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Knott, A. & Kee, C. C. (2005). Nurses’ Beliefs About Family Presence During Resuscitation. Applied Nursing Research, 18(4), 192-198.

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Staff Attitudes and Beliefs Regarding Family Visitation After Implementation of a Formal Visitation Policy in the PACU
Maria Walls, BSN, RN
A quality improvement project was created to examine staff attitudes and beliefs regarding visitation after implementation of a formal visitation policy in the PACU. A 10-item questionnaire was distributed and collected from each staff member in the PACU after implementation of the formal policy. Results showed that although 83.7% of staff would want the option to visit their family member in the PACU, only 47% of staff believe that families should have the option to visit in their own PACU. The perceived barriers reported by staff were staffing issues, the possibility of exposure to infection, privacy issues, staff anxiety, the possibility of visitors witnessing resuscitation, and lack of education of families. The survey results show that more existing education is needed. Consequently, the current policy is posted in all waiting areas for families, and a mandatory in-service was created and presented to staff on how to communicate effectively with family members. Keywords: family visitation, staff attitudes, perceived barriers, PACU. Ó 2009 by American Society of PeriAnesthesia Nurses

ALTHOUGH MANY EMERGENCY DEPARTMENTS around the country are allowing family members at the bedside during resuscitations, there is resistance to family visitation in the postanesthesia care unit (PACU). Family visitation benefits both families and patients,1 and at a time when competition for surgical patients exists, hospitals must continue to improve patient and family satisfaction. The PACU where this project was conducted had no formal visitation policy. Reasons for having no formal policy, according to staff, were lack of privacy, lack of space, fear of families witnessing resuscitative efforts, and staff anxiety. As empirical evidence mounted in support of visitation and with the support of management, a formal policy was created. In November of 2007, a formal visitation policy was implemented in the PACU. The policy reads ‘‘postoperatively, patients will be able to have family or significant others visit according to the stability of the patient and
Maria Walls, BSN, RN, is a PACU nurse at Barnes-Jewish Hospital, St Louis, MO. Address correspondence to Maria Walls, PACU, Barnes-Jewish Hospital, 1 Barnes-Jewish Plaza Drive, St Louis, MO 63110; e-mail address: marialenarn@msn.com. Ó 2009 by American Society of PeriAnesthesia Nurses 1089-9472/09/2404-0004$36.00/0 doi:10.1016/j.jopan.2009.03.015
Journal of PeriAnesthesia Nursing, Vol 24, No 4 (August), 2009: pp 229-232

the activity level of the PACU, as assessed by the patient’s nurse and the unit charge nurse. The waiting area liaison will call the PACU to coordinate the visits that will begin at 0945 and continue throughout the day at 45 minutes past the hour until 1345. After 1345, the scheduled visits are then coordinated every 2 hours. Visits are limited to 5 minutes, at which time the liaison will escort the visitors back to the waiting area.’’2 After implementation of the policy, there are still mixed feelings regarding visitors and much resistance among staff. Because visitation is left to the nurse’s discretion, inconsistencies continue to be present that some visitors have noticed. Problems tend to arise when all nurses do not practice the same policy.3 The purpose of this process improvement project is to examine staff attitudes and beliefs regarding visitation after implementation of the formal family visitation policy.

Literature Review
Many reasons are cited to support the importance of family visitation. Visitation has been shown to help with the recovery of patients4,5 and serves as a valuable connection for anxious family members.6 Communication with the patient’s family is one of the most important services we provide, and failures in communication quickly break
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the trust families have in health care professionals.7 Lastly, family and friends should be involved in decision-making, care giving, and always welcomed in all phases of care.8 There are many benefits of visitation. Allowing families to visit may reduce patient anxiety, decrease the number of complaints by patients and families,3 facilitate communication,4,5,9-11 and improve overall patient outcomes.3 For more than 70 years, the Gallup organization has been known to deliver accurate and precise research on the knowledge and thoughts of people around the world.12 According to the Gallup Poll, nursing has repeatedly been voted the most ethical, trusting profession.13 By including family members in the patient’s care, we can profoundly affect this trust and respect.6 Also, if we are interested in achieving true holistic care, we must provide the best of care for both families and patients. Several articles discuss changing the current visitation policies in the critical care unit.3-5 Three factors are involved when changing a policy including knowledge, beliefs, and attitudes of nurses; administrative policies; and structural barriers. Variables that may affect nurse attitudes are their own personal experiences and those of a significant other in critical care, age, sex, years as a nurse, education, and religious beliefs.3 Visitation in the PACU began to appear in the literature in 1984 when an obstetrics instructor wrote an article that publicly questioned visitation in PACUs. Capiello criticized the claim by health care professionals that having family visitation would upset the patient and challenged nurses to do the same.14 Soon after, RNs responded with angry and volatile articles advocating against it. Nurses thought that visitors would create an unmanageable environment and that families would not be able to handle what they saw.15,16 In 1987, Vogelsang surveyed patients after visitation and found that visitation actually decreased anxiety scores in these patients. 17 The study was then repeated in a group of female surgical patients and, again, anxiety scores were lower in the intervention group.18 In the early 1990s there were two studies that focused on both patients and their families. In 1991, Noonan and Anderson surveyed patients and families after visitation and found that 89% of patients and 96% of families found visitation to be beneficial.19 In 1992, Cormier and Pickett studied perceived needs of patients and families versus nurses’ perceived needs. They found that patients and families ranked visitation as the second most important need, whereas nurses ranked it as seventh.20 In 1997, Tuller and McCabe conducted a research study after implementation of open visitation. They were inter-

