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Family presence and visitation in critical care : a rapid evidence assessment Charlton, Sara-Grey Maureen 2015

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FAMILY PRESENCE AND VISITATION IN CRITICAL CARE:  A RAPID EVIDENCE ASSESSMENT By  SARA-GREY MAUREEN CHARLTON  B.S.N, The University of British Columbia, 2003  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Nursing)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  April 2015  © Sara-Grey Maureen Charlton, 2015  ii Abstract Patients and families want to be in close proximity to one another during the phase of critical illness.  This has historically been challenged by restrictive hospital visiting hours.  Nurses have played the gatekeeper role and decided who could visit the patient, when, and for how long.  A scholarly review of the existing literature was conducted to identify what patients, families and nurses believe about visiting and to determine and suggest best evidence for practice, policy, education and research.   Using a Rapid Evidence Assessment (REA) methodology 18 studies were evaluated through the lens of Patient and Family Centred Care.  The best evidence is presented as well as the recommendations for best practice, policy, education and future research to help promote family presence in the Intensive Care Unit.   Families and patients had improved outcomes, physiological and psychological, when Intensive Care Unit policy supports the presence of the family at the bedside.  Nurses felt that working with families was part of their expected practice but struggled with the increased workload.  They also struggled with relinquishing control over visitation but when they did patients and families felt empowered.  The key recommendations are to create flexible patient controlled visitation policies in the Intensive Care Unit, replicate studies to reinforce the findings from the studies presented, provide education for nurses about family nursing, and education for families and patients regarding the unit policies and events.    iii Preface I, hereby, declare that this thesis is my work alone.  I have published no part of this work previously.  There was no ethics approval required because of the nature of this work.      iv Table	  of	  Contents	  Abstract ........................................................................................................................................... ii Preface ............................................................................................................................................ iii List of Tables ................................................................................................................................. vi List of Figures ............................................................................................................................... vii List of Abbreviations ................................................................................................................... viii Acknowledgements ........................................................................................................................ ix Dedication ....................................................................................................................................... x Chapter 1: Introduction ................................................................................................................... 1 1.1 Background ........................................................................................................ 3 1.1.1 History and Definition ................................................................................. 3 1.1.2 Experiences and Perceptions of Nurses ....................................................... 5 1.1.3 Patient and Family Experiences ................................................................... 6 1.2 Rapid Evidence Assessment Process ................................................................. 6 1.2.1 Process Steps ................................................................................................ 7 1.2.2 Problem Statement ....................................................................................... 7 1.2.3 Researchable Questions ............................................................................... 9 1.2.4 Limitations ................................................................................................... 9 1.2.5 Ethical Considerations ................................................................................. 9 1.2.6 Financial Honorariums ............................................................................... 10 1.2.7 Thesis Structure ......................................................................................... 10 Chapter 2: Methods ....................................................................................................................... 11 2.1 Introduction ...................................................................................................... 11 2.2 Conceptual Framework .................................................................................... 12 2.3 Methods ............................................................................................................ 13 2.3.1 Purpose and Benefit ................................................................................... 13 2.3.2 Procedure ................................................................................................... 15 2.3.3 Formulating the Questions ......................................................................... 16 2.4 Search Strategy ................................................................................................ 17 2.4.1 Inclusion, Exclusion and Selection Criteria ............................................... 18 2.4.2 Sources for the Search ................................................................................ 21 2.5 Search Methods and Search Terms .................................................................. 22 2.5.1 Search Terms ............................................................................................. 22 2.5.2 Search Methods .......................................................................................... 