Staff Response to Flexible Visitation in the Post-Anesthesia Care Unit (PACU)

Background. Family visitation in post-anesthesia care is recommended by The American Society of Perianesthesia Nurses and meets JCAHO’s requirement for Family-centered care. Based on evidence supporting expanded family visitation in post-anesthesia units, the PACU in a 750 bed Texas hospital implemented a visitation policy for family members of patients in 2009, including a survey of staff attitudes towards the practice change. Components of the program included: 1) creation of a Nurse Liaison Position, 2) implementation of an Electronic Tracking System with documentation from direct caregivers throughout all stages of care, 3) guided family visitation, 4) increased signage, 5) written materials for families and 6) staff education.  In 2013, five years since implementation, the original survey of staff attitudes toward expanded visitation was replicated.

 Methods: This project is a cross-sectional study employing mixed methods to analyze the beliefs of surgical staff regarding expanded family visitation before and after implementation of an enhanced PACU visitation policy. A survey, including scaled and qualitative items, was administered to a sample of multidisciplinary personnel involved in the care of the post-anesthesia patient. Differences between the 2009 and 2013 groups on scaled responses were assessed using the Mann-Whitney –U statistic due to unequal group size and non-normal distributions of variables. Content analysis including conceptual and relational coding was performed on the qualitative items in the survey.

 Results. Twenty-five individuals responded to the survey in 2009 and 56 responded in 2013. Categories of personnel included physicians (anesthesia only), registered nurses, and Other (volunteers, technicians, clerks). The response rate in 2009 was about 40% and the response rate in 2013 was about 90% based on estimates of personnel available (60-65) to complete surveys in the study periods. In 2009 71% of the respondents were registered nurses, while that proportion dropped to 48% in 2013. The proportion of physicians who responded to the survey remained about the same from the first survey to the second, but “other” respondents, which included unlicensed personnel such as patient care technicians, increased. In both years respondents tended to agree to the same extent that emotional care of families was a part of their job and that appropriate emotional care was being provided to family members in PACU.  

 After four years of expanded visitation, the 2013 cohort reported feeling significantly more comfortable providing emotional support to families in the PACU. There was also a significant difference in the belief that family members should have the option to visit in the PACU. Internal consistency reliability of the set of three identical scaled items was good in both the 2009 and 2013 study periods (alpha = 0.94 and 0.81 respectively).

 In 2009, 72% of respondents reported that their jobs were hampered by family presence. Four years later only 37% believed their jobs were hampered by family presence. This represents a significant difference between cohorts (X² = 8.5; p = 0.004). Furthermore, the 2009 cohort showed no relationship between perception that the job of caring for the patient was hampered by family presence and the desire to be able to visit one’s own family members in PACU. In contrast, 2013 respondents who reported their work was not hampered by family presence were significantly more likely than the 2009 cohort to want to be able to visit their own family members in PACU (X² = 9.03; p = 0.003). There was no significant difference between RNs and other workers in regard to perception of jobs being hampered by family in the PACU.

 Qualitative data supported the change trends noted in the scaled survey items and also highlighted issues that had not changed. In 2009 96% of respondents provided comments about what they perceived as barriers to family visits in PACU; in 2013 64% of respondents provided text about perceived barriers. From 2009 to 2013 concerns about lack of space dominated the list of perceived barriers to family visits in the PACU and concerns about lack of patient privacy followed closely. Other factors respondents identified as barriers to family visits in the PACU included interference by family members with patient care, staff failure to enforce visitation rules, staff resistance to visitation, lack of pre-operative education for family members regarding visitation policies, noise, and risk for infection.

 Discussion. The fact that response rates increased dramatically from the first survey to the second may indicate greater staff engagement and/or interest in the PACU visitation process over time. Increased willingness to participate in research surveys may also be related to the changing culture in the institution, which was Magnet designated for the third time recently. As a result of increased sensitivity to Magnet values, classes and events emphasizing the importance of research and the role of evidence in professional practice have occurred on a regular basis at the hospital.

 Persistent exposure to family members visiting patients in the PACU is associated with increasing staff commitment to family-centered care and greater comfort of staff in the provision of emotional care to families; however it is simultaneously a substantial stressor for staff. Even in environments in which staff are highly committed to providing emotional care to family members, barriers, such as lack of space, noise, privacy concerns, and failure of staff to consistently apply visiting rules affects the experience of staff, and may well affect the patient and family experience, as well. In post-anesthesia units where family visiting is permitted, staff stress may be prevented and family visitation sustained by excellent pre-operative education of family members regarding visitation, frequent reminders to staff about the importance of compliance with visitation guidelines, affordable environmental interventions, and training to empower nurses and other staff members to be compassionately assertive to enforce requirements of the family visit situation.