A Change of Plans

For those that have been reading my blog - you know that I was working in a ICU for a rural hospital and also worked as an adjunct clinical instructor for a community college. Most also know that I am rounding out the completion of my graduate degree in nursing education. Whew! Ok - that helps me set the stage because I recently (almost 6 months now) accepted a position as a Nurse Educator for another rural hospital. The hospital never really had a nursing education department, so I was charged with the responsibility of developing this department from scratch.

In my humble opinion - how can a hospital exist without a nursing education department? For obvious reasons - I really can't go into any major detail about what happens when a hospital does not have a nursing education department. Suffice to say - bad things really do happen. Anyway, now I am charged with the responsibility of developing a fully integrated nursing education program of learning that includes the establishment of a nursing orientation, new graduate program and a program of on-going continuing education. It is very exciting, but also very overwhelming. It seems like they had no nursing education and now that they have a nurse educators, every educational need is urgent and a priority. That is the overwhelming part. The best part - being able to construct a nursing education department from the ground floor up and knowing that what you are doing is really laying an infrastructure to help nurses given patients better care. That is pretty awesome!

I will keep you informed of my journey. It should be very interesting to say the least.

Teenagers

Okay - so I am a parent of three teenagers. My youngest is 16, my middle is 17 and my oldest is 19. Soon, the months will all collide and they will be 17, 18 and 19. All through their life, it was a challenge. They were all born so close together that managing all their individual needs was pretty tough. But, through it all, I felt like a competent parent that did a great job. As a single father, there were times when I felt like I needed to give them more of me than I had, but always seemed to find the energy.

As the years past, I always felt connected to each of them; watching their budding personalities and seeing them grow into some really wonderful people. This bliss all ended when they turned 16.5 years old. Suddenly, I became this uncool guy that had "unreasonable" rules. I was mean, yelled alot and expected that they act like people that had manners. I mean, asking them to put a dish in the dishwasher was like congress declaring war.

Today, I find myself wondering why I became a parent. I was actually very happy to have children until the aliens came down from afar and stole them from me. My Friends tell me that they will return soon, around age 20. I am starting to see the return on my oldest who is on the verge of 20. Our relationship is almost back to normal. I asked her where she went and her response was "it is a secret - no parent is allowed to know where we go because they always return us." She said, you went their too when you were 16.5 and returned home when you were 20 but they made you forget." Perhaps she is right - I do remember times when I thought my parents were pretty uncool and wanted to spend every waking minute with my awesome and cool friends. I guess I never realized how traumatic it was on my parents or those that cared about me.

Anyway - I have made a decision as I journey through this right of passage as a parent - I will be glad when it is done and I have my normal kids back. I know they will be adults then, but at least I can see what they have become. I wonder though - will I still like them? Wow - that's a thought. I do know that I am ready for the teenage years to end. I only hope when my kids are parents and they have teenagers - they get to experience everything they have helped me experience as a parent of teenagers. I guess mom was right - pay back is really a bitch.

A Simple Hard Working American Man

Dear President Bush and President - Elect Obama,

In light of the recent events with our economy and the millions of dollars our government is giving to failed Wall Street companies and the proposed additional millions of dollars to be given to other failing banks and companies, I would like to let you know my thoughts as an American and as a citizen of this great country.

First, as a free market society, it is the responsibility of the big companies to effectively and properly manage their budgets in an effort to remain in business. This means that a company must use it's financial resources wisely so that it can meet its financial obligations, and ultimately make a profit and stay in business. But, somehow, the companies that are needing financial assistance from our government have failed to meet this basic standard of operation. I believe a first year MBA graduate student would recognize when revenue was less than expenses and perhaps even take steps to either shore up revenue or simply reduce expenses to stay a float and in business. Yet, despite their rich salaries, the leadership of some of these financial institutions are unable to manage their books and stay a float. While I can understand that they made bad business decisions that are now impacting Americans, I don't understand why we (the taxpayer) should burden the poor business decisions of these organizations.

I believe we live in a free market society - this means that when one organization fails, another will rise in it's place and perhaps do a better job managing their financial affairs, stay in business and they may even offer a product that would be superior to the failed company. Yet - the government is preventing this failure with millions of dollars from taxpayers. I certainly understand the argument that if we allow these organizations to fail, it could ripple across the world and cause the entire world to fall into a deep recession. Wow - a global economy has some real bad drawbacks I guess!

