Family Involvement in the Hospital - From a Nursing Perspective

By Elna Osso, RN MPH | 15 Oct, 2012

Family Involvement in the Hospital - From a Nursing Perspective
By Elna Osso, RN, MPH

Achieving a balance between creating a safe therapeutic environment for hospitalized patients and allowing family involvement for support is a challenge, here in the US and in developing countries. As nurses we may serve as facilitators and advocates, both at the bedside and in developing hospital policies.

In contrast to what I have seen as a staff nurse in US hospitals, patients are often accompanied by family when they come to hospitals in rural parts of developing countries. Siblings, parents, spouses, children, or other companions are at the bedside taking turns throughout the hospitalization. They sleep at the bedside, on the floor next to the bed or by the ward’s door or camp nearby in the open air on hospital grounds. They sit vigil, bathe their loved ones, run to the pharmacy to find medicine if they can afford it, make meals and feed them to the patient. That meal may be that same chicken that ran loose on the grounds of the ward a few hours before. It is what people have learned to do when they know hospitals struggle to provide care and seldom provide the services we assume are basic to hospital care.

Involvement from family in that setting is often ignored or it is taken as a necessary nuisance; people can help as long as they don’t get in the way, don’t ask questions and remain in a submissive role. I have seen families asked to leave a room in the way cattle is chased away by hospital staff.

The challenge is then to show we value such involvement and to maintain the support of the family, while creating guidelines that maintain privacy for other patients and effective infection control measures. As nurses, we have the potential to influence this attitude towards families/companions by our own actions, taking advantage of the fact that we spend most of our time at the bedside. Involving a family member while we provide care to the patient while explaining why what we are doing will benefit the patient could be an effective way. At the policy level, we can provide documentation and anecdotal evidence of the benefits of companions at the bedside (such as fewer falls, less anxiety, extra help lifting, to name a few), and we can model the behavior we would like to see from families and other health care professionals.

It should be noted that, in our emphasis to create a controlled, clean, private space at US hospitals, we have created unwelcome places for companions. Busy work schedules and family responsibilities don’t always coincide with visiting hours for example. The amount of time patients spend alone in our hospitals is tremendous; rare are the cases of a patient with extensive involvement from the family.

I don’t see family involvement as a negative for patient care. It is often a huge burden to the families. They put their lives on hold to care for their sick. Children are left unattended at home, fields not worked, household items sold for cash. While we strive to create hospitals where high quality services are provided and the burden on the family is significantly decreased, family contributions could be recognized in the hospital and channeled in the best way.
 
-Have others encountered similar situations?
-How can nurses influence change by taking advantage of the fact that we work in parts of the world where improvement in hospital services is still in process?
-How do we adapt to local perceptions of privacy and support?

Replies

 

Maggie Sullivan Moderator Replied at 4:06 PM, 15 Oct 2012

Thank you so much for posting this compelling case situation, Elna. We are lucky to have your input and to be able to share in your experiences. I invite members to respond to Elna's case, the questions or to post any comments. I, myself, have also been involved in several similar situations and would love to know what others think. For those of you interested, Elna's bio follows below:

Elna Osso, RN, MPH is a Coordinator for a Tuberculosis Clinical Study at the Department of Global Health and Social Medicine Harvard Medical School. Before joining HMS, Ms Osso was the Socios En Salud/Partners In Health (SES/PIH) International Project Coordinator.

Ms Osso received her Nursing Diploma from New England Deaconess Hospital School of Nursing in Boston, a Bachelor of Science in Nursing degree from the University of Southern Maine, and a Masters of Public Health with emphasis in International Health from Boston University.

Ms Osso worked in Maine for 19 years as a Clinical Staff Nurse at Maine Medical Center and as a Clinical Nursing Instructor at Southern Maine Community College. In addition to her ample experience working with the underserved population in Portland, Maine, Ms Osso volunteered with SES/PIH on many occasions and participated in medical missions to a number of countries. Born and raised in Peru, she volunteered with Deseaperu, an NGO based in the high Andes region of Peru, where she worked facilitating access to health care with fellow nurses and community health workers. She has served as a member of the Board of Directors for a Maine-based medical organization that works in Haiti and is a member of the Global Nursing Caucus.

Amungwa Athanasius Nche Replied at 2:29 AM, 16 Oct 2012

Many thanks Elna for starting this discussion.

I worked as a Nurse and Nurse Trainer in the Ministry of Health in Cameroon
for 30 years and I have had the same expereince you have painted here.

The problem is whether the hospitals do appreciate this positively.
Sometimes there are harsh visiting hours limit that do not permit the
maximization of the phenomenon. I have also noticed that for poverty
reasons, some people do neglect their loved ones in the hospital for fear
of being requested to buy drugs if they do avisit the sick in hospital.

