Maintaining person-centred care in hospitals during restrictions on family presence
Intended for healthcare professionals
Evidence and practice    

Maintaining person-centred care in hospitals during restrictions on family presence

Mark Munsey Patient relations manager, Sharp Memorial Hospital, San Diego CA, US
Selena Juarez-Alvarado Clinical nurse, Sharp Memorial Hospital, San Diego CA, US
Pam Wells Chief nursing officer, Sharp Memorial Hospital, San Diego, CA, US
Verna Sitzer Director, Sharp Memorial Hospital, San Diego CA, US

Why you should read this article:
  • To recognise the importance of providing person-centred care to patients and their families

  • To learn about how one hospital maintained and developed person-centred care practices during the coronavirus disease 2019 (COVID-19) pandemic

  • To consider strategies you could use in your area of practice to support communication and collaboration between patients, families and the healthcare team

Providing person-centred care to hospitalised patients and their families can be challenging in the context of restrictions on visiting, such as those widely implemented in healthcare settings during the coronavirus disease 2019 (COVID-19) pandemic. In the US, several strategies have been deployed to work around the restrictions on family presence in hospitals, most of which focused on communication between the patient and family, and collaboration between the family and the healthcare team. Sharp Memorial Hospital, an acute care hospital in San Diego CA, US, was determined to maintain its person-centred care practices during the pandemic. A Family Resource Centre started operating in March 2020 with the aim of enabling hospitalised patients and their families to connect in a safe manner. This article describes this innovative approach to maintaining person-centred care in hospital during restrictions on family presence.

Nursing Management. doi: 10.7748/nm.2021.e2011

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

mark.munsey@sharp.com

Conflict of interest

None declared

Munsey M, Juarez-Alvarado S, Wells P et al (2021) Maintaining person-centred care in hospitals during restrictions on family presence. Nursing Management. doi: 10.7748/nm.2021.e2011

Published online: 30 November 2021

Meaningful relationships between patients, families and the healthcare team are central to person-centred care, also termed patient- and family-centred care (Institute for Patient- and Family-Centered Care (IPFCC) 2021, Planetree 2021a). Four essential components of person-centred care are dignity and respect, information sharing, participation, and collaboration (IPFCC 2021).

On 11 March 2020, the World Health Organization (2020) declared the outbreak of coronavirus disease 2019 (COVID-19) to be a pandemic. Subsequently, in the US and across the world, healthcare services implemented drastic measures to protect staff, patients and the public from the spread of infection, which included restricting visits to hospitalised patients. The safety imperatives implemented due to COVID-19 presented hospitals with unique challenges, one of which was how they would be able to continue to provide person-centred care in the context of restrictions on visits (Coulter and Richards 2020). In the US, several strategies have been deployed to work around the restrictions on family presence in hospitals, most of which focus on communication between the patient and family and collaboration between the family and healthcare team (Hart et al 2020, Rosenbluth et al 2020).

Sharp Memorial Hospital, an acute care hospital in San Diego CA, US, was determined to maintain its person-centred care practices and culture during the COVID-19 pandemic. Part of its response to the COVID-19 pandemic was to develop a Family Resource Centre to enable hospitalised patients and their families to connect in a safe manner while visits were restricted. This article describes this innovative approach, including how the centre was established, what services it offered and what effects these services had.

Establishing the centre

Setting

Sharp Memorial Hospital is a non-profit acute care hospital. It has 656 beds for adults, including 48 intensive care beds, and is a designated trauma centre for San Diego County. Sharp Memorial Hospital has achieved Magnet status, which recognises a commitment to nursing excellence (American Nurses Credentialing Center 2021), and gold-level certification awarded by the not-for-profit organisation Planetree International, which has developed a framework for healthcare organisations to evaluate their provision of person-centred care (Guastello and Jay 2019, Planetree 2021b). The hospital’s response to the COVID-19 pandemic included a command centre, with the role of incident commander being assumed on a rotational basis by one of the hospital’s directors.

Visiting policy

The hospital’s nursing leadership team defined a visiting policy for families, friends and informal carers, which differentiated between ‘visitor’ and ‘support person’. Visitors would be allowed to pay casual visits to certain patients, while support persons would be authorised to visit patients due to their role in providing essential care. Nursing managers on each unit determined who would be allowed to visit, whether the person would be considered a visitor or a support person, and the timing and duration of visits. Exceptions were made on a case-by-case basis.

