Evidence has shown that unrestricted presence and participation of a patient support person can improve the safety of care, enhance patient and family experience and satisfaction, reduce costs, improve the management and continuity of care, and improve safety for older patients with impaired cognitive function.1 At The National Institutes of Health (NIH) Clinical Center (CC), visitation practices were reviewed to develop rooming-in accommodation guidelines for patients and families. Rooming-in allows a designated family member, patient support person, or authorized representative to remain with the patient during the overnight hours.
The review of visitation practices at the NIH CC paralleled a decision to convert semiprivate rooms to private in support of requests for family members to room-in for short or extended stays. As a result, rooming-in guidelines for patients, families, and healthcare providers were developed to promote participation in a patient- and family-centered care (PFCC) model for visitation.
The PFCC core concepts of participation and collaboration were integral to defining guidelines. Healthcare providers acknowledged responsibility to families wanting to be near their loved ones and their sense of comfort by just being there during hospitalization. The families' level of participation is determined on admission and depends on the patient's wishes, their ability to provide care, and the patient's overall status. The decision for family inclusion and rooming-in practices has evolved as a model of collaboration between and among patients, families, and healthcare providers.2
Shaping accommodations
An interdisciplinary care team was comprised of nurses, physicians, social workers, housekeeping, epidemiology, and hospital administration. The interdisciplinary team discussions mirrored the core concepts of PFCC by addressing access, decision making, respect and dignity, information sharing, participation, and collaboration.1,2
Access and decision making
The interdisciplinary team identified that visiting needs are different for everyone and access to the patient should be determined by the patient. The patient decides who visits, when, and for how long. If the patient can't make the decision, then it becomes the decision of the designated family member, support person, or legally authorized representative. The nurse may accept verbally or in writing the patient's designation of an individual(s) as his or her support person for rooming-in.
At times, decisions to restrict or limit rooming-in accommodations are necessary.3 Knowing when to restrict visitors is key to reducing stress, allowing for adequate patient rest and care requirements. Healthcare professionals must exercise their best judgment when determining if rooming-in requests are clinically reasonable.
The nurse manager weighs several factors when determining if there are restrictions or limitations that should be considered when approving rooming-in requests. These factors include:
* infection control requirements
* space availability related to medical equipment needed in the patient room
* administration of medications or treatments that may affect the well-being of the rooming-in guest
* rooming-in guests who engage in disruptive or inappropriate behavior
* court mandated restriction of contact3
* age of the rooming-in guest (must be over age 18).
Should there be a change in condition warranting a transfer of care to another unit, rooming-in accommodations are renegotiated with the receiving unit based on the availability of a private room or appropriateness in a semiprivate room.
Although the nurse manager maintains responsibility for granting rooming-in requests, the clinical nurse plays an integral role in determining when the rooming-in guest needs relief to care for him or herself. The nurse must assess and encourage the rooming-in guest to leave the patient's bedside for short or extended periods of time to ensure adequate rest. Nursing staff members, in collaboration with the patient and the healthcare team, play a pivotal role in the decision making, facilitation, and control of patient access. The social work department is available to assist family members with planning for alternate lodging arrangements on campus at the Family Lodge, the Children's Inn, or at local hotels.
Respect and dignity
The core concepts of respect and dignity are central to supporting the patient's decision for care and participation in research studies to include privacy and confidentiality.2 At the NIH CC, the interdisciplinary team struggled with the concept of rooming-in utilizing semiprivate rooms. The team was concerned about the physical layout of the room, the impact of keeping the guest's personal belongings in the room, the gender of the rooming-in guest, and the ability to maintain privacy and confidentiality. Interestingly, during a role reversal discussion, team members acknowledged that if their family member was hospitalized, they would request to stay even if it was a semiprivate room. The team acknowledged the double standard and decided to support semiprivate rooming-in accommodations. Education on the core values of respect and dignity was determined to be essential for healthcare providers, patients, and rooming-in guests to maintain privacy and confidentiality. In situations where rooming-in isn't feasible in a semiprivate room, every effort is made to move the rooming-in guest and patient to a private room.