23 2.5.3 Search Results ............................................................................................ 23 2.5.4 Selected Studies ......................................................................................... 24 2.5.5 Excluded Studies ........................................................................................ 25 2.5.6 Appraisal Tools .......................................................................................... 28 2.5.7 The Government Social Research Score and Weight of Evidence Tool ... 28 2.5.8 The Critical Appraisal Skills Programme .................................................. 29 2.5.9 Maryland Scale of Scientific Methods ....................................................... 30 2.5.10 Synthesis of Findings ................................................................................. 32 2.5.11 Communicating the Findings ..................................................................... 33 2.6 Chapter Summary ............................................................................................ 33   v  Chapter 3: Findings ....................................................................................................................... 35 3.1 Introduction ...................................................................................................... 35 3.2 Qualitative Studies ........................................................................................... 35 3.2.1 Weight of Evidence: High ......................................................................... 36 3.2.2 Weight of Evidence: Medium .................................................................... 46 3.3 Quantitative Studies ......................................................................................... 48 3.3.1 Weight of Evidence: High ......................................................................... 49 3.3.2 Weight of Evidence: Medium .................................................................... 53 3.4 Mixed-Methods Studies ................................................................................... 57 3.4.1 Weight of Evidence: Medium .................................................................... 58 3.5 Chapter Summary ............................................................................................ 62 Chapter 4: Identifying Key Themes .............................................................................................. 63 4.1.1 Introduction ................................................................................................ 63 4.1.2 Identifying Themes .................................................................................... 63 4.2 Global Themes ................................................................................................. 66 4.2.1 Global Theme: Proximity .......................................................................... 66 4.3 Organizing Themes .......................................................................................... 67 4.3.1 Organizing Theme: Communication .......................................................... 68 4.3.2 Organizing Theme: Control ....................................................................... 69 4.3.3 Organizing Theme: Empowerment ............................................................ 70 4.3.4 Organizing Theme: Outcomes ................................................................... 71 4.3.5 Organizing Theme: Workload ................................................................... 73 4.4 Chapter Summary ............................................................................................ 74 Chapter 5: Discussion and Implications ....................................................................................... 76 5.1 Chapter Introduction ........................................................................................ 76 5.2 Applying the Findings to the Research Question and Sub-questions .............. 76 5.2.1 Benefits and Drawbacks for Patients ......................................................... 77 5.2.2 Benefits and Drawbacks for Families ........................................................ 78 5.2.3 Benefits and Drawbacks to Nurses ............................................................ 79 5.3 Policy and Practice Recommendations ............................................................ 80 5.3.1 Suggested Changes to Visitation Policy .................................................... 80 5.3.2 Enhanced Family Participation .................................................................. 82 5.3.3 Enhanced Information Sharing .................................................................. 84 5.4 Education Recommendations ........................................................................... 86 5.4.1 Supporting Nurses to Work with Families ................................................. 86 5.4.2 Patient and Family Education Needs ......................................................... 87 5.5 Research Recommendations ............................................................................ 88 5.5.1 Replication Studies .................................................................................... 88 5.5.2 Suggested Areas for Further Research ....................................................... 89 5.6 Chapter Summary ............................................................................................ 90 5.7 Overall Summary: Knowledge Gained from REA .......................................... 91 Bibliography ................................................................................................................................. 93 Appendices .................................................................................................................................. 101  vi List of Tables Table 1. REA Elements of Population, Intervention, Comparison, and Outcome ....................... 17	  Table 2. Number of Studies Selected by Database ....................................................................... 24	  Table 3. Selected Studies in Alphabetical Order of Author .......................................................... 24	  Table 4. Excluded studies in Alphabetical Order by Author ........................................................ 25	  Table 5. Qualitative Studies Weight of Evidence High by Author and GSRS Category Score ... 