As a general rule, one visitor was allowed for a non-COVID-19 patient hospitalised in the intensive care unit; one support person was allowed to visit a patient who needed assistance because of learning disabilities, physical disabilities or cognitive impairment; and two support persons were allowed to visit a patient at the end of life at the same time – the end of life being defined as the last 24 hours to 48 hours before expected death. Initially, the visitor or support person had to be the same individual throughout the hospital stay. However, to reduce carer fatigue, this was later changed to the visitor or support person having to be the same individual on any given day, so that parents could come on alternate days, for example.

Leadership and best practice guidance

The hospital’s executive team tasked the patient relations manager (MM) with addressing the needs of patients and families arising from the restrictions on visits. With a small work group, the manager developed a temporary Family Resource Centre that he agreed to oversee. The Family Resource Centre was established based on best practice guidance on person-centred care (Johnson and Abraham 2012, Hart et al 2020, IPFCC 2020, Planetree 2020), much of which was specific to the COVID-19 pandemic. The IPFCC (2020) compiled responses to frequently asked questions about how healthcare organisations could continue to provide person-centred care during the pandemic, including communicating changes in family presence policies, maintaining connections between patients and families, and supporting patients, families and staff.

Box 1 summarises some of the recommendations for preserving family presence during the COVID-19 pandemic.

Box 1.

Recommendations for preserving family presence during the coronavirus disease 2019 (COVID-19) pandemic

  • Continually assess the need for restrictions on family presence

  • Minimise the risk of exposure to COVID-19

  • Communicate restrictions on family presence proactively and compassionately

  • Establish compassionate and explicit exceptions to restrictions

  • Offer families ways to meaningfully connect with their relative if they cannot be present physically

  • Provide information and education to support decision-making

  • Enlist families as care partners for quality and safety

  • Enhance discharge education and post-discharge follow-up care

(Adapted from Planetree 2020)

Physical space and equipment

The Family Resource Centre opened in March 2020 as a tent structure that was erected outside the hospital near its main entrance. The tent was progressively enlarged to 37m2, equipped with electric power sources and expanded to enable optimal physical distancing. Stanchion posts and tables were used to separate functions for families and staff. An area towards the rear of the tent was dedicated to sensitive conversations between staff and families, discharge education and family support.

Essential equipment included folding tables, chairs, disinfectant wipes, hand sanitiser, disposable face masks, tissues and bottled water. Walkie-talkies were borrowed from the hospital’s safety department to assist staff in coordinating patient collections and drop-offs. Internet access through the hospital’s Wi-Fi was improved by a dedicated router.

Tablet computers donated by the hospital’s interventional cardiology department were used for communication between hospitalised patients and their families. Communication apps were downloaded onto the tablet computers used in the various hospital units. Laptop computers were reallocated to the Family Resource Centre from other areas of the hospital and used for tracking patients’ locations and communicating with nurses on the units through the electronic health record system. Later, dedicated laptop computers were purchased.

Staffing

The Family Resource Centre was open from 7am to 7.30pm seven days per week and run by a team of five or six members of staff. A core staff group of 12-15 people covered the shifts. To ensure continuity of care, the centre was consistently staffed by the same people. Initially, staff were assigned to the Family Resource Centre by the command centre from a pool of staff redeployed from other areas of Sharp Memorial Hospital and from other hospitals belonging to the same healthcare provider. Eventually, staff working in services that had been paused due to the pandemic – including nurses, physical therapists, occupational therapists, exercise physiologists and nursing assistants – were invited to volunteer to work at the Family Resource Centre.

To provide examples of desired staff attributes, staff at the centre devised and adopted the ‘four Fs’: friendly, flexible, firm and the ‘face’ of the hospital (that is, the ability to play an ‘ambassador’ role). These desired attributes were reviewed with staff before their redeployment to the centre. Ensuring staff had adequate communication skills – including compassionate language and de-escalation skills – was essential, and these skills were continuously assessed by the centre’s manager through observation and real-time feedback. The team’s work culture and dynamism prompted numerous hospital staff to offer to volunteer at the centre.

Work processes

Staff at the Family Resource Centre kept a log of activities. Analysing activity trends helped to identify the types of services provided or required and to plan staffing needs. Regular staff members assisted in defining role expectations and standard work processes, including an orientation checklist and opening and closing procedures. This enabled new staff to receive an orientation to the centre and its work.

Staff communicated with the command centre throughout the day to determine operational priorities. To coordinate work and promote a process of continuous improvement, there were two daily staff briefings – one in the morning and one in the afternoon – in which staff discussed what was effective, what needed to be improved and how to address any issues that had arisen. Stressful, complex and/or traumatic situations were debriefed in real time and staff were supported by a spiritual care adviser, a resident chaplain and a trauma social worker.