Here I sit as a single, simple American man raising my family, paying my bills (at least most of them), sending my daughter to college, making my mortgage payment every month and working off my butt to have enough money to buy groceries. Yes gentleman, I am probably like a lot of Americans that go to work each day and try to make ends meet. Sometimes they do and if they don't, my family and I cut back until we have enough money to buy what we need and sometimes - what we want.

I was originally going to ask for a personal bailout for me, but, I am a bigger person that this. I work and do what I think is right. I will not be a victim or dependent on my government to support me. Nope - no bailout for me. I would suggest that before anymore money is sent to failing companies that you consider the plight of simple Americans like me and how hard we work to support the government's infrastructure. Don't just give our money away!

Thank you for taking the time to read the words of a simple American man. I really do appreciate the job you have and I know and pray that you (both of you) will do the right thing.

Sincerely,

A Simple American Man

About Time

I bet most of you that follow my blog (maybe 5 people in total - ha!) have been wondering what happened to me. Well, the truth of the matter is that I lost my sign on and password and could not figure out how to sign back in. But - after several months of trying to locate my sign on - I finally found it. I now have it in a better place. So hopefully - I can keep blogging. Hope you all did not miss me too much. I will be back with some new stuff soon.

My Latest Literature Review! Family Centered Care in the Intensive Care Unit Through Open Visiting Hours