37	  Table 6. Qualitative Studies Weight of Evidence (WOE) Medium by Author and GSRS Score 47	  Table 7. Quantitative Studies by Authors, Weight of Evidence (WOE) and Maryland Score ..... 50	  Table 8. Quantitative Studies Weight of Evidence Medium by Authors, GSRS Score, and Maryland Score ............................................................................................................................. 53	  Table 9. Mixed Methods Studies Weight of Evidence Medium by Author, GSRS Score, and Maryland Score ............................................................................................................................. 58	  Table 10. Rapid Evidence Assessment Themes from the Literature Organized by Type of Theme....................................................................................................................................................... 64	    vii List of Figures Figure 1. Hierarchy of Evidence ................................................................................................... 15	  Figure 2.  Government Social Research Weight of Evidence Assessment Tool .......................... 29	  Figure 3.  CASP 10 Questions Qualitative Research Analysis Tool ............................................ 30	  Figure 4.  Maryland Scale of Scientific Methods ......................................................................... 32	  Figure 5.  Stages of Synthesis ....................................................................................................... 33	  Figure 6.  Thematic network organized from global theme to organizing theme to basic theme 65	    viii List of Abbreviations Critical Appraisal Skills Programme …………………………………...………………… (CASP) Cumulative Index of Nursing and Allied Health Literature…………………………… (CINAHL) Excerpta Medica Database……………………………………………………………. (EMBASE) Government Social Research Score ……………………………………………………… (GSRS) Institute for Patient and Family Centered Care……………………………...…………… (IPFCC) Intensive Care Unit………………………………………………………………………….. (ICU) Institute of Medicine…………………………………………...…………………………… (IOM) Medical Literature Analysis and Retrieval System Online……………………………. (MedLine) Patient and Family Centered Care………………………………………………………… (PFCC) Population, Intervention, Comparison, Outcomes………………………………………… (PICO) Rapid Evidence Assessment…………………………………………………………........... (REA) Restricted Visiting Policy Group…………………………………………………………… (RVP) University of British Columbia…………………………………………………………….. (UBC) Unrestricted Visiting Policy Group………………………………………………………… (UVP) Weight of Evidence……………………………………………………………………...… (WOE)  ix Acknowledgements I offer my sincerest gratitude to my thesis committee for their time, questions, and motivation.  I owe particular thanks to Dr. Maura Macphee for inspiring me to constantly think deeper and differently.  Additional thanks are due to Dr. Cathryn Jackson and Ms. Candy Garossino for their thoughtful input and contribution to this work.   To my family I would like to offer heartfelt thanks for their support as I completed this degree.  My husband, Zach, deserves special recognition for his constant encouragement, effort and support.     x Dedication FOR JACK & GEORGIA   1 Chapter 1: Introduction Patient and family centred care (PFCC), although not new, is a growing philosophy and movement in healthcare today.  The growth in this philosophy comes, in part, as a result of The Institute of Medicine report “Crossing the Quality Chasm” which called for radical changes in healthcare, and the Institute for Healthcare Improvement’s call for the use of the Triple Aim both of which state that PFCC is the best way to improve healthcare quality and reduce costs (Committee on the Quality of Health Care in America, 2001; Institute for Healthcare Improvement, 2015).  The Institute for Patient and Family Centered Care (IPFCC) defines PFCC as healthcare that creates mutually beneficial partnerships between patients and healthcare providers.  There are four core principles of PFCC: respect and dignity, information, participation and collaboration.  Underpinning this philosophy is the belief that patients and their families should be invited to be members of the healthcare team and that they are key partners in ensuring safe, quality care is delivered (Balik, Conway, Zipperer, & Watson, 2011; Conway, 2008; Epstein, Fiscella, Lesser, & Stange, 2010; Institute for Patient and Family Centered Care, 2009, Committee on the Quality of Health Care in America, 2001).  Family is understood as fundamental to the health, wellbeing and healing of patients according to PFCC, and family presence should be encouraged based on the preferences of the patient (Institute for Patient and Family Centered Care, 2009) Finally, family is defined broadly as anyone that the patient identifies as their family and is not restricted to the traditional ties of blood and marriage (Institute for Patient and Family Centered Care, 2009.  These understandings challenge the current practice in many adult acute care hospitals of restricting family presence based on individual clinician decision.  2 The specific use of language can have powerful effects.  In the hospital family members are often referred to as visitors.  The term visitor denotes transience in the life of the patient when most often the opposite is the case.  These people who are labelled visitors are husbands, wives, children, or lifelong friends of the patient.  All of them may be seen as family by the patient.  When this term is re-examined it is clear that the temporary people in the life of the patient are in fact the healthcare providers working with the patient.  The husbands, children, and friends are the people who provide care prior to hospitalization and will continue to do so after discharge.  To continue to restrict the patient’s access to their families is to maintain an archaic and paternalistic system that strips the patient of their choice to decide who they need with them at a point of critical illness.  PFCC is the guiding philosophy that is signalling the need for a policy and practice change that would see families, patients and healthcare providers working together in partnership.   The purpose of this Rapid Evidence Assessment (REA) is to explore the evidence that surrounds this notion of family presence in adult critical care and the role that nurses, as clinicians, play in allowing or restricting family presence with their acutely ill loved ones.  