One thing I have also observed is that many people, friends and sometimes
relatives do not really have the principle to visit their sick ones to give
them gifts including money to tide them over the difficulty to finance
health care in developing countires like Cameroon but these same people
would go the sick persons funeral in case that person died with lots of
food and drinks and gunpowder to fire at the death delebration. There is a
culture of funerals that commands more value for these people than visiting
the sick in hospital. In my opinion, the society could spend a hundredfold
the budget that would be spent on a hospitalized family member on funeral
expenses. This has been noted as a serious problem in my region and the
traditional leaders are regulating against long funerals and expenses but
such habbits had been so internalized by the people that a lot of change
behaviour campaign needs to be planned an implemented with this in mind.

However there are referral hospitals in Cameroon that do not allow this to
happen so the atients have to sleep alone without this family support and
warmth.

I don't remember reading any research from my country that pits this family
roles in the two categories of health units against each other but I think
it something to be promoted, though with caution.

The bottom line would be to recognize the role that these friends and
relatives play and renforce their capaities to do so.

Regards

On 15 October 2012 23:07, GHDonline (Maggie Sullivan) <
> wrote:

> Maggie Sullivan replied to the discussion "Family Involvement in the
> Hospital - From a Nursing Perspective" in the Global Health Nursing &
> Midwifery community.
>
> Reply contents:
> "Thank you so much for posting this compelling case situation, Elna. We
> are lucky to have your input and to be able to share in your experiences. I
> invite members to respond to Elna's case, the questions or to post any
> comments. I, myself, have also been involved in several similar situations
> and would love to know what others think. For those of you interested,
> Elna's bio follows below:
>
> Elna Osso, RN, MPH is a Coordinator for a Tuberculosis Clinical Study at
> the Department of Global Health and Social Medicine Harvard Medical School.
> Before joining HMS, Ms Osso was the Socios En Salud/Partners In Health
> (SES/PIH) International Project Coordinator.
>
> Ms Osso received her Nursing Diploma from New England Deaconess Hospital
> School of Nursing in Boston, a Bachelor of Science in Nursing degree from
> the University of Southern Maine, and a Masters of Public Health with
> emphasis in International Health from Boston University.
>
> Ms Osso worked in Maine for 19 years as a Clinical Staff Nurse at Maine
> Medical Center and as a Clinical Nursing Instructor at Southern Maine
> Community College. In addition to her ample experience working with the
> underserved population in Portland, Maine, Ms Osso volunteered with SES/PIH
> on many occasions and participated in medical missions to a number of
> countries. Born and raised in Peru, she volunteered with Deseaperu, an NGO
> based in the high Andes region of Peru, where she worked facilitating
> access to health care with fellow nurses and community health workers. She
> has served as a member of the Board of Directors for a Maine-based medical
> organization that works in Haiti and is a member of the Global Nursing
> Caucus."
>
> --
> View this post online:
> <
> http://www.ghdonline.org/nursing/discussion/family-involvement-in-the-hospita...
> >
>
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--
*Amungwa Athanasius Nche*
*Health and Development Certified Training Professional*
*P.O. Box 2157*
*Alakuma, Road-Mankon*
*Bamenda*
*North West Region *
*Cameroon*
**

"*Always Remember to take your Vitamins: Take your Vitamin A for ACTION,
Vitamin B for Belief, Vitamin C for Confidence, Vitamin D for Discipline,
Vitamin E for Enthusiasm!!" Pablo*





**

Mary Steinke Replied at 10:30 AM, 16 Oct 2012

Thank you, Elna, for this interesting discussion. I have seen similar
occurrences on my medical trips to Nicaragua. We visited many public
hospitals in Nicaragua, and each patient seemed to have at least one or two
family members, with the exception in the ICU where there were stricter
visiting hours. There were also people milling about outside. Ideally, this
would be a time for public health education, maybe in short intervals, as
well as recruitment of community health workers. Some family members might
welcome the diversion, and give them some empowerment to help their loved
ones when they take them home. I am sure some are watching the procedures
that are being done, so why not take the time to educate? Perhaps hospital
administrators would appreciate the family more.
Mary

Barbara Waldorf Moderator Emeritus Replied at 10:58 AM, 16 Oct 2012

I really appreciate bringing up this topic and your description of your
experience Elna. I have had similar experiences with family involvement in
different settings. In India, in a rural area where families moved into the
hospital and provide much of what we consider nursing care. And in the US,
where there is a very different focus, as you described.

