Griffin T. Visitation Patterns: The Parents who visit too much. Neonatal Netw. 1998;17(7):67–68. 14. Lust BL. The patient in the intensive care unit: a family experience. Crit Care Q. 1984;6(4):449–457. 15. Dunkel J, Eisendrath S. Families in the intensive care unit: their effect on staff. Heart Lung. 1983;12(3):258–261. 16. National Research Corporation (NRC). NRC picker pediatric inpatient experience survey (4 point). Proprietary instrument. http://www.nationalresearch.com. Accessed November 24, 2013.
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17. Griffin T. A family-centered “Visitation” policy in the neonatal intensive care unit that a welcomes parents as partners. J Perinat Neonatal Nurs. 2013;27(2):160–165. 18. Berman H. Nurses’ belief about family involvement in children’s hospital. 1991;14:141–153. 19. Hazinski MF. Nursing care of the critically ill child: a sevenpoint check. Pediatr Nurs. 1985;11(6):453–461. 20. Griffin T. Family-centered care in the NICU. J Perinat Neonatal Nurs. 2006;20(1):98–102. 21. Cypress BS. Family presence on rounds a systematic review of the literature. Dimens Crit Care Nurs. 2012;31(1): 53–64. 22. Griffin T. Bringing change of shift to the bedside: a patient and family-centered approach. J Perinat Neonatal Nurs. 2010;24(4):348–353. 23. Tidwell T, Edwards J, Snider E, et al. A nursing pilot study on bedside reporting to promote best practice and patient/family-centered care. J Neurosci Nurs. 2011;43(4): E1–E5. 24. Garrouste-Orgaes 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.
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25. Perlman N, Freedman J, Abramovitch R, Whyte H, Kirpalani H, Perlman M. Informational needs of parents of sick neonates. Pediatrics. 1991;88(3):512–518. 26. Kasper J, Nyamathi A. Parents of children in the pediatric intensive care unit: what are their needs? Heart Lung. 1988;17(5):574–581. 27. Fisher M. Identified needs of parents in a pediatric intensive care unit. Crit Care Nurse. 1994;14(3):82–90. 28. Daley L. The perceived immediate needs of families with relatives in the intensive care setting. Heart Lung. 1984;13(3):231–237. 29. Shellabarger S, Thompson T. The critical times: meeting parental communication needs throughout the NICU experience. Neonatal Netw. 1993;12(2):39–45. 30. Fenwick J, Barclay L, Schmied V. Struggling to mother: a consequence of inhibitive nursing interactions in the neonatal nursery. J Perinat Neonatal Nurs. 2001;15(2):49–64. 31. Talmi A, Harmon RJ. Relationships between preterm infants and their parent: disruption and development. Zero to Three. 2003;24(2):13–20. 32. Cleveland L. Parenting in the neonatal intensive care unit. J Obstet Gynecol Neonatal Nurs. 2008;37(6):666–691.
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