Family Centered Care in the Intensive Care Unit Through Open Visiting Hours
Nurses today have a unique challenge and opportunity to effectively balance the provisions of critical care on the acutely ill patient while also striving to meet the needs of family members impacted by the patient’s critical illness. The concept of family has changed over the years and expanded to include blood relatives as well as people that are significant to the patient. It is a fact that many people will either personally experience a critical illness or be impacted by a critical illness by a friend or family member (Gavaghan & Carroll, 2002).
The concept of family centered care and open visiting hours in the intensive care unit (ICU) has recently come into light as health care professionals, family members and researchers seek to examine the benefits of a more liberal policy for visitation. According to Farrell, Joseph, & Schwartz-Barcott (2005), visitation regulation have largely gone unchanged since the U.S. Public Health Service published visitation recommendations for the intensive care unit in 1962. The research on the subject matter remains limited and far more research is necessary in an effort to acquire empirical data relating to patient responses to a more liberalized visitation policy that is focused on family centered care.
This paper seeks to examine the literature available to answer the compelling question as to whether open visitation policy within the critical care environment provides recovery benefits to the patient. Adjunctive to this question is the need to recognize the family as an extension of the patient and determine their needs and motivation. This paper will explore five comprehensive studies in an effort to develop information on the compelling question. Further, each study will be critically reviewed to determine commonalities among the research as well as differences. Finally, the results of the review will provide conclusions that support change in practice and provide strategies for hospitals to develop a visitation policy that is consistent with the research and focused on family centered care.
Literature Review
The first research article is a study conducted by Gavaghan & Carroll (2002) with a purpose to integrate current knowledge about family centered care as a means to develop nursing interventions that promote family centered approach to care in the ICU. The primary thrust of the research was focused on family centered care theory, where the family is viewed as a “social unit that has significant effect on the patient’s outcomes” (Gavaghan & Carroll, 2002, pg. 65). Gavaghan & Carroll (2002) hypothesized that family members have needs that must be recognized by nurses in the critical care environment. Further, the authors set out to clarify these needs through the development of the Critical Care Family Needs Inventory (CCFNI). The CCFNI focused on five conceptual areas that researchers felt were important to the family and included: proximity, assurance, information, support, and comfort. According to Gavaghn & Carroll (2002) psychometric testing of the CCFNI supported appropriate measurement of the data collected by the tool. The study sample consisted of forty family members that completed the CCNFI (N=40). The results of this inventory revealed that family members often felt that their needs for information as well as proximity were met. However, the study revealed that visiting hours, support and comfort were often inconsistently provided by nurses and medical staff. Of special interest is the notion that while the hospital had a posted policy for visitation, nurses were inconsistent in their application of the policy. This inconsistency often made the family feel a sense of distrust to the nurses.
The final conclusion of this survey provided for suggested recommendations to improve family relationships in the ICU and improved satisfaction. Nurses are the primary means of information and support because they are the health care professionals that have direct and constant access to the patient. The study suggests that as a means to improve satisfaction, hospitals develop a visitation policy that embraces family in the care of the patient. Further, the facility should develop a brochure about family centered care and visitation that provides the family with an orientation to the activities of the ICU. Lastly, the author suggested that the use of volunteers to engage families in the orientation process provided needed relief to the nurses and actively involves a group of people that have the time to spend nurturing the family needs.
Another research article written by Farrell, Joseph, & Schwartz-Barcott (2005), focuses on the need to balance patient, visitor and staff needs in terms of open visitation in the ICU. This phenomenological qualitative study was driven by the need to answer the question about nurse perceptions while working with visitors in the ICU. The study focused on a sample of nurses (N=8) that work in the ICU and have voiced concerns over balancing the care of the critically ill patient while attempting to meet the increasing needs of family members. The tools used for this research included observation, questionnaire and interviews with the sample participants. The measurement and analysis of the data included host verification, where the researcher validates the quotes from the sample participants and allows the participants to verify their answers (Polit & Beck, 2004).
The findings of the survey demonstrated that nurses are central to access of the patient. Nurses hold the key to the gateway and depending upon their needs for the day can deny or grant access to the patient by family members. The major concern with this responsibility is the general lack of consistency by the nurses. One nurse may grant family access while another nurse denies access creating a disparity in the nurse-family relationship (Farrell, Joseph, & Schwartz-Barcott, 2005). Central to the nurse-family relationship is for the nurse to understand that family members have a need for information, and access to the patient. Likewise, families need to understand that nurses must balance the critical care of the patient, safety and have the ability to complete the nurse’s work while the family is present. The study also focused on how nurses manage family visitation during the patient’s routine care and when it is appropriate to ask a family member to leave. Study participants overwhelming cited that they asked family members to leave during the provisions of personal care (Farrell, Joseph, & Schwartz-Barcott, 2005). Further, nurses were conflicted as to whether family members should be present during codes. The study suggested that family presence during a code is very individualized and should be left to the discretion of the health care team and the family members (Farrell, Joseph, & Schwartz-Barcott, 2005).
In comparison to the first study reviewed by Gallaghan & Carroll (2002), Farrell, Joseph, & Schwartz-Barcott (2005) suggest that the ICU appoint one individual that can effectively manage the complex needs of the family, thereby allowing the nurse time to care for the patient. While Farrell, Joseph, & Schwartz-Barcott (2005) do not suggest a volunteer can manage this function, it is interesting to note that both studies made this recommendation.
Another study conducted by Livesay, Gilliam, Mokracek, Sebastian & Hickey (2005) detail the experiences of nurses that work in a Neuroscience Intensive Care Unit (NICU). The purpose of this study was to examine nurse’s perceptions about open visitation, determine if the nurses believe the policy needs to be changed, and how the actual policy in place impacts their patient’s recovery. This quasi-experimental research design had a participant sample of registered nurses and patient care technicians (N=30). The measurement tools employed were questionnaires that were distributed to study participants. Of the thirty participants, twenty-six responded (Livesay, et al, 2005). According to the study, 85% of the sample were aware of the visitation policy and provided this information to family members when they inquired about visiting hours. Nurses were more likely to be liberal with the visitation policy (10 of 25) if the patient’s condition was serious. Most of the nurses in the sample indicated they would ask family members to leave the ICU during normal care routines. The majority of nurses would recognize caregiver fatigue on the part of the family member and would suggest that the family member take a break to get a cup of coffee or go for a walk (Livesay, et al, 2005). An interesting point to note here is that the nurses studied most often recognized the family members need for information concerning the condition of the patient. Many family members were reluctant to leave the bedside if there were not some assurances from the nurse that they would contact the family member if the patient’s condition were to change. Another point of interest is that fact that when nurses provided the family with assurance that they would monitor the patient closely; the family member would leave the unit for a rest period (Livesay, et al, 2005).
The conclusion of this study resembled the conclusions of the two other studies reviewed. This study recommended that clear policy be established on visitation and that nurses apply the policy consistently across the board. In addition, the development of educational material and perhaps a contract for care is made between the family member and the nursing staff. This study identified the educational material be used as a means to provide the family with education about the patient’s needs, the nurses responsibilities and ways in which the family can be engaged in the care of the patient. Finally, like the other studies, this study also recommended that support personnel be included in the units of staffing in an effort to relief the nurse from the responsibility of meeting the complex needs of the family. Support personnel can provide the family member with needed information and contact during the critical care stay and increase the family’s satisfaction with the hospital (Livesay, et al, 2005).
The next study reviewed was one conducted by White (1994) that randomly selected 125 hospitals that had an intensive care unit (N=125) and to compare and contrast visiting policies for each hospital. 40% of the sample responded to the survey conducted by White (1994) during the study period. Of this 40% all participants had a visiting policy in place for pediatric and adult ICU. Visiting hours ranged from 8 hours to 14 hours with few having any form of visiting hours after 9:00PM. The general premise of the study was to determine if there were physiological reasons for more liberalized visitation as well as to describe the legal and ethical considerations for a more liberalized visitation policy.
As has been true throughout this literature review, most of the studies, including this study by White (1994) speak to the fact that the nurse is considered the gatekeeper. Use of this term employs the understanding that nurses are often the professional responsible for applying the policy of visitation within the critical care environment. In addition, the nurse directly impacts the family’s ability to have access to the patient or be denied access to the patient (White, 1994). The major difference in this research is the focus on ethical and legal considerations for visitation. According to White (1994), patients and their families have the right to be together through an acute illness. White (1994) suggests that as patients are isolated and in some cases forced isolation, this can and often does cause a general sense of distrust with the staff and increases the recovery period of the patient. Patients need the support and nurturing of their family during times of acute crisis or illness.
The conclusion of this survey suggested that nurses need to have a wide depth of understanding about the policy of the hospital in terms of visitation. Nurses often denied access to visitors if the business of the unit required such actions. Most often cited was the increased acuity of the patient or the staff limitations (i.e. shortages of staff members) (White, 1994).
The final research study that was reviewed was conducted by Eriksson & Bergbom (2007) and was designed to answer the question of whether family visitation actually helps the patient during recovery. While there is much discussion about family visitation, there is very limited research to support or deny the claim that increased visitation by family actually is beneficial to the patient. Eriksson and Bergbom (2007) used a prospective, explorative observational study design to answer the referenced question. They surveyed a sample group of 198 patients and their families during the study period (N=198). The nature of the study was longitudinal because it provided a study review period of eight months. The primary thrust of the study was to examine the results of family visitation on the clinical manifestations of the patient and whether these clinical results were related to increase family support. Data was collected over an eight month span of time and reflected a total of 198 patients. The data was analyzed via the Statistical Package for Social Sciences, Version 12 and deemed reliable (Eriksson and Bergbom, 2007).
At the completion of the study, the data revealed that there is really no conclusive evidence that increased family visitation had a direct positive or negative impact on the patient’s overall clinical performance. In fact, the researchers suggested that more research and study is needed in an effort to provide further evidence on the subject. The authors made reference to the fact that patients in the study that had no visitation during their stay in the ICU had a better mortality rate than those that had visitations (Eriksson & Bergbom, 2007). This result might lead one to believe that family visitations do not have any correlational relationship to clinical performance and recovery.
Discussion
Each study reflected a reasonable design and analysis methodology. Some studies reflected the perception of nurses with open visitation policies, while other studies focused on the patient’s clinical performance with increased family visitation. In each study, the data was compelling and revealed that family members have a need for close proximity (access) to the patient, a need for information, and a way to be engaged and involved in the patient’s care. Further, most of the studies reviewed suggested that educational material be developed in an effort to provide family members with an orientation to the critical care environment and the stated visitation schedule. Nurses were recognized as the gatekeeper for access to the patient and when there is disparity among nurses in terms of enforcement of vitiation policies it can negatively impact the nurse-family relationship. Some studies went so far to suggest that when visitation policies are not consistently enforced that it can cause a distrustful relationship between staff and family members and reduce overall family satisfaction with care.
Some inconsistency with the studies center around the overall influence open visitation has on the clinical performance of the patient. The study by Eriksson & Bergbom (2007) provided empirical data to refute the hypothesis that increased family visitation actually improve patient’s overall mortality and decreases the recovery process. Evidence from their study is contrary to the new age assumption that open visitation makes a real difference to the patient. While the results of their data may be true, the authors of the study suggest that more research be conducted to in an effort to analyze more data on the subject.
Conclusion
Open visitation in the critical care environment is being widely discussed as a means to improve patient outcomes and provide families with proper access. Research on the topic continues to be very limited. However, there is enough evidence to suggest that family-center care theory can be used as the corner stone of this foundational understanding into human dynamic. Families are evolving and changing and health care professionals must recognize that people who are important to the patient must be considered family members (Gavaghan & Carroll, 2002). While the industry adapts to the changing family unit, there are several strategies that nurses and hospitals can employ in an effort to better meet the needs of patients and their families. Some of these strategies include: the development of consistent and fair visitation policies designed to address the needs of the family, educating nursing staff about the need to fairly and consistently apply the visitation polices across the board without the need for disparity, and the development of educational material designed to orient the family member to the critical care environment as well as provide them with written information about stated visitation schedules. Further recommendations suggest that a member of the volunteer staff be appointed as a family liaison and conduct the family orientation. Also the development of a family engagement contract was suggested by one study in an effort to involve the family with the provisions of care. Finally, in an effort to provide ample access to the patient and allow fatigued caregivers the opportunity to take reasonable rest breaks, one study suggested that the hospital invest in beepers that can be assigned to family members that leave the ICU for breaks. Beepers provide the family member with a peace of mind that if they are needed or if the patient has a change in condition, the nursing staff will have ready access to alert them of these changes.
As hospitals and critical care environments develop their policies, they must keep in mind that nurses play a critical role as gatekeepers for the patient. The primary concern must always be for the well-being of the patient, but the family and their complex needs must be met as well. The challenge faced by today’s professional nurses is truly in the balance of these two different priorities.