Critical care in this context refers to any inpatient unit in the hospital where care is provided at a critical or intensive level.  Family presence and visitation is an issue of importance right now because it offers a direct clinical application of PFCC and can be the impetus begin to change the culture in healthcare.  PFCC offers a way in which to refocus the existing paradigm in healthcare to one that invites mutually beneficial partnership between clinicians and the people and families that they serve (Institute for Patient and Family Centered Care, 2009).  If healthcare is truly expected to move from a model of doing to or doing for to a  3 model of doing with then families will need to be embraced, both as part an integral component of the patient’s wellness and as part of the healthcare team.   I have chosen to focus on family presence in the critical care areas as a point of practicality.  Initially, I began my search much more broadly and sought to include all of inpatient acute care studies.  Through the use of an iterative process I refined the focus of this REA to only include critical care areas because there was simply not enough literature in the other areas to include them.  This finding certainly points to a gap that exists in the literature and could be addressed by future research.    1.1 Background The following section will discuss the history and definition of visiting hours in the ICU.  Additionally, the experiences of both the nurses and the patients and families will be described.    1.1.1 History and Definition Historically hospital policies and nursing practice have been shaped by the dominant biomedical paradigm.  This paradigm situates providers (including nurses) in a position of power where they exert control over the patient and family, whether consciously or unconsciously (Henderson, 2003).  The power of biomedicine contributes to the social construct of healthcare providers as experts that should be seen as the authority and decision maker (Levine & Zuckerman, 2000).  This unwritten hierarchy in healthcare is implicit and often unrecognized by those within the system.  The power dynamics that exist between healthcare workers also exist between healthcare providers and patients.  Visitation is no  4 exception to this and nurses often assume the role of ‘gatekeeper,’ deciding when and for how long families should be allowed to be present with their hospitalized loved ones (Agard & Lomborg, 2010; Berwick & Kotagal, 2004).   The decision to restrict family presence is often based on good intentions with the aim of protecting the patient from infection, stress, and sleeplessness yet these good intentions are not evidence-informed and tend to reflect nurses fears and personal biases (Ahman, Abraham, & Johnson, 2004; Ciufo & Hader, 2011).  Other times the decision to restrict family presence is based on the physical environment (not enough space), increased workload (families require more psychosocial work), and perceived poor behaviour (families with challenging interpersonal skills) (Ciufo & Hader, 2011; Garrouste-Orgeas, et al., 2008).  It is easy to see then how nurses can become caught up in the role as gatekeeper and as the holder of power when it comes to visitation and are reluctant to reduce restrictions and place control into the hands of the patient. The current challenges faced by healthcare, in particular inpatient hospital care, are influenced by a political system that is based on western neo-liberal ideology (Beagan & Ells, 2007).  Chomsky(2002) describes neo-liberalism as an economic system that stresses profit in the private sector and a reduction in spending in the public or social sectors.  As a result of this neo-liberal influence there is mounting pressure on public Healthcare to be more productive with less funding.  This ideology is highly dependent on individualism, the idea that everyone is responsible for themselves regardless of the confounding variables at play within the political or social climate (Chomsky, 2002).  At the level of clinical delivery of care this means that there are multiple competing demands and increased workload with little additional resources to remedy the problem.  This is relevant because PFCC is suggested as  5 one of the ways to remedy the system and the effects of the current system are one of the barriers nurses see to implementing PFCC in their practice.   Open visitation has been interpreted differently in the literature and in practice.  For the purposes of this paper open visitation will be defined as a visitation policy which encourages, invites and empowers families to be present with their acutely ill loved one based on that person’s preferences as discussed with their primary care nurse.    1.1.2 Experiences and Perceptions of Nurses Nurses fundamentally understand PFCC as a core principle of nursing practice and as such an assumption could be made that the profession would value family presence (Canadian Nurses Association, 2011).  However, as alluded to above, in practice nurses experience a heavy workload in a fast-paced and often stressful work environment (Beagan & Ells, 2007).  Several authors describe nurses as understanding the value of family presence and visitation, whilst being reluctant to accept either in practice (Marco et al., 2006; Farrell, Joseph, & Schwartz-Barcott, 2005; Soury-Lavergne, et al., 2011).  Agard and Lomborg also note- that nurses employ a variety of rationales for restricting or allowing family presence largely based on their individual assessment and not on engagement with the patient (2010).  Nurses’ assessments are influenced by some or all of the following elements: their own mood, how busy the unit is, the level of acuity of the patient or neighbouring patients, the policy of the unit or hospital, and the presence of medical rounding (Agard & Lomborg, 2010; Soury-Lavergne, et al., 2011).  Despite the reservations of some nurses there are benefits to nursing practice within an environment of open visitation (Agard & Lomborg, 2010).  Many nurses cite improved communication with family, improved patient collateral  6 information, and better understanding of the patient and their needs (Agard & Lomborg, 2010; Gonzalez, Carroll, Ellitott, Fitzgerald, & Vallent, 2004; Hardin, Bernhardt-Tindal, Hart, & Henson, 2011).  