Currently, I work at a residential diagnostic psychiatric unit where
families have been quite welcome. The nursing staff is involved in an
ongoing discussion about how to set boundaries; to give other patients
privacy and be able to respond to a fluctuating acuity level on the unit.
There is a recognition that family members have key role in the ongoing
care of the patient and that their education is an extremely important
aspect of patient care.

I think we have a lot to learn from how various cultures see these
boundaries. And look forward to hearing from others about their
experiences.

Regards,

Barbara
--
*Barbara Waldorf BSN, MPH

Elna Osso, RN MPH Replied at 11:35 PM, 16 Oct 2012

Thank you Amungwa for sending your comments and for sharing your ample experience working for the MOH in Cameroon.

You bring up very important points; the hospital’s inherent perception of family and visitors, the expectations inbeded in the local culture and, of course, economic pressures.

Visiting the sick, seems to be a common human duty, however it takes such different forms in different cultures. I believe that as nurses we can continue to influence how hospitals perceive families, work within the local cultural context and minimize economic pressures. The complexity of the issue demand we attend to it at the bedside, through research and advocacy at the policy level .
Regards, Elna

Elna Osso, RN MPH Replied at 12:11 AM, 17 Oct 2012

Mary, thank you for participating in the discussion and telling us about your experience in Nicaragua.

What you mention is quite similar to what I have encountered , always someone at the bedside or in the corridors., even watching procedures. I agree with you, as nurses we can take advantage of this “captive audience” to educate, empower and even recruit future community health workers.

Nurses and family/visitors share a common cause; the wellbeing of the patient and our actions towards them and the patient can be very influencial towards the wellbeing of the community.
Best regards

Elna Osso, RN MPH Replied at 12:39 AM, 17 Oct 2012

Barbara, thank you for your thoughful comments.

Your work as psychiatric nurse illustrates how important is our work to facilitate family participation Inherent in our practice is evaluating and determining how we can provide the maximun benefit to the patient under the current circunmstances., but in your field particularly, finding a balance between providing the patient with human connection, establishing boundaries, and allowing time for solitud can be delicate.

It is encouraging to learn that places such as where you work are engaged in educating family members to create the best situation for the patient and that this is the result of an institutional recognition of the importance of the participation and education of family memebers.

I agree with you, we benefit from learning how other cultures care for their sick.

Warm regards. Elna

Sheila Davis Moderator Emeritus Replied at 3:00 PM, 17 Oct 2012

Great topic and overview Elna. I agree that in our quest for "control/infection control" it is often difficult in our US hospitals to be flexible with families. In many resource limited settings ,nurse staffing is often done based on the fact that families do most of the physical care. Although this can be a good thing in terms of engaging the family ,it also can lead to some disengagement of the nursing staff who are unable to do skin assessments and spend hands on time with patients. It is a challenging balance.

Tess Panizales, DNP, MSN, RN Replied at 3:52 PM, 17 Oct 2012

One of the training I have received in Nursing School and been ingrained in
me is the importance of family support in the healing process and shared
health care delivery. I totally believe in this holistic concept in care
management.

Family/ Significant Others - presence is integral in the psychological
needs of a patient. The connectedness and support provided by a loved one
is a healing environment that is important. Again we have to factor in
cultural practices and patients choice/consent.

Shared health care delivery - the importance of family/patient education at
the onset, during and prior to discharge is a valuable tool that can
alleviate anxiety, enhance understanding of the disease process and care in
progress. These provides empowerment to both parties and allows for a
better decision when it comes to choices/options in care. Most often when
family members/patient are confronted with intense overload of medical
information - we tend to strip them with control of their 'being human'.

It is important that we weed through appropriate cultural approaches when
we address issues related to family/significant others presence and/or
assistance in health care delivery. We also need to consider safety
and quality in its implementation. Hope that this continues to be part of
our nursing training. (Tess)

Elna Osso, RN MPH Replied at 4:19 PM, 17 Oct 2012

Thank you Sheila for adding your comments. It is a challenging balance indeed, and depending on the setting, it can be a very different picture.
Here in the US with control/infection control and privacy regulations in one hand and the wish to make our patients feel less isolated while sick in the other; both important on their own merit.
In resource-limited areas, taking for granted the support from family evolves to influence expectations of the nurses and from nurses, with detrimental disengagement from the nurses and resentment from the family.
As you point out, when we trade time away from providing hands-on care we miss opportunities for assessments (skin, mood, mobility, etc.), education and the time that requires to develop trusting relationships as well. Ideally, we can aim at encouraging family involvement (particularly where is not likely to come from anywhere else) but also openly recognizing that contribution . At the same time we can support capacity building within country that would result in higher standards of bedside nursing care.
Warm regards, Elna

Elna Osso, RN MPH Replied at 12:48 AM, 19 Oct 2012

Thank you for your comments Tess. You have explained nicely how the values we received in our training shape our practice. I also was taught the importance of family/loved ones involvement to benefit patients healing, and hope that this continues to be part of nursing education.

