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Providing family-friendly care – even when stress is high and time is short

“Why can’t we come in? We’re family!”

“We need to be here. Can’t we stay?”

“Why won’t someone tell us what’s going on?”

You’ve heard the questions. And you’re familiar with the anxiety they bring. You wonder, “How can I care for the patient and manage the family?”

Tensions often arise between families and the healthcare team when family members want to be at the bedside during a loved one’s illness. In many healthcare facilities, the days of brief, regulated visiting hours are gone. Liberal visiting policies now are widely accepted as beneficial for patients and families.

But research also shows family presence can increase nurses’ workload. Many of us struggle to find the right approach when family members are too noisy or when they impede patient care. How can we respond to family challenges effectively even when time is limited and resources are few?

Start with the right thoughts

Successful nurse-family interactions start with the right attitudes toward family presence. Some nurses believe families interfere with important patient-care activities by asking a lot of questions, expressing skepticism about care, being noisy, and being too numerous. To simplify care and save time, these nurses may prefer to focus solely on the patient—and in the process they marginalize the family. (See What’s your family-friendly rating? by clicking on the PDF icon above.)


But research suggests the family’s presence can yield many benefits with no known detriments to patients. Family presence is linked to fewer cardiac complications, reduced stress, improved mental status, and better family education. It may even help reduce length of stay, readmissions, and healthcare expenditures. The American Association of Critical-Care Nurses, Emergency Nurses Association, American Heart Association, and Society of Critical Care Medicine now call for family presence even during crises.

So we do have a choice. We can choose to keep resisting family presence and cling to familiar ways of clearing the room so we can perform patient care in solitude. Or we can embrace family presence as a way to improve clinical outcomes, keep families connected during the crisis, and provide the best possible patient experience.

To improve your family-friendly rating, begin by examining your thoughts. Identify all your negative beliefs about families, and replace these with more positive ones. Repeat this exercise as often as negative thoughts intrude. Consider verbalizing the replacement thoughts aloud. After 3 weeks, this becomes easier. You can celebrate when you realize your thoughts about families are surprisingly positive. (See Reframing your attitude toward families by clicking on the PDF icon above.)

Decide on a policy—then stick to it

Family-friendly care is most effective when all nurses and families follow a set policy. Visitation policies vary widely across acute-care settings, from closed to flexible to open.

  • Closed policies allow brief family presence during certain times, such as 15 minutes every 4 hours. Evidence doesn’t support this approach; current trends favor open and flexible policies.
  • Flexible policies allow family presence at all times except certain predetermined hours, such as a
    2-hour period every afternoon.
  • Open policies let families come and go as they wish around the clock.Written, signed agreements may help clarify family presence arrange­ments. Predetermined quiet times give families time to rest or run errands. But be aware that mandated separation periods may increase patient and family anxiety.Policies on overnight family presence also vary. Special deliberation is needed when the room is semiprivate and family members are of a different gender than the patient’s roommate.

    Even with written policies, nurses sometimes decide independently when families can be present. Those who resist family presence or have less confidence in their family-friendly skills are more reluctant to invite family presence. Families report confusion and anger when some nurses encourage them to be at the bedside and others don’t. But when all nurses consistently implement family presence policies, families know what to expect and satisfaction increases.

    Assess visiting preferences early and often

    Even with a written policy, nurses should assess patient and family preferences for family presence during hospitalization, beginning on admission. The chapter “Professional nursing practice” in Relationship-Based Care: A Model for Transforming Practice (M. Koloroutis, ed.) provides a framework for integrating family preferences. (See Integrating family presence preferences.)

    Involve the family in patient care

    The quality and safety of patient care can improve when families play an active role at the bedside. Family members can give unique information about the patient; interpret information from caregivers to the patient; and offer the patient touch and emotional comfort, personal hygiene, dressing changes, coaching through painful procedures, and food and fluids. What’s more, when families participate in care, they can envision what the patient will need when discharged—or better understand why the patient didn’t survive.

    When the family is too noisy

    Noisy family members are a common concern. Ask the patient if he or she is bothered by the noise level in the room. Noisy families may disturb other patients, too.

    When speaking with families about noise levels, always use therapeutic communication skills. Family members may think you’re trying to exclude them, so adjust the volume and tone of your voice and monitor your nonverbal expressions to avoid seeming confrontational. Here are some approaches to try:

    “Like you, I want what’s best for your loved one. I want her to heal and regain strength. I’m concerned that the volume of voices in the room right now isn’t in her best interests or those of other patients.”

    “It might be hard for you to whisper all the time, so I’ll find a place nearby for some of you to sit, relax, and visit in a normal voice.”