References
Eriksson, T. & Bergbom, I. (2007). Visits to intensive care unit – frequency, duration and impact on outcome. British Association of Critical Care Nurses 12(1). 20-26.
Farrell, M., Joseph, D., & Schwartz-Barcott, D. (2005, January). Visiting hours in the ICU: finding the balance among patient, visitor and staff needs. Nursing Forum, 40(1), 18-28. Retrieved January 29, 2008, from CINAHL Plus with Full Text database.
Gavaghan, S., & Carroll, D. (2002, March). Families of critically ill patients and the effect of nursing interventions. Dimensions Of Critical Care Nursing: DCCN, 21(2), 64-71. Retrieved January 29, 2008, from MEDLINE database.
Livesay, S., Gilliam, A., Mokracek, M., Sebastian, S., & Hickey, J. (2005, April). Nurses' perceptions of open visiting hours in neuroscience intensive care unit. Journal of Nursing Care Quality, 20(2), 182-189. Retrieved January 29, 2008, from CINAHL Plus with Full Text database.
Polit, D. F., & Beck, C. T. (2004). Nursing research: Principles and methods (7th ed.). Philadelphia: Lippincott Williams & Wilkins.
Verhaeghe, S., Defloor, T., Van Zuuren, F., Duijnstee, M., & Grypdonck, M. (2005, April). The needs and experiences of family members of adult patients in an intensive care unit: a review of the literature. Journal Of Clinical Nursing, 14(4), 501-509. Retrieved January 29, 2008, from MEDLINE database.
Whitis, G. (1994, January). Visiting hospitalized patients. Journal Of Advanced Nursing, 19(1), 85-88. Retrieved January 29, 2008, from MEDLINE database.