Key points

  • Safety imperatives implemented due to coronavirus disease 2019 (COVID-19) presented hospitals with unique challenges, one of which was how they could continue to provide person-centred care in the context of restrictions on visits

  • In one US hospital, a Family Resource Centre was established to address the needs of patients and families arising from the restrictions on visits

  • The main services offered by the Family Resource Centre were facilitating communication, facilitating family presence, managing patient belongings, managing community donations and coordinating discharge

  • Survey results indicate that the hospital succeeded in maintaining its person-centred care practices during the COVID-19 pandemic

Services offered by the centre

The main services offered by the Family Resource Centre were:

  • Facilitating communication.

  • Facilitating family presence.

  • Managing patient belongings.

  • Managing community donations.

  • Coordinating discharge.

Facilitating communication

Staff facilitated communication between families and the healthcare team, as well as between families and patients. They arranged for doctors, nurses, social workers, case managers and spiritual care workers to meet family members at the centre, where they would update them on their relative’s condition, discuss the goals of care, and provide support and resources. Staff arranged remote communication between hospitalised patients and their families. They gave families cards that stated the direct phone number to their relative’s room and assigned nurse. They instructed and assisted family members to use electronic devices and virtual platforms, and arranged a convenient time to assist hospitalised patients to connect remotely with their families.

Staff determined the preferences of patients and families regarding communication modalities and, where possible, matched them with what the centre had available. To ensure virtual platforms were used appropriately, staff received guidance on recommended telehealth practices, including how to protect patient privacy and confidentiality (Centers for Disease Control and Prevention 2020).

Facilitating family presence

Staff at the Family Resource Centre facilitated family presence at the bedside by checking that people coming to visit patients were on the approved list of visitors and support persons, screening them for COVID-19 symptoms and escorting them to the unit.

In the case of patients at the end of life, nursing managers on the units notified staff at the Family Resource Centre about who was approved as a support person and could be present at the patient’s bedside. Staff communicated with spiritual care workers and social workers throughout the day to update them on patients at the end of life and support persons arriving at the hospital, coordinating the presence of family with the availability of spiritual care and/or social work support as needed. Staff ensured families’ cultural and religious practices around death and dying were respected and facilitated. When visitors who were not on the list came to see a patient at the end of life, staff accommodated them at the Family Resource Centre and used virtual platforms to enable them to communicate with the patient.

Managing patient belongings

Family members were directed to the Family Resource Centre when they wanted to bring something for their relative. Patient belongings were logged and delivered to the various units every 30 minutes. Patient belongings brought by families and delivered by staff to the units included durable medical equipment such as oxygen tanks, oxygen concentrators, walkers and wheelchairs, as well as flowers, food from home and greetings cards.

Managing community donations

At the start of the pandemic, community organisations and businesses contacted the hospital – or spontaneously came to the premises – to donate various items such as personal protective equipment, hand sanitiser, hospital scrubs, meals and food. Family Resource Centre staff worked with the command centre to distribute the donations equitably across the hospital. Over time, distributing donations became overwhelming for the Family Resource Centre team, partly because donations had increased and partly because staff were increasingly involved in the centre’s services, which took precedence. The command centre reassigned the distribution of donations to the manager of volunteer services. Donations continued to be received at the Family Resource Centre and staff only needed to notify the manager of volunteer services.

Coordinating discharge

Staff at the Family Resource Centre arranged for members of the healthcare team to meet families at the centre, where they would give them information and instructions about discharge. For patients and families who did not have their own transport, staff arranged ride-sharing or provided taxi vouchers or bus passes. When a patient was ready to leave the hospital, staff coordinated their collection with unit nurses and family members. Families waited in a designated area of the car park, where staff came to greet them and let them know how long they would have to wait. Once the patient was physically present outside the centre, staff would call the family on their mobile phone to let them know they could come to collect their relative.

Effects on patients, families and staff

The services offered by the Family Resource Centre had positive effects on patients, families and staff. Table 1 provides examples of the centre’s services and their effects.

Table 1.