1.1.3 Patient and Family Experiences Patients are members of families and cannot be removed from this fact simply due to a critical care hospitalization..  Most patients prefer to choose who visits them and for how long and find this to be a healing and non-stressful experience (Agard & Lomborg, 2010; Olsen et al., 2009; Gonzalez et al., 2004; Roger, et al., 2010).  Families crave proximity to and information about their acutely ill loved ones and open visitation facilitates both of these (Ahman, Abraham, & Johnson, 2004; Gonzalez et al., 2004).  Patients and families that experience open visitation have an improved satisfaction with their experience of care, less anxiety and, in some cases, improved physiological outcomes for the patient (Fumagalli, et al., 2006; Olsen et al., 2009; Gonzalez et al., 2004; Marco, Bermejillo, Garayalde, Sarrate, Margall, & Asiain, 2006)  1.2 Rapid Evidence Assessment Process The subsequent section will detail the process steps of a REA, the problem statement and researchable questions.  Further, the limitations, ethical and financial considerations, and the structure of the thesis will follow.   7 1.2.1 Process Steps The REA is typically applied when there is a clinical problem that needs a solution and there are little financial or time resources (Bevan, Connelly, Francis, Marshall, Williams, & Wilson, 2010; Garrett, Taverner, Masinde, Gromala, Shaw, & Negraeff, 2014).  This is because REAs are typically completed within a three to six month timeline and although meticulous do not require the same amount of resources as do systematic reviews.  The methods used to conduct an REA will be discussed in greater depth in the subsequent chapter.  However, in order to provide some context I will briefly outline the procedure.  The steps involved for this REA are: definition of the question, database search using identified key words, abstract review based on criteria, article selection based on criteria, article scoring based on three different tools (to be described in chapter two), article analysis, summary of key findings, and recommendations for practice (Bevan et al., 2010; Garrett et al., 2014).    1.2.2 Problem Statement The healthcare system is under increasing pressure to be more efficient, productive, and safer and to do so without increased resources and PFCC may offer one avenue to do this (Beagan & Ells, 2007; Committee on the Quality of Health Care in America, 2001; Institute for Healthcare Improvement, 2015).  Nurses are often impacted at the point-of-care where neo-liberal policies are enacted.  This means nurses need to be leaders in the creation of policy and programs that enhance their ability to provide care for patients.  One avenue for nurses to increase their own ability to work within such a tightly squeezed system is to tap into families as a resource.  No greater ally or advocate for patients will be found and families can be brought into the healthcare team as partners for safety and quality.  One way  8 to begin this process is to invite and empower families, as defined by the patient, to be present with their loved ones through a liberalization of visiting hours.  Not only is allowing the patient unfettered access to their loved-ones the right thing to do but it may also improve their outcomes.   Open visitation controlled by the patients may also be an additional, albeit difficult to quantify, method of costs savings.  Patients had less anxiety, lower heart rates, fewer arrhythmias, and reduced cardiopulmonary complications which one could posit would lead to fewer days in a higher level of care which would result in a costs savings for the healthcare system (Fumagalli, et al., 2006).   Communication is also aided by the increased presence of families.  Particularly in a critical care setting where patients may be cognitively impaired due to their condition or medication or be unable to speak due to intubation.  Families can more accurately interpret the patient’s communications as well speak on the patient’s behalf.  This can help the healthcare team enact their plans in a timelier manner and in a way that better meets the needs and better matches the values of the patient.   My goal is to review the existing body of literature that explores family presence, open visitation, and the interplay of nurses, patients, and families within it.  Moreover, I would like to explore attitudes, beliefs, and perceptions of families, patients, and nurses with regards to visitation.  Ultimately, the findings of this REA may encourage healthcare organizations to review and revise their current visitation policies in order to employ an evidence informed policy to be enacted as a partnership between nurses, patients, and families.     9 1.2.3 Researchable Questions 1. “What are the benefits and/or drawbacks (perceived or real) to open visiting versus restricted visiting for patients, families, and nurses?” a. “What are the best strategies to meet the visiting needs of patients and families?”   1.2.4 Limitations This REA has some limitations.  Due to the rapid nature of REA’s the review conducted will not adhere to the same level of rigour that a systematic review might (Craig & Smyth, 2012 (Civil Service, 2010).  In order to acutely focus my topic and to produce a completed REA in a short amount of time I did not include any grey literature, systematic reviews, unpublished studies, opinion papers, quality improvement or case studies.  This creates the possibility of a publication bias.  Publication bias can occur when the sources reviewed have all been published rather than those that are outside of standard publications, for instance conference posters or student projects (Craig & Smyth, 2012).    1.2.5 Ethical Considerations Application to an ethics board was not undertaken for this particular paper, as there was no new original human research being initiated.  The work of an REA is to review existing literature and therefore ethical considerations for the works reviewed have already been taken into account and ethical approval previously obtained by the original authors.     10 1.2.6 Financial Honorariums Financial honorariums were not received for the completion of this work.    1.2.7 Thesis Structure The structure of this thesis into five chapters that describe the process of an REA was derived, in part, from the thesis of a former University of British Columbia (UBC) School of Nursing graduate student who also used an REA for her thesis (Jetha, 2013).  