Isolation and loneliness magnify when one is sick, facilitating family involvement, is a powerful nursing tool to foster healing. We seem to understand that readily when we refer to pediatric nursing care, pediatric hospitals are welcoming places to families. When it comes to adult care, other than the maternity ward, the standard seems to aim towards providing privacy, both for the patients and the practitioners. My observation has been that even in the case of adult care, in resource-limited areas family/loved ones presence is greater.

Cultural beliefs, economic pressures, political will, to name a few, all play a role in the degree of family involvement. It is so important nurses receive the training required to be able to best weight the forces at play in their work environment, here in the US and abroad, so that nurses can continue to find the right balance for family involvement. When too much, as Sheila mentioned earlier, the nurse may become disengaged and the family overwhelmed, when not enough, the patient may be isolated and may lack continuity of care at home . Thanks again for your comment.

Best regards, Elna

Susan Wood, PNP-BC, MPH, IBCLC Replied at 1:26 PM, 20 Oct 2012

Greetings: I am new to GHDonline and am delighted to be here! I have practiced & taught nursing internationally in a number of venues, most recently in Cambodia at the Angkor Children's Hospital in Siem Reap. Similar to other international clinical settings, the family plays an integral role in bedside care: from feeding to bathing to general patient support, while nurses perform the more technical aspects of care (blood drawing, wound care, med administration, etc.) On this most recent trip, I was struck with how nursing kept missing the opportunity to engage the family on a deeper level - what we in this country know as "Family Centered Care." At AHC, there was ample education by nurses for the families (mainly in the form of inpatient groups, led by nursing) , but no reciprocity where parents could share their observations/feedback/questions about their child with nursing or medical staff. This resulted not only in a degree of disengagement between staff and families but, importantly, in the family's ultimate compliance with the plan of care for their child. I became active in teaching the principles of Family Centered Care, as it might be applied in that particular setting. The nursing staff were energized and excited to hear how they could move their own practice to another level, and now there is a Family Centered Care initiative being implemented there. Naturally, there are cultural barriers galore, but the focus of maximizing care for the benefit of the child was what excited nurses to this approach. However, every setting is different and has its own unique set of challenges, as many of you have discussed above.

Elna Osso, RN MPH Replied at 11:35 PM, 22 Oct 2012

Susan, thank for posting your comments and welcome to the GHDonline community.

Your experience working in Cambodia tell us how family involvement in patient care can also be an opportunity for nurses to benefit from feedback and the knowledge the family brings about the patient. This has been true for me working with adults, particularly with patients suffering from chronic illness.

Congratulations for your efforts to support Family Centered Care at the Angkor Children’s Hospital. I am glad the staff ultimately was receptive to move their practice to another level.

A hospital like that must have brought many foreign practitioners to the area and through the years, earn the trust and recognition of the locals by embracing their traditions and by seeking to provide the best possible care. I understand that this is a hospital that also makes a priority building local capacity given the tragic past of Cambodia, when war decimated the majority of educated workers.

You showed you were able to overcome some barriers and find common ground – the desire to benefit the patient- and by paying attention to local customs and values you were able to influence nursing practice.

Many thanks, Elna

Bistra Zheleva Replied at 2:46 PM, 26 Oct 2012

This is a very interesting discussion and something that we have been working on for the last three years. At Children's HeartLink, we recently developed the Parent Education/Discharge Instructions. It is a packet of materials that pediatric cardiac programs can use to educate families and caregivers of children who have undergone open heart surgery on how to take care of them after hospital discharge. Every hospital we have introduced it at, it has been accepted with a lot of enthusiasm from both families and nurses. We are in the process of finalizing the materials and plan to make them available for pediatric cardiac programs around the world to use. The project grew out of the observation that there was not much family involvement in the care of the patients and as a desire to make nursing staff more involved in the discharge process.

Susan Wood, PNP-BC, MPH, IBCLC Replied at 9:35 PM, 27 Oct 2012

Bistra: That sounds wonderful! A great way to involve families around their child's care and so important. Once you have finalized those materials, it would be wonderful to share them. I'd love to see them! Susie

Bistra Zheleva Replied at 11:00 PM, 28 Oct 2012

Yes, absolutely will share them. The package includes booklets for literate families, booklets with illustrations and very little text for families with lower literacy, posters with the same images to be used in hospital wards, and an electronic nurse training module for nursing staff to get trained to use the materials.