Although information sharing is beneficial in supporting the patient's care needs, maintaining privacy and confidentiality must remain paramount. In order to protect patient confidentiality, the healthcare team has the responsibility to confirm if the rooming-in guest is authorized to receive the patient's confidential medical information before conducting medical rounds in the patient room or having confidential conversations in front of the guest.2
Participation and information sharing
By sitting at the patient's bedside, families learn the details of his or her current status and become partners in care by watching, listening, and forming personal cues to alert them to the psychological or physical needs of the patient. This is especially true on the evening, night, and weekend shifts when activity and staffing levels decrease. Implementation of a rooming-in policy allows guests to stay with the patient, providing emotional support and assisting in keeping the patient engaged. Additionally, the rooming-in guest knows the patient best and is able to provide information about the patient's care needs or changes in his or her condition.
Rooming-in guests have expressed satisfaction and a level of comfort by understanding the physical environment and participating in the patient's care. Rooming-in guests should be oriented to where they can find basic care items, such as linens, water, and nutritional supplies. In the same respect, nurses reported that rooming-in builds relationships with the family to share valuable information about care preferences or concerns to the nursing staff.3
Collaboration
Collaboration between healthcare providers and the patient creates a supportive environment, and highlights the relationship that's established when a family member's request for rooming-in accommodations is supported. At the NIH CC, patients are referred from across the country and around the world to participate in clinical research or natural history trials. This unique aspect of care at the CC requires collaboration with staff, physicians, research nurses, and social work services to assist with coordination and planning for room accommodations. Providing the flexibility to allow the family to choose to stay with the patient overnight highlights the collaborative relationship with the healthcare team.
Educating patients and guests
A pamphlet was developed for the ease of nurses educating patients and their rooming-in guests. Infection control practices are emphasized, including:
* Rooming-in guests must follow all infection control practices. Nursing and epidemiology staff members are responsible for providing education specific to the patient's isolation status, general infection control, and hand hygiene requirements.
* Guests may not room-in with transplant patients if the guest has received a live vaccine within the last 21 days. Consultation with epidemiology staff is recommended for information and guidance.
* Guests aren't permitted to room-in if they're ill or are experiencing signs and symptoms of illness, such as cold symptoms, diarrhea, fever within the last 24 hours, or a rash within the last 7 days.
Education is also provided detailing what the patient can expect regarding rooming-in accommodation:
* Rooming-in accommodation is recommended for one guest at a time. The nurse manager uses judgment and flexibility when considering end-of-life requests for more than one overnight guest at a time.
* For safety reasons, rooming-in guests aren't allowed to sleep in an unoccupied semiprivate bed. Sleeper or reclining chairs are provided based on furniture availability, space, and medical appropriateness.
* Meals aren't provided to guests. Directions to cafes, cafeterias, and restaurants are provided.
* Bathrooms and showers in the patient room are for the patient's use. Public bathrooms and facilities are located throughout the building for guest use. Laundry rooms are available for extended stays.
* The patient and family are encouraged to download the NIH directory app as a map and resource to locate restrooms, points of interest, shuttle buses, parking, and patient services.
A novel approach to visitation
Supporting rooming-in provides an opportunity to improve patient care and collaboration with the patient's family. Research demonstrates that separation of patients from people who know them best during vulnerable times increases the likelihood of medical errors, emotional harm, and inconsistencies in providing care.2 Rooming-in guests staying with patients who have impaired cognitive function improve safety by allowing a familiar family member to stay with the patient. Rooming-in guests can reduce the use of sitters to prevent harm of the impaired patient. Nurse managers need to be flexible when responding to diverse patient and family needs, and work to educate staff members who have traditional views of visiting hours.
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