I found this thesis posted on the Internet on the UBC cIRcle page after conducting a search engine search for the words ‘REA thesis format’.    11 Chapter 2: Methods 2.1 Introduction This chapter presents the conceptual framework of Patient and Family Centred Care (PFCC) that guides this work and the methods used to conduct a Rapid Evidence Assessment (REA).  Through my initial investigation into the literature and through my interest in PFCC I became aware that there was a need for a quick review of the existing evidence regarding visiting hours in adult hospital inpatient care.  Through an iterative process I refined my approach to focus-in on critical care, as that was where the bulk of the literature arose.  There is a call from notable organizations such as the Institute of Medicine (IOM), the Institute for Healthcare Improvement (IHI), and the IPFCC to liberalize hospital visiting hours.  This push for policy change is driven by the philosophy of PFCC (Committee on the Quality of Health Care in America, 2001; Institute for Patient and Family Centered Care, 2009).   Following the discussion of the conceptual framework I will explain the design of this REA and delineate what an REA is and why it is useful within the context of the issue of visiting hours.  Further, I will describe the meticulous procedure used to conduct an REA.  The section of this chapter will follow the order of the stages of an REA as each one is defined.  Through this process the selection criteria, inclusion and exclusion criteria will be shared along with how they were used to select the appropriate studies for this work.  Details of the search strategy, the key words, and databases used will also be discussed.  The appraisal tools and the final lists of studies that were included and excluded will also be shared.  Finally, I will share the plan for synthesis of the findings and communicating the findings.    12 2.2 Conceptual Framework I have chosen PFCC as the lens through which this REA was conducted.  The IPFCC defines PFCC as: An approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among healthcare providers, the people they serve and their families.  It is founded on the understanding that the family plays a vital role in ensuring the health and well-being of people of all ages.  In PFCC, the people we serve define their family and determine how they will participate in their care and decision-making.  (Institute for Patient and Family Centered Care, 2009)  The philosophy of PFCC invites families and patients to participate in their care at the level of their choosing and thus creates a dynamic of power sharing between patients, families, and providers.  Visitation is a practice that is often linked with PFCC because it represents a vital shift in hospital policies and the way that patients and families are viewed by staff and by the organization.  I believe this is because visitation – particularly in the incarnation of patient directed open visitation – touches upon each of the four core values of PFCC that I will discuss next.   The four core values of PFCC are: dignity and respect, information sharing, participation, and collaboration.  Dignity and respect means that healthcare providers listen to and respect the choices, perspectives, and cultural background of patients and their families.  This means that in the case of visiting hours patients would be included in the decision making process and their preference would be respected.  Information sharing references the ability of healthcare providers to share pertinent, relevant, and easy to understand information to the patient and their family.  When patients are allowed to decide when and who they would like to visit them then it can enable the team to share information more easily with the family of the patient.  Reciprocally, the family can provide the team with collateral and historical information regarding the patient that can help with the planning and care for that patient.  Participation allows patients and families to take part in the care of that  13 patient at the level of their choosing.  Once again this means creating a space that allows for power to be placed in the hands of the patient and family.  Collaboration refers to a higher level of working together at all levels of healthcare.  One way this could be enacted would be for patients and families to work with healthcare staff to devise a policy for visitation that would be favourable for all. PFCC is a powerful philosophy that is being used to shape healthcare practice and policy.  Using this philosophy as my guide while conducting this REA allowed me to ground myself in the idea that family is essential for the health and well being of all patients and that policy must strive to create mutually beneficial partnerships between patients, their families, and healthcare providers.    2.3 Methods The following sections will describe the methods used to conduct the REA.  This includes the purpose, benefit, inclusion, exclusion and selection criteria.    2.3.1 Purpose and Benefit In this section I will discuss the purpose and benefit of using a REA and how it compares to the more widely known process of Systematic Review.   Systematic reviews are a comprehensive critical assessment of research studies on a particular topic using a methodical approach (Polit & Beck, 2012).  They are widely considered the gold standard for the presentation of the best current evidence and are often the basis for evidence-based practice (Polit & Beck, 2012).  Researchers who utilize the systematic review methodology draw upon a set of explicit criteria for searching and  14 selecting studies.  This organized methodology allows the material to be located, assembled, and evaluated in a precise and meticulous manner.  The process of conducting a full systematic review would require a substantial amount of time, money and effort and usually requires a team of people, as it is a large undertaking.  A REA provides a way for researchers to locate, assemble and evaluate existing evidence on a particular topic but with less time and effort required (Bevan et al., 2010).  Additionally, REA can be conducted by one person rather than requiring a team.  