Examples of the Family Resource Centre’s services and their effects

Service Examples of its effects
Facilitating communication
  • A patient who had undergone a heart transplant and was on a complicated post-operative course of treatment required care planning. Family Resource centre staff facilitated a meeting between the patient’s wife and adult children and the healthcare team. The doctor showed medical imaging results to the family on one of the centre’s laptop computers. The meeting enabled participants to discuss and agree patient care goals

Facilitating family presence
  • A 17-year-old patient was hospitalised for a traumatic brain injury. Both parents were approved as support persons and staff at the Family Resource Centre facilitated their daily presence at their child’s bedside. Nurses observed that the patient’s intracranial pressure decreased when the parents were present. The patient made a significant recovery

  • A Buddhist patient with life-limiting illness was approaching the end of life. The family asked for a ‘chant box’ to be placed in the patient’s room and requested that their body not be moved for 6-8 hours after death. Family Resource Centre staff ensured the family’s wishes were fulfilled and liaised with the spiritual care team and the command centre. The family expressed their appreciation for the culturally sensitive care provided

Managing patient belongings
  • A patient with coronavirus disease 2019 (COVID-19) was hospitalised in the intensive care unit for more than eight weeks. Family Resource Centre staff delivered several belongings to the patient, including family pictures and a tape recording of the patient’s daughter singing a favourite song. The patient later recalled hearing the song while sedated and being mechanically ventilated

Managing community donations
  • Various members of the city’s sports teams donated food for hospital staff. Family Resource Centre staff distributed the food equitably to all units. They also organised an appreciation event where the sports teams showed their support by lining the hospital’s U-shaped driveway and applauding staff

Coordinating discharge
  • A patient with cancer who was homeless and residing in a neighbouring city needed assistance with transport on discharge. A hospital staff member purchased a bus ticket to the neighbouring city and Family Resource Centre staff arranged a ride-share for the patient so they could get to the bus station

Enhancing the centre’s operation

In August 2020 the continuous improvement process at the Family Resource Centre resulted in the creation of a dedicated discharge area operating from 9am to 7.30pm. An old entrance to the hospital was repurposed and renamed the ‘departure plaza’. Rather than having to manage each patient discharge separately, staff could now take several patients to the waiting area and coordinate their collection. This reduced the overall time spent by staff waiting for families to collect their relative.

After six months of operation, the Family Resource Centre was recognised by the hospital executive team as an essential structure for providing person-centred care during and beyond the COVID-19 pandemic. In October 2020 the centre became a permanent and official service at Sharp Memorial Hospital and was renamed the Family Resource Service. Although it was anticipated that restrictions on family presence would eventually be lifted, it was felt that the centre could continue to assist in streamlining operations and guiding visitors. As the visiting policy was gradually relaxed, staff were screening increasing numbers of visitors and support persons for COVID-19 symptoms and checking test results and vaccination status.

With support from the hospital’s engineering team, a former waiting area near the main entrance to the hospital was transformed to accommodate the permanent centre. A budget and cost centre were established, and four full-time equivalent roles were allocated to the centre:

  • One lead nurse responsible for daily operations and scheduling.

  • One nurse responsible for facilitating discharges – often referred to as the ‘turbo discharge nurse’.

  • Two nursing assistants responsible for staffing the departure plaza, screening visitors and delivering patient belongings.

Some staff already working at the centre became permanent employees. From December 2020, nurses were assigned the task of facilitating discharges each day from 8am to 6.30pm. Their responsibilities included visiting the units to identify patients ready for discharge, obtaining discharge orders from doctors, providing discharge instructions to families and collaborating with case managers. The nurses identified and addressed barriers to timely discharges, including potential delays in obtaining medicine prescriptions, medical equipment for the patient’s home, physiotherapy discharge evaluations and transport. Their work contributed to expanding the hospital’s discharge capacity by increasing the number of discharges occurring early in the day. The percentage of patient discharges occurring before 11am increased from around 3% in August 2020 to just under 6% in January 2021.

Feedback from patients and families

The Family Resource Centre received abundant informal feedback from patients and families in the form of cards and letters expressing appreciation for the work undertaken by the team. At Sharp Memorial Hospital, patients and families can also show their appreciation through the Guardian Angel programme, whereby they donate money to the hospital in recognition of a member of staff who has made a significant contribution to their care. Since the launch of the centre, five of its staff have received Guardian Angel recognition.

At Sharp Memorial Hospital, formal feedback from patients and families is obtained from:

  • A comprehensive patient and family survey specific to the hospital.

  • The Healthcare Consumer Assessment of Healthcare Providers and Systems survey, which is a national, standardised and publicly reported survey of patients’ perceptions of hospital care in the US. The first public reporting of this survey’s results occurred in March 2008 (Centers for Medicare & Medicaid Services 2021).

