Moderator
Maurene Harvey, MPH, MCCM
Critical Care Educator and Consultant
Past President SCCM
Lake Tahoe, Nevada, USA
The AACN Clinical Scene Investigator (CSI) Academy is a 16month nursing leadership and innovation training program to
empower hospital-based staff nurses as clinician leaders and
change agents whose initiatives measurably improve patient
outcomes and hospital bottom line
Devin Bowers RN, MSN, NE-BC
CSI Program Manager
AACN
Copyright © 2014 American Association of Critical-Care Nurses
The CSI Academy seeks to enable participants to:
 Demonstrate the components of innovative
project management
 Develop, plan, and implement an innovative project that targets a
patient or organizational outcome on the unit
 Create measurable improvements in
patient or organizational outcomes
Copyright © 2014 American Association of Critical-Care Nurses
Project Dispatch
Society of Critical Care Medicine
Project Dispatch is focused on
patient-centered outcomes
research and aims to provide
clinicians with information on
how to adapt and adopt
successful interventions in
their own ICU.
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Presenters on Today’s Webcast
Erica Edwards, RN, MSN, CCRN-CMC, CHFN
Attending RN, Cardiac Intensive Care Unit
Massachusetts General Hospital
No disclosures
Alicia Sheehan, RN, BSN
Staff Nurse, Cardiac Intensive Care Unit
Massachusetts General Hospital
No disclosures
Creating and Sustaining a Culture of
Family Engagement and
Empowerment in the ICU
Erica Edwards, RN, MSN, CCRN-CMC, CHFN
Attending RN, Cardiac Intensive Care Unit
Massachusetts General Hospital
Objectives
• Identify factors described in the literature about
the importance of family engagement
• Describe the background of family inclusion in the
cardiac ICU
• Discuss the implementation of family engagement
and empowerment in the ABCDEF bundle
Poll Question
Which of these statements are true as it pertains to
families where you practice? Select all that apply.
A. Families are considered an important part of the
patient care team.
B. Families are encouraged to visit daily.
C. Families are coached to be active participants in
achieving patient goals.
D. An interprofessional approach is used to support
families.
MGH CSI Team
Background
• F for family added to ABCDE bundle for AACN CSI
process improvement project “Massachusetts
General Hospital Collaborate to Extubate – A Needs
Assessment and Educational Program on the
ABCDEF Bundle”
• Participants:
Erica Edwards, RN, Alicia Sheehan, RN,
Norine O’Malley-Simmler, RN, and Lisa O’Neill, RN
• Coaches:
Colleen Snydeman, RN, and David Hanson, RN
Definition of family
• “Family” refers to two or more persons who are related
in any way – biologically, legally, or emotionally.
Patients and families define their families. (Institute for Patient and
Family – Centered Care, 2010) “Significant others” may also be used.
• If the patient is awake and able to answer – the family
is whoever the patient designates
• If the patient is unable to answer – how do we know?
• Health Care Proxy
• Documented in a previous admission
• Who accompanied with the patient?
• Why is this important? This will determine who is going
to support and/or assist in decision making.
Family needs
• Families experience stress and anxiety when a loved
one is admitted to the ICU.
• Many studies have identified the needs of families of
critically ill patients and nurse interventions that may
decrease this stress.
• In 1979 Molter conducted a study to identify specific
needs of significant others. The top five needs were to:
•
•
•
•
•
have hope
feel that the hospital staff cares for the patient
be near the patient
be informed of any change in the patient status
know the staff (Molter, 1979)
Family needs
Critical Care Family Needs Inventory (CCFNI)
identified five concept areas:
• Proximity
• Assurance
• Information
• Support
• Comfort (Leske, 1992)
Consequences of unmet needs
• Anxiety and Fear (Simon, Phillip, Badalamenti, and
Ohlert, Krumberger , 1997)
• Depression
• Post traumatic stress syndrome
• Concerns that not everything possible was being
done (Meyers, Eichhorn, Guzzetta, 2000)
Clinical practice guidelines for
support of the family
• A shared decision-making model
• Early and repeated care conferences
• Honoring cultural requests
• Spiritual support
• Family presence at rounds and during resuscitation
Clinical practice guidelines for
support of the family
• Open visitation
• Family-friendly signage
• Family support before, during, and after a death
• Staff education and debriefing (ACCM Task Force of
the SCCM, 2007)
AACN Practice Alerts
• AACN Practice Alert: Family presence during
resuscitation and procedures. (2010) aacn.org
• AACN Practice Alert: Visitation in the adult ICU.
(2011) aacn.org
How to add family (F) into
ABCDE bundle
Questions:
• How can we engage families in activities that
benefit the patient?