In this way the REA is an ideal way for clinicians, practitioners, or researchers to quickly gather information on a given topic of clinical importance and to present it back to those who need the evidence (Bevan et al., 2010; Garrett et al., 2014).  In particular this approach of evidence appraisal and presentation is useful in settings such as nursing education departments and nursing professional practice departments.  REAs, due to their swift approach, allow for a more realistic application in the world of professional nursing.  The current state of professional nursing and indeed healthcare in general, is one of constant change and requires vigilance to maintain standards to the most current level of evidence.  The REA can ensure the availability of current evidence and can help the application of this evidence in practice in a timely manner within nursing policy compared to the use of a time and cost prohibitive systematic review. REAs are quick by design.  The REA is meant to narrow in on a constrained topic that can then be systematically researched and evaluated (Bevan et al., 2010).  Limits are placed on the amount of time for each section of the REA and in total a typical REA can take from two to six months (Bevan et al., 2010).  Depending on the constraints faced by the researcher, an REA may not include grey literature, unpublished studies, quality  15 improvement reports, or case studies.  This can lead to a potential for publication bias but the risk is low (Bevan et al., 2010; Garrett et al., 2014; Polit & Beck, 2012).   The following figure was retrieved from the Civil Service website which clearly shows where the REA falls in the hierarchy of evidence (Bevan et al., 2010).    Figure 1: Hierarchy of Evidence Hierarchy of Evidence diagram.  (Civil Service, 2010) Retrieved from: http://www.civilservice.gov.uk/networks/gsr/resources-and-guidance/rapid-evidence-assessment/how-to-do-a-rea May 10th 2013  2.3.2 Procedure The method for completing an REA is not dissimilar to a systematic review.  It is just limited in its breadth and depth.  There are six steps within each REA.  The process I followed for this particular REA will be outlined in the subsequent sections of this chapter.  The six steps used for an REA as defined by Bevan et al.(2010):  1. Formulate a researchable question 2. Conduct a systematic, yet constrained, search  16 3. Screen the studies found in the search 4. (Optional) Map the evidence found 5. Extract the data from the studies 6. Appraise the quality of the chosen studies  2.3.3 Formulating the Questions The initial step in undertaking an REA is to formulate the question and sub-questions and then to create inclusion and exclusion criteria that will assist in narrowing in on the appropriate information (Bevan et al., 2010).   There are two types of questions that can be applied within the REA format: Impact or non-impact questions (Bevan et al., 2010).  Impact questions are the most common type of questions used in the REA process and they seek to find out what works.  Non-impact questions seek to answer: what do people need, what process works, what do people feel or want, what is needed to make something work, or what is the relationship between phenomena (Bevan et al., 2010).  My questions are non-impact questions because I am looking at what patients, families, and nurses think and feel and what they need to make visiting hours work for everyone.  Below is a table of PICO (Population, Intervention, Comparison, Outcome) elements that illustrates how I began to formulate the questions for this particular REA.     17 Table 1 REA Elements of Population, Intervention, Comparison, and Outcome  PICO Letter  PICO Elements P Adult patients (18 years or older) and their families admitted in acute care in hospital AND nurses working in acute care hospital setting.  Acute care includes: general medicine, critical care areas, palliative care, and post-anaesthetic care units.   *Criteria were refined as the search progressed and critical care areas were narrowed as the focus.  There was little evidence in the other areas and the studies found in critical care could be easily used in areas with lower levels of care.   I ‘Open’ visiting hours (Family Presence) C Compared with restricted visiting hours or status quo (if comparison was a part of the study) O Improved satisfaction of care (only if this was available in the study; not all studies have direct outcomes)  Please see previous chapter for researchable question and sub-question.    2.4 Search Strategy REA search strategies can be driven by specific questions or by iteration.  My researchable questions drove my search strategy but I also used an iterative process; as I learned more about the topic through the search certain things were added or removed as needed.  The Civil Service ‘How to do a REA’ website recommends that REA search strategies be meticulously documented and reported and that they include the following four elements (Bevan et al., 2010):  1. Inclusion criteria 2. Sources for the search 3. How the sources will be searched and their search terms 4. Search methods  18 2.4.1 Inclusion, Exclusion and Selection Criteria The process of defining inclusion and exclusion criteria for a REA is similar to the process that researchers use to identify population criteria for inclusion in a study.  For the purposes of practicality only studies written or readily available in translated format in English were considered.  Additionally, only studies published after 2003 were used. .  Despite the existence of visiting hours and family presence being located in the literature starting in the 1970’s there have been too many substantive changes in healthcare and in the political environment that influences healthcare policy to justify using evidence from prior to 2003.  Further, only those articles that are focused on an adult population (18 years or older) were included due to the focus on adult care.  While there could be lessons learned from paediatric settings families are viewed much differently than in adult care settings, because ‘visitors’ are often parents.  For efficiency’s sake only full text studies available in electronic format were used and there was no inclusion of grey literature, opinion or position papers, case studies, quality improvement, systematic or literature reviews.  