ested in studying recollection of the visit and the benefits of visitation. They found that 64% of patients remembered the visit, 76% reported it to be helpful to themselves, and 85% reported the visit to be helpful to their visitors. Furthermore, 94% of visitors reported the visit to be helpful.21 Up to this point, visitation was more informal and came from staff perceptions of the needs of patients. It was not until several years later that a suggestion for a formal policy was published. In 2003, Smykowski and Rodriguez implemented a program in which the family was contacted by the patient’s nurse within 90 minutes of the patient’s arrival to the PACU. The nurse set up an individualized plan with the family regarding visitation. There was no time limit and no limit on the number of visitors. The researchers noted that staff were united, the nurses empowered, and staff received education on how to communicate more effectively.22 That year, ASPAN responded to many perianesthesia nurses’ concerns and the mounting evidence of the benefits of visitation by releasing a position statement on the matter. The statement, at this time, leaves individual departments responsible for establishing guidelines at their discretion.23

Methods
The convenience sample for this quality improvement project included 48 employees. The setting was in Phase I recovery at a 1,200-bed teaching institute in a Midwestern urban area. A 10-item questionnaire was developed for the purpose of this project. The survey was given to staff 6 months after implementation of the policy. The questionnaire was a 5-point Likert scale, with areas for narrative comments (Table 1). The instrument was modeled after a survey developed by the Emergency Nurses Association regarding family presence during medical resuscitations. Family visitation was used in place of family presence. No psychometric properties were performed. The questionnaire was distributed and returned by each employee in the PACU including nurses, patient care technicians, secretaries, the nurse manager, and clinical nurse specialist.

Results
The sample included 34 registered nurses, 10 patient care technicians, two secretaries, one manager, and one clinical nurse specialist. Of those surveyed, 98% reported they had participated or had been present during family visitation in the PACU, and 3.1% of employees reported that their performance had actually been hampered by family members.

FAMILY VISITATION POLICY IN THE PACU

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Table 1. Visitation in the PACU—Staff Survey
1. Providing emotional support to family members in the PACU is part of my job/practice. Strongly Agree Strongly Disagree 1 2 3 4 5 2. I feel comfortable providing emotional support to family members in the PACU. 1 2 3 4 5 3. I feel appropriate emotional support is provided to family members in the PACU. 1 2 3 4 5 4. I believe family members should have the option to visit the patient while in the PACU. 1 2 3 4 5 5. Have you participated or been present during family visitation in the PACU? 6. Has your job performance ever been hampered by the presence of a patient’s family member? 7. If your family member was undergoing surgery, would you (as a health care provider) want the option to visit them in the PACU? Why? 8. If you were undergoing surgery, would you want the option to have your family member visit you while in the PACU? 9. What do you believe are system barriers to family visitation? 10. List any personal reservations you have about family visitation in the PACU.

The questionnaire addressed the emotional support provided to families in the PACU. Of those surveyed, 57.1% of employees thought that providing emotional support to family members is part of their practice, 57.2% of employees felt comfortable providing emotional support, and 38.8% of employees felt appropriate emotional care was provided to family members in the PACU. The questionnaire also looked at the employees’ personal feelings regarding visitation. Of those surveyed, 47% reported that family members should have the option to visit the patient while in the PACU, and 83.7% of employees would want the option to visit their family member if they are undergoing surgery. If given the option, 73.1% of employees would want their family to visit them after surgery. Employees commented that the reason they would want to visit their family in the PACU is to be assured they are really okay. Staff commented that they ‘‘would just want to make sure my family member is okay to ease my mind’’ and that ‘‘by hearing a familiar voice, they can be comforted.’’ Employees’ reported reasons why they would not want to visit their family are because pain control and sleep are more important, and they would not want to see their family with tubes, intravenous lines, etc. The main system barriers reported by employees were staffing issues, privacy, and interfering with the care given to the patients. Employees also reported exposure to infection, staff anxiety, families possibly witnessing resuscitations, lack of education of families, and interfering with pain control as additional barriers.