    “I don’t want to remove you at all. It’s important for family to be together at times like this. But I do want to keep things quiet and calm for your loved one. Please consider rotating in and out of the room.”

    “Our waiting area is especially designed for families. You can take turns slipping in to visit.”

    “Thank you for being so considerate.”

    When too many family members are present

    With too many people in the room, nurses may have difficulty moving around and may be distracted more easily. Be sure to assess patient preferences regarding the number of visitors desired at one time.

    Be aware that cultural factors can affect the size and involvement of the extended family. If the patient wants fewer people in the room or if you’re examining the patient or sharing confidential information, consider asking the family to step out of the room. Here are some ways to do this tactfully:

    To family members: “Mr. Jacobs asks that we limit people in the room to three at a time. There are seven right now. Can you decide among yourselves who would like to take a break, perhaps to get some coffee or dinner?”

    To the patient: “A nurse colleague and I will be talking about your condition right now, and I’ll be uncovering you for a quick examination. For your privacy, I’m going to ask your family to step out briefly. When we finish, I want them to return.”

    When family members don’t get along

    Family tensions can flare up during a loved one’s hospitalization. Through skilled communication, you can ease tension so consensus can be formed and decisions made. The following statements can help:

    “I can understand how emotions would be intense right now. Often during serious illnesses, families set aside differences and work together in new, respectful ways. I’d like to see that happen for you.”

    “I haven’t known you long, but I sense all of you can rise above your own needs to help your loved one heal (or die peacefully).”

    “It seems hard for you both to be at the bedside at the same time. Most families like to agree on a set schedule so each of you gets uninterrupted time with your loved one.”

    “Let’s identify a mediator who can help you make some of these hard decisions together.”

    When minors and dependent adults visit

    Nurses sometimes express concerns about noise and safety when minors and dependent adults visit. Preferably, define expectations on the patient’s admission. Approaches include keeping visits short, minimizing noise, ensuring direct and continuous supervision by an adult (other than the patient), and providing education to prevent infection transmission.

    A welcome message

    Nurses can learn to negotiate family presence in beneficial ways that minimize disruptions to patient-care activities. With the right thoughts, a written policy, an accurate grasp of the evidence, skilled communication, and a commitment to consistency, families who once felt like intruders can hear the welcome message, “Come on in. You belong here.”

    Selected references

    Aknasel N, Kaymakci S. Effects of intensive care unit noise on patients: a study on coronary artery bypass graft surgery patients. J Clin Nurs. 2008;17(12):1581-1590.

    Berti D, Ferdinande P, Moons P. Beliefs and attitudes of intensive care nurses toward visits and open visiting policy. Intensive Care Med. 2007;33(6):1060-1065.

    Davidson JE, Powers K, Hedayat KM, et al. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004-2005. Crit Care Med. 2007;35(2):605-622.

    Dougherty M. Assessment of patient and family needs during an inpatient oncology experience. Clin J Oncol Nurs. 2010;14(3):301-306.

    Fumagalli S, Boncinelli L, LoNostro A, et al. Reduced cardiopulmonary complications with unrestrictive visiting policy in an intensive care unit: results from a pilot, randomized trial. Circulation. 2006;113(7):946-952.

    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.

    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.

    Koloroutis M. Professional nursing practice. In: Koloroutis M, ed. Relationship-Based Care: A Model for Transforming Practice. Minneapolis, MN: Creative Health Care Management; 2004.

    Lee M, Friedenberg A, Mukpo D, Conray K, Palmisciano A, Levy M. Visiting hours policies in New England intensive care units: strategies for improvement. Crit Care Med. 2007;35(2):497-501.

    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.

    Molter N. AACN Protocols for Practice: Creating Healing Environments. Boston, MA: Jones and Bartlett; 2007.

    Sims JM, Miracle VA. A look at critical care visitation: the case for flexible visitation. Dimens Crit Care Nurs. 2006;25(4):175-180.

    Twibell RS, Siela D, Riwitis C, et al. Nurses’ perceptions of their self-confidence and the benefits and risks of family presence during resuscitation. Am J Crit Care. 2008;17(2):101-111.

    Van Horn E, Kautz D. Promotion of family integrity in the acute care setting. Dimens Crit Care Nurs. 2007;26(3):101-107.

    The authors work at Ball Memorial Hospital—A Clarian Health Partner, and Ball State University in Muncie, Indiana. Alexis Neal is the administrative director of Women’s Health and senior administrative director of Women and Children’s Services. Renee Twibell is an associate professor of nursing and a nurse researcher. Karrie E. Osborne is a charge nurse and direct-care nurse in the cardiac intensive care unit. Diana Harris is a charge nurse and direct-care nurse in the medical stroke unit.

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