A.

Develop a written proposal by doing the following:

1. Identify a problem or issue related to practice, policy, population, or education
that aligns with the organizational priorities you seek to solve.
The problem I hope to solve is limited visiting hours in the Intensive Care Unit.
a. Explain the problem or issue, including why it is applicable to the area of
practice you chose and the healthcare environment.

I am an ICU registered nurse at a local hospital in Tucson, AZ. On my unit there is

currently a policy of limited visiting hours. This limits the patient’s family’s and other visitors
the ability to participate in care. Often in the ICU setting, we are faced with making life
prolonging decisions. Too many times ICU staff end up making the patient’s decision in the lieu
of the family. This happens sometimes because we cannot reach designated family members.
Medical providers are put in the position to make life prolonging decisions instead of family
members can result in patient’s wishes not being honored. From my personal experience as an
ICU RN family at bedside may reassure patients, provides comfort, reduces anxiety and provides
good planning of patient care. When families are not permitted to visit, they feel as though they
are not participating in care, or well informed. At present, visiting is limited to 8-10am/pm, no
family members are to stay overnight in the patient’s room, and visiting is allowed during
extenuating circumstances, such as withdraw of care, or imminent death. On patient satisfaction
surveys, responses have been negative regarding the limited visiting hours. Patients and families
have stated they feel the unit is not accommodating.

2. Discuss your investigation of the problem or issue.

a. Include evidence to substantiate the problem or issue.

I have interviewed several of my patient’s families during my involvement with their

care. Two out of the three families I have interviewed stated they felt as though the visitation
policy was too restrictive. They went on to say they felt as though they were not involved in
decision making. Some recent studies have found that relaxed visitation polices can improve
patient outcomes (Chapman, D. K. 2016). In a study cited in the American Journal of Critical
Care, states that family members of patients in a unit with open visitation felt their needs were
met to a high standard vs previous studies of units with restrictive visitation (Jacob, M. 2016).
Our hospital has a sister hospital located across town. The sister hospital has a similar
ICU with an open visitation policy. I have had the opportunity to work on that unit. One or two-
family members or visitors can remain at bedside with few exceptions. Families of patients feel
they are participating in patient care and generally are more satisfied.
I reviewed our unit visitation policy to determine what parts of the policy may need to be
modified. The American Association of Critical-Care Nurses believes that family at bedside is
greatly beneficial to patient outcomes. I spoke with several ICU nurses in my unit. They had
legitimate concerns with an open visitation policy. Several concerns brought up include; families
hindering patient care, additional stress caused to patients, privacy concerns due to family
members being present during shift change.
3. Analyze the state of the situation using current data.
a. Analyze areas that might be contributing to the problem or issue.

Nurses. Some nurses have worked in my unit for over 20 + years. With
veteran nurses come old habits. It is widely known that nurses are stubborn
creatures. We develop habits and are set in our ways. This restrictive policy was
last updated over 10 years ago. Some nurses on my unit feel as though
unrestrictive family visits impede their ability to provide critical care. I have
witnessed this first hand. Overbearing family members overstimulating an
intubated patient, or a family member placing three blankets on a febrile patient
after numerous directions not too. I have seen it all. On the opposite end of the
spectrum, I have seen a confused, agitated, and frightened patient respond well to
having family at bedside providing frequent redirection.

4. Propose a solution or innovation for the problem or issue.

a. Justify your proposed solution or innovation based on the results of your
investigation and analysis.

After completing interviews with my fellow nurses, charge nurses, and unit
manager my recommendation is to allow open visitation for the ICU. All staff
responded positively to my proposal. Open visitation policy has shown to increase
patient, nurse, and family satisfaction by improving participation in care (Kozub,
E, 2017). To facilitate this change, I suggest involving staff in the desired policy
change. If staff are involved in the policy change, they may be less resistant to
change.

5. Recommend resources to implement your proposed solution or innovation.

a. Include a cost-benefit analysis of your proposed solution or innovation.

There is no direct increase in cost associated with open visiting hours. Extra costs
that may be incurred by the unit could be in the form of extra training for staff or
printed posters explaining the open visiting policy. Increased patient/family
satisfaction could produce higher reimbursement rates for the hospital. Unit policy
will require modification to change the limited visitation policy to an open visitation
policy. Staff will need to be notified of the change in the form of emails, in-service
education, and print outs of new policy. The unit manager, charge nurses, and staff
nurses will have the expectations of the new policy explained.

6. Include a time-line for implementation based on your proposal.

Project planning will begin January 2018. Surveys and interviews will be
conducted and wrapped up no later than February 28th. Results of interviews and
 surveys will be analyzed and reviewed no later than April 15th. The proposed policy
will be presented to facility administration in the form of a draft by May 1st. If
administration has any recommendations for revisions they will be completed by May
15th. Unit in-services will be planned and scheduled by June 1st. Unit staff will be able
to sign up for in-services over a two-week period. June 15th will be the official date of
open visitation in the ICU.
7. Identify key stakeholders and/or appropriate partners that are important for the
implementation of your solution or innovation.
a. Discuss why each key stakeholder and /or appropriate partner is
important for the implementation of the solution or innovation.