• What effect does engaging families in patient
activities have on the family?
Advantages to family engagement
For patients:
• Decreases anxiety, confusion and agitation (Hupcey,
1999)
• Reduces cardiovascular complications (Fumigalli,
Boncinelli, Lo Nostro, et al., 2006)
• Decreases the ICU LOS (Davidson, Powers, Hedayat, et al. 2007)
• Makes the patient feel more secure
• Increases patient satisfaction
• Promotes quality and safety
Family contributions
• “Active presence” to facilitate communication and
what is known about the patient’s condition
• “Protector” creates sense of safety by having a
family member at the bedside to watch over and
advocate for them
• “Historian” provides information about patient’s
medical history and personal preferences
Family contributions (cont)
• Facilitators” to maintain meaningful
relationships
• “Coaches” to provide encourage and inner
strength
• “Voluntary caregiver” assists in providing
actual care
(McAdam, Arai, and Puntillo, 2008)
Family contributions to
patient recovery
As part of the care team, families can assist with:
• Being present during SATs
• Delirium assessment and interventions
• Early mobilization
• Your thoughts?
Engaging the family
• Provide education
• What to expect
• Family roles
• Model caring behaviors
• Support
• Encouragement
Google images, 2015
Engaging the family in the MGH
Cardiac Intensive Care Unit
Alicia Sheehan, RN, BSN
Massachusetts General Hospital
The culture of family centered care
in MGH Cardiac Intensive Care Unit
Fostering a change in culture
• Unrestricted visiting hours
• Volunteer liaison in waiting room
• Cots in rooms
• Comfort cart (meals provided during EOL care)
• “Moment of Silence”
Moment of Silence Script
We would like everyone here to join in remembering ___(name)___ who was
entrusted to our care.
He/she was a
daughter / son
wife / husband
mother/ father
Some thing(s) we got to know about her/him were:
Something(s) I will remember about her/him are:
Let’s join in a moment of silence to remember her/him and to reflect on her/his
life and death, and what we did to help her/him. (pause 30 seconds or more)
Thank you.
Fostering a change in culture
• Family presence during resuscitation and
procedures
• Family presence at rounds
• Interprofessional access available to family
including social worker, chaplain, nutritionist, PT,
OT, RT, case manager
Innovations creating a
culture change
Responsible Decision Making Rounds
• Complex patients are discussed
• Occurs weekly
• Uses interprofessional approach
• Right care, right time, right patient
Innovations creating a
culture change
Attending Nurse: New Role at MGH
• Assists with patient’s journey through the hospital stay,
including discharge
• In the ICU, focuses on patient and family needs for
communication, education, support
• Facilitates daily interprofessional rounds and long term
rounds
Organizational core values
Incorporated into the values of the Massachusetts
General Hospital Patient Care Services is the
statement of recognition of the importance of
patients and their families in the decisions affecting
their care This value extends throughout the life
cycle, including the end of life. The family is viewed
as an extension of the patient and therefore should
be considered in all aspects of the patient’s care.
(Patient Care Services, 2009).
Families of critically ill patients and the
effect of nursing interventions.
• This article reviewed the evidence related to family
needs
• Listed implications for practice:
•
•
•
•
•
•
•
Encourage more family visitation
Encourage child visitation
Explore animal visitation
Facilitate nurse-family interactions
Allow family presence during procedures and resuscitation
Refer families to support or educational groups
Use hospital volunteers for waiting area
(Gavaghan, Carroll, 2002)
Visiting preferences of patients in the intensive
care unit and in a complex care unit
• The purpose of this study was to describe patient preferences for
family visiting in an ICU and in a complex medical care unit.
Patients described:
• Visiting was a non-stressful experience
• Having visitors offered moderate levels of reassurance, comfort
and calming
• Valued the fact that visitors could interpret information
• That visitors could provide information to assist health care
providers’ understanding of the patient
• Were very satisfied with a visiting guideline that is flexible enough
to meet their needs and those of their family members
(Gonzalez, Carroll, Elliott, 2004)
Changes in provider perceptions of family
presence during resuscitation and invasive
procedures.
Purpose: to measure changes in perceptions of healthcare
providers (HCPs) in the cardiac intensive care unit (CICU)
before and after an implementation of an educational
program that included approval of a unit-based guideline for
family presence (FP) during resuscitation and invasive
procedures.
Result: the educational program and the approval of a unitbased guideline improved HCPs' perception of risk and
benefit of FP during resuscitation and the actual presence of
family during resuscitation.