When comparing the fourth quarter of 2019 (n=1,090 returned surveys) and the fourth quarter of 2020 (n=1,010 returned surveys), these two surveys demonstrated consistently high satisfaction scores regarding the level of person-centred care and the discharge process. In the hospital-specific survey, respondents are asked to rate survey items on a Likert scale from 1 (very poor) to 5 (very good). Figure 1 shows the mean scores for five items in the hospital-specific survey reflecting the person-centredness of care. The mean scores for the five items were at similarly high levels in the two periods. Figure 2 shows similar results for two Healthcare Consumer Assessment of Healthcare Providers and Systems survey items relating to the discharge process, for which around 90% of ‘always’ responses were consistently obtained in the two periods.

Figure 1.

Mean scores for five items in the hospital-specific survey reflecting the person-centredness of care (where a high score represented ‘very good’ and a low score ‘very poor’)*

nm.2021.e2011_0001.jpg
Figure 2.

‘Always’ answers to two Healthcare Consumer Assessment of Healthcare Providers and Systems survey items relating to the discharge process

nm.2021.e2011_0002.jpg

These survey results indicate that the hospital succeeded in maintaining its person-centred care practices during part of the COVID-19 pandemic. Considering how much the restrictions on family visits would have negatively affected the person-centredness of care, it seems likely that the Family Resource Centre had a significant role in achieving these results.

Achievements, challenges and future plans

The main aim of the Family Resource Centre was to enable hospitalised patients and their families to connect in a safe manner during the COVID-19 pandemic. Various services were offered, according to need, to support and promote connections between patients and families at a time when most hospitals were restricting visits (Coulter and Richards 2020, Virani et al 2020).

The centre facilitated the presence of family members at the bedside in specific cases, such as for patients with disabilities or cognitive impairment and for patients at the end of life. The Family Resource Centre team ensured families’ wishes regarding cultural and religious practices around death and dying were fulfilled, contributing to providing a humane environment, important connections and spiritual support at the end of life (Cook et al 2021). In addition, discharge coordination, which had been a long-standing challenge for the hospital, was optimised.

Nurses and doctors recognise that optimal communication with hospitalised patients and their families is crucial for the provision of person-centred care (Rosenbluth et al 2020). The Family Resource Centre served as the central point of contact for families. Consistent, clear and compassionate communication was essential. In the context of an evolving pandemic that required several iterations of the visiting policy (Planetree 2020, Hart and Taylor 2021), staff experienced various challenges and had to demonstrate adaptability and flexibility, particularly in sensitive and emotional cases. Ensuring staff had the required communication skills – including the use of compassionate language and de-escalation techniques (Planetree 2020, The Joint Commission 2020, Cook et al 2021) – was crucial, as was assessing staff’s need for emotional and psychological support and providing this where necessary (Robert et al 2020, Cook et al 2021).

With hindsight, the team could have improved how it informed stakeholders of its services so as to facilitate partnership working and identify additional unmet needs. The team is exploring the idea of providing personalised discharge education to patients and their support persons during the hospital stay. Future plans include offering hospital staff experiential exposure to person-centred care at the Family Resource Service, and detailing the service on the hospital’s internal and external websites alongside the visiting policy. In the future, the team needs to consider using shared decision-making tools (National Hospice and Palliative Care Organization 2020), contributing to advance care planning (Paladino et al 2021) and offering patients and their support persons follow-up calls by a mental health professional to assist with managing any stress they experience after discharge (Robert et al 2020).

Conclusion

At the start of the COVID-19 pandemic, Sharp Memorial Hospital established a Family Resource Centre to enable hospitalised patients and their families to connect in a safe manner, thereby demonstrating its commitment to person-centred care. The team at the centre proved adaptable and flexible in responding to patient and family needs, and was instrumental in maintaining and developing person-centred care practices.

The Family Resource Centre appears to be a useful and innovative approach that hospitals can deploy to maintain person-centred care in the context of restrictions on family presence. The centre has been recognised as an essential structure for providing person-centred care during and beyond the COVID-19 pandemic, and it has subsequently become a permanent service that acts as the hospital’s main hub for person-centred care.

Further resources

Planetree International – Resources on Person-Centered Care during COVID-19

planetree.org/person-centered-pandemic-resources

Institute for Patient- and Family-Centered Care – Patient- and Family-Centered Care and COVID-19

www.ipfcc.org/bestpractices/covid-19/index.html

World Health Organization – The COVID-19 Risk Communication Package for Healthcare Facilities

www.who.int/docs/default-source/coronaviruse/risk-communication-for-healthcare-facilities.pdf

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