For obvious reasons it is imperative to include the staff nurses in the

implementation of the policy. These nurses are at the front line of the policy
change and will deal with it daily. They must be well versed in the policy to be
able to effectively enforce it. Charge nurses will need to be involved because they
will be dealing with any issues that arise from the policy change. For example,
family members that have difficulty leaving during shift change report. The unit
manager will need to be involved because this is her unit. She will ultimately have
the final say in whether the policy is appropriate for her unit. Risk management
and the CNO will need to be involved in writing the policy and determining any
legalities that need to be addressed prior to official implementation.

b. Summarize your engagement with the key stakeholders and/or

appropriate partners, including the input and feedback you received.

I spoke with charge nurses, staff nurses, and the unit manager, everyone was
very supportive of the purposed policy change. Nursing staff did bring up some
valid concerns. With the purposed change the following concerns were brought
up; overcrowding in the patient’s rooms, increased risk of infection, violation of
privacy, and increased stress to the patients. Nursing staff were reminded that they
ultimately had the final say in deciding when visitation was appropriate. The issue
of visitation during emergencies was also a concern. Our unit is small,
approximately 16 beds. It was suggested that if there was a code and family
members were visiting in other rooms, a staff member would be designated to
close the doors to those rooms. Also, due to the size of our unit and concern for
the privacy of other patients, family members would be asked to wait in the
waiting room during shift report.

c. Discuss how you intend to work with those key stakeholders and/or
appropriate partners in order to achieve success.
 Unit nurses, charge nurses, and the ICU manager are the primary stakeholders.
The ICU manager will be the most important stakeholder. Ultimately, she will
decide whether this policy is appropriate for her unit. I will present all research
and data I have collected and present it to her in a one-on-one meeting. After
winning her approval I will move to the rest of the stakeholders. The unit nurses
will likely be the staff most affected by the policy change. Their feedback and
support are necessary for success. Charge nurses, must be well versed in the
policy change as they will deal with any issues. I intend to meet with the unit
charge nurses and address any of their concerns. Any feedback provided by the
charge nurses will be taken into consideration when formulating the policy. The
CNO and risk management should be involvement in policy change as they
approve any policy change within the facility. Nursing staff are mandated to
attend meetings during the development of the new policy. This will provide a
time for staff to voice concerns and give suggestions. The unit manager will be
the designated leader of the unit meeting. After the unit manager has spoken to
unit staff, she will meet with the CNO and risk management. During that meeting
data, research, and experiences will be shared. The desired policy change will be
presented.

8. Discuss how your proposed solution or innovation could be implemented.

a. Discuss how the implementation could be evaluated for success.

To evaluate success, surveys will be administered upon discharge to

families/patients. Discharge surveys are already administered post discharge, so
the survey will be modified to address satisfaction of visitation. Experience with
the open visitation policy will be assessed on the survey. Families and patients
will be continually rounded on during the hospitalization to evaluate their
experience with the policy change. During monthly unit meetings staff will be
given the opportunity to share their experiences with the open visitation policy.

B. Explain how you fulfilled the following roles during your process of investigation
and proposal development:
1. Scientist
I was a scientist by evaluating data and research. I also conducted interviews and
collected my own data. I used this data to evaluate the problem and develop a
solution.
2. Detective
I conducted an investigation of the problem, determined the need for change, and
developed a policy change.
3. Manager of the healing environment
 I developed a policy change that will help contribute to better patient outcomes and
healing. This new policy of allowing open visitation will facilitate a better healing
environment for patients.

C. Submit the completed attached “Professional Verification Form” from the

organizational leader advising you in your leadership experience.

SEE ATTACHED FORM

References:

Chapman, D. K. (2016). SATISFACTION WITH ELIMINATION OF ALL VISITATION

RESTRICTIONS IN A MIXED-PROFILE INTENSIVE CARE UNIT. American Journal Of
Critical Care, 25(1), 46. doi:10.4037/ajcc2016789

American Association of Critical Care Nurses. (2016). AACN Practice Alert - Family Visitation
in the Adult Intensive Care Unit. Retrieved from http://www.aacn.org/wd/
practice/docs/practicealerts/family-visitation-in-the-adult-icu-pa-2015.pdf


Jacob, M. (2016). NEEDS OF PATIENTS' FAMILY MEMBERS IN AN INTENSIVE CARE

UNIT WITH CONTINUOUS VISITATION. American Journal Of Critical Care, 25(2), 118-
125.

Kozub, E., Scheler, S., Necoechea, G., & O'Byrne, N. (2017). Improving Nurse Satisfaction
With Open Visitation in an Adult Intensive Care Unit. Critical Care Nursing Quarterly, 40(2),
144-154. doi:10.1097/CNQ.0000000000000151