own PACU. Even after implementing a formal policy and educating staff on the benefits of visitation, there continues to be resistance among some staff. The survey results and the narrative comments showed that more existing education is needed. First, education needs to exist to explain to family members detailed information about PACU care such as patients with unfamiliar tubes or machines in the room. Issues such as patient privacy and the importance of sleep and relaxation in the recovery process also need to be discussed with the family. The unit is responding to this need by posting the visitation policy in all the waiting areas (including those in the surgical floors and intensive care units) and also what to expect, the importance of patient privacy, and who to contact for assistance. In addition, in-services are currently scheduled with medical and administrative staff on the PACU visitation policy. Education is needed to teach staff how to interact and communicate effectively with family members in the PACU. In response, a PowerPoint presentation was developed by two evidence-based practice representatives in the PACU on effective communication with family members. The presentation includes a review of the literature with an emphasis on the importance of effective communication, with examples of noneffective versus effective communication techniques. Each of these examples were ideas provided by the staff with several pictures of the staff members displaying the various techniques. By having staff contribute to the content of the presentation and by adding humor, staff seemed to be more receptive to the in-service.

Discussion
Although a majority of employees (83.7%) report they would want to visit their family member in the PACU, only 47% feel it is appropriate for families to visit in their

Conclusion
Although this project demonstrated that many of the staff members in the unit did not support visitation in their PACU, the hope is to provide an environment where

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families are welcome in all phases of care through continued support of the leadership and process improvement teams, education of family members, and education of staff. Although changes in staff attitudes have been slow, the unit has progressed significantly since the data have been collected. It has now been 14 months since implementation of the formal policy. There have been noticeable

changes in staff such as less resistance to visitation, and nurses are working as a team to facilitate a better environment for families to visit. Although change is difficult, by allowing visitation in the PACU, we have found that it appears to not only increase patient and family satisfaction, but also staff satisfaction when they realize that they are truly providing the best care to their patients in the PACU.

References
1. Gato D, Windle P, Santiago T, et al. Family visitation in the post anesthesia care unit. Poster session presented at the annual ASPAN conference, Orlando, Florida, April 2006. 2. Unit Practice Council. Visitation in the PACU Policy. St Louis, MO: Barnes-Jewish Hospital; 2007. 3. Sims JM, Miracle VA. A look at critical care visitation. Dimens Crit Care Nurs. 2006;25:175-181. 4. Roland P, Russell J, Richards KC, et al. Visitation in critical care: Process and outcomes of a performance improvement initiative. J Nurs Care Q. 2001;15:18-26. 5. Ramsey P, Cathelyn J, Gugliotta B, et al. Restricted vs open ICUs. Nurs Manag. 2003;31:42-44. 6. Iacono MV. Nurses: Trusted patient advocates. J Perianesth Nurs. 2007;22:330-334. 7. Thompson D. Interprofessionalism in health care: Communication with the patient’s identified family. J Interprof Care. 2007;21:561-563. 8. Hooper VD. Patient-family centered care: Are we there yet? J Perianesth Nurs. 2008;23:440-442. 9. Peterson M. Process helped gain acceptance for open visitation hours. Crit Care Nurs. 2005;25:70-72. 10. Berwick DM, Koragal M. Restricted visiting hours in ICUs. JAMA. 2004;292:736-737. 11. Brilli RJ. Restrictions on family presence in the ICU. JAMA. 2004; 292:2721. 12. The Gallup Organization. About Gallup. Available at: http:// www.gallup.com/corporate/115/About-Gallup.aspx. Accessed January 18, 2009. 13. Moore DW. Nurses top list in honesty and ethics poll. The Gallup Organization. Available at: http://www.gallup.com/poll/1654/HonestyEthics-Professions.aspx. Accessed August 21 2008. 14. Capiello EJ. The recovery room: Off limits to family [letter]. RN. 1984;7:7. 15. Sapp RM. Why a recovery room is no place for visitors [letter]. RN. 1984;7:7. 16. Burden N. Why a recovery room is no place for visitors [letter]. RN. 1984;7:7. 17. Vogelsang J. Nursing interventions to reduce patient anxiety: Visitors in the PACU. J Perianesth Nurs. 1987;2:25-31. 18. Vogelsang J. Anxiety levels in female surgical patients. J Perianesth Nurs. 1987;2:230-236. 19. Noonan AT, Anderson P. Family-centered nursing in the post-anesthesia care unit: The evaluation of practice. J Post Anesth Nurs. 1991;6:13-16. 20. Cormier S, Pickett SJ. Comparison of nurses’ and family members’ perceived needs during postanesthesia care unit visits. J Perianesth Nurs 1992;387-391. 21. Tuller S, McCabe L. Patient, visitor, and nurse evaluations of visitation for adult postanesthesia care unit patients. J Perianesth Nurs. 1997; 12:402-412. 22. Smykowski L, Rodriguez W. The post anesthesia care unit experience: A family-centered approach. J Nurs Care Qual. 2003;18:5-15. 23. American Society of PeriAnesthesia Nurses A position statement on visitation in phase I level of care 2003 ASPAN Cherry Hill, NJ: ASPAN; 2003. Available at: http://www.aspan.org/Portals/6/docs/ClinicalPrac tice/PositionStatement/11-Visitation_Ph_I.pdf. Accessed June 19, 2009.

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