(Edwards, Despotopulos, Carroll, 2013)
Narratives
• Culture of narrative writing
• Grounded on the work of Benner
• Focus is on patient and family centered care
• Highlights excellence in practice
• All members of the Patient Care Services (nursing,
PT, OT, RT, SLP, SW, chaplain)
Nurses perceived barriers to
family involvement
• Assessing appropriateness
• Respecting unit culture/boundaries
• Overstaying
• Clutter in room/safety issues
• Need for limit setting
• Balancing patient privacy
• Patient and family specific
Families as active members of the
patient care team
Families in the CICU:
• Provide a patient history
• Provide a HCP document
• Identify spokesperson
• Educate staff on cultural and spiritual needs
• Active presence for the patient
• Assist with language and communication barriers
Families as active members of the
patient care team
• Assist to calm patient during vent wean
• Identify changes in patient’s condition and behavior
(aids with delirium assessment)
• Encourage or coach patients during PT or
procedures
• Advocate for the patient
• Reduce need for restraints
Benefits of family engagement far
outweigh perceived barriers
A team approach is needed to
support, educate and
communicate with families.
• Involvement of interdisciplinary team is critical to
the success of family engagement
• Demonstrated in our project logo
CSI logo
Interprofessional Collaboration
Nurses
Chaplain
Physicians
Patient
& Family
Respiratory
Care
Dietician
Physical
Therapist
Social
Worker
Engaging families in the ICU
In summary:
• Family engagement and empowerment is fostered
by the culture of the unit.
• A multidisciplinary approach is necessary to
support family engagement.
• Families can be included in many aspects of patient
care and that benefits both patient and family.
Acknowledgements
• Jeanette Ives Erickson, RN, DNP, FAAN
• Theresa Galvin, RN, MS
• Vivian Donahue, RN, MSN
• Susan Stengrevics, RN, MSN
• Colleen Snydeman, RN, PhDc
• Susan Lacey, RN, PhD
• Dave Hanson, RN, MSN
References
• AACN Practice Alert: Family presence during resuscitation
and procedures. (2010) aacn.org
• AACN Practice Alert: Visitation in the adult ICU. (2011)
aacn.org
• Clinical practice guidelines for support of the family in the
patient-centered intensive care unit: American College of
Critical Care Medicine Task Force (2007). Davidson, J. et al.
Crit Care Med 35(2) 605-23
• Edwards, E., Despotopulos, L., Carroll, D. (2013) Changes in
provider perceptions of family presence during resuscitation
and invasive procedures. Clinical Nurse Specialist Volume
27(5). 239-44
References
• Fumigalli, S., Boncinelli, L., Lo Nostro, A. , et al. (2006)
Reduced cardiocirculatory complications with unrestricted
visiting policy in an intensive care unit: results from a pilot,
randomized trial. Circulation 113, 946-52
• Gavaghan, S., Carroll, D. (2002) Families of critically ill
patients and the effect of nursing interventions. Dimensions
of Critical Care Nursing Volume 21(2). 64-71
• Gonzalez, C., Carroll, D., Elliott, J., Vallent, H. (2004) Visiting
preferences of patients in the intensive care unit and in a
complex care unit. American Journal of Critical Care 13(3)
194-8.
References
• Davidson JE, Powers K, Hedayat KM, et al. (2007) 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. 35(2) 605-22
• Leske, J. S. (1992). Needs of adult family members after critical
illness: a prescription for interventions. Critical Care Nursing Clinics
of North America. 4, 587-96
• McAdam, JL., Arai,S. and Puntillo, KA. (2008). Unrecognized
contributions of families in the intensive care unit. Intensive Care
Med. 34, 1097-1101
• Meyers TA, Eichhorn DJ, Guzzetta CE, et al. Family presence during
invasive procedures and resuscitation: the experiences of family
members, nurses, and physicians. Am J Nurs. 2000;100(2): 32-42
References
• Rukstele, C., Gagnon, M. (2013) Making strides in preventing
ICU acquired weakess: involving family in early progressive
mobility. Crit Care Nursing Quarterly 36(1), 141-7
• Simon SK, Phillip K, Badalamenti S, Ohlert J, Krumberger J.
(1997) Current practice regarding visitation policies in
critical care units. Am J Crit Care. 6(3):210-217.
• Hupcey JE. (1999) Looking out for the patient and
ourselves—the process of family integration into the ICU. J
Clin Nurs. 8(3):253
Questions/Comments
Erica Edwards, RN, MSN, CCRNCMC, CHFN
Attending RN, Cardiac Intensive
Care Unit
Massachusetts General Hospital
Alicia Sheehan, RN, BSN
Staff Nurse, Cardiac
Intensive Care Unit
Massachusetts General
Hospital