Password?

Ok - I have admitted that I am new to the whole blogging experience, but to not be able to sign into your own blog - well, that is really pathetic! Yes, I guess that descibes me! Anyway - I have been unable to sign in becuase blog spot changed the way you enter your blog. I guess I did not remember my google sign in and apparently it was different than my blog. But, alas, I am here and I did find my way. Now, if I could only remember my yahoo sign in for myblogspot account, I would be all set.

Does it strike you as funny that in our lives today - we actually have to have a file for passwords and user IDs. I can remember way back when ... when there was no such thing as a user ID, or if we had a user ID, it was for our lunch account at the hospital.

Oh well - with advances come challenges. I guess someone needs to invent a password reminder - probably already done and a great thing to hack. That's a funny thought - the hackers can remember your user ID and passwords better than you!

I think that is why I am a nurse.

"Green" Nurses

From the title, you might expect I was once again pontificating on the new graduate nurse. But, you would be wrong! The post title is really something significant to nurses as we look at the amount of disposable waste we generate in the hospital or health care environment each day. I have to admit - I am certainly no expert on this, but it would seem to me that every time I use a pair of gloves or use supplies that are perfectly packaged, I am making a not so wonderful contribution to the waste issue on our planet.

Have you considered the amount of waste you generate in one single shift? What happens to all this waste? I am sure it is incinerated, but the power necessary to incinerate this waste has to also take its tool on the natural resources of the planet as well. Are there better ways to package supplies? Are there better ways that health care professionals can promote a green attitude in the health care environment that does not place them or the patient at risk? I would certainly believe that we can and really should strive to look into this issue.

While I may not have the answers professionally about health care waste, I can start at home. I can make a difference at home and begin to explore how I can make a difference professionally. Hopefully you can too.