Studies were available in the following databases chosen for searching for this REA: The Cumulative Index of Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (EMBASE), PubMed, Medical Literature Analysis Retrieval System Online (MEDLINE).  These databases were chosen because they provide a massive amount of data from which to search and are largely focused on nursing, allied and medical literature.  The Cochrane Database of Systematic Reviews and Joanna Briggs Institute Library of Systematic Reviews were searched, only, to see if there were any relevant systematic reviews already in existence on this same topic.   In order to be able to accurately compare the experiences of patients and families and nurses within different hospitals I chose to include only studies from western-like countries:  19 my assumption was that western-style critical care areas have similar visitation policies..  This means that all studies from the United States of America (US), Canada, Europe, United Kingdom (UK), Scandinavia, Australia, and New Zealand were included for review.  Any studies originating from Central or South America, Africa, Asia, the Middle East or India were not included.   Studies were chosen based on their quality.  This was determined through a process of data analysis and extraction using three different tools.  These tools will be discussed in more depth in a subsequent section.  The Government Social Research Score (GSRS) Weight of Evidence (WOE) tool is used for all studies and scored from Low to High.  The Critical Appraisal Skills Programme (CASP) tool for qualitative evidence is a 10-question tool that evaluates the quality of Qualitative studies.  The Maryland scale is a four level scale used for Quantitative studies.  Studies with a score of Low on the GSRS WOE will not be included.      20 The following are the inclusion criteria for this REA: • Written in English • Published 2003 to 2013 • Population based in a western-like healthcare system: North America, Europe, United Kingdom, Scandinavia, Australia, or New Zealand.   • Available in electronic format • Patient population 18 years or older • Patients, families, or nurses from an acute in-hospital setting The following are the exclusion criteria for this REA: • Grey literature • Opinion or position papers • Case studies  • Quality Improvement  • Systematic reviews or literature reviews • Paediatric studies • Non-hospital setting • Hospital setting but non-critical care • Studies originating from a non-western healthcare system: Africa, Asia, Central or South America, India, or the Middle-East.   • GSRS WOE score of LOW     21 The following are the selection criteria for this REA: • Available in English • Published 2003-2013 • Quantitative, Qualitative or Mixed Methods studies of strong design • Studies describing: • Families, patients, or nurses experiences with visiting hours.  Their preferences for specific boundaries (or lack of) for visiting hours.  The importance of visiting or presence as stated by the patient, family, or nurses.  Benefits or drawbacks to different styles of visitation or how to meet the needs of patients, families, and nurses with different styles of visitation.   • GSRS WOE score of MEDIUM or HIGH • Available in the following databases:  • CINAHL • EMBASE • PubMed • MEDLINE • Cochrane Database of Systematic Reviews • Joanna Briggs Institute Library of Systematic Reviews   2.4.2 Sources for the Search  In this section I will describe the methods with which I undertook a search of multiple databases in order to discover the literature used for this REA, the full list of  22 databases searched is listed in detail later in this chapter.  CINAHL, PubMed, and Medline were included to ensure that a broad representation of evidence from current peer reviewed healthcare journals.  EMBASE was added to allow for a broader perspective and because it typically has greater reach with European journals.  I searched the Cochrane and the Joanna Briggs Institute Library of Systematic Reviews databases to ensure that there were no current systematic reviews on the same topic.  2.5 Search Methods and Search Terms My search strategy was purposive and I sought out those databases that would provide me with a quick, easily searched, large body of results from which to choose.  Once I began to go through the abstracts of the search results I began to hand-search the reference lists of the articles that seemed to match some or all of the selection criteria.  From these reference lists I compiled a list of articles that by their title seemed to meet the inclusion and selection criteria.  Once my search was complete I went through that list of articles pulled from reference lists and hand-searched through the University of British Columbia (UBC) library search engine for electronic copies of those articles.  Search terms were tailored to the specific database, as some require words to be put together differently in order to elicit the best possible results.  Below are the key words and Boolean phrasing that I used in my search.   2.5.1 Search Terms • 'adult critical care unit' AND/OR ‘inpatient' AND/OR ‘intensive care’ AND/OR ‘hospital’ NOT ‘Pediatric’ ‘Paediatric’  23 • 'visiting hours' AND/OR 'visiting policy' AND/OR 'visitors to patients' AND/OR 'open visiting' AND/OR 'flexible visiting' AND/OR ‘family Presence’  • ‘Visit*’ • 'patient and family-centred care' AND/OR ‘patient centred care’ AND/OR ‘family centred care’ AND/OR ‘patient partnership’ *will include both spellings of centred and centered  2.5.2 Search Methods The above-described search resulted in 92 articles.  I read through the abstracts of these studies and then based on whether they met the selection criteria or not I then moved forward with reviewing the entire article.  After reviewing the abstracts I had 62 articles to read and critically appraise.  These articles were added to RefWorks in order to keep track of the full reference.  I also created a Microsoft Excel spreadsheet to catalogue all of the articles and organize the findings.  I applied the critical appraisal tools (GSRS, CASP, and Maryland Scale) to determine the quality of the studies.  Finally I had 18 articles that met the selection criteria and were admitted into this REA and are listed below in Table 2.    2.5.3 Search Results The following table shows the number of studies that were selected from each database after the abstracts were reviewed and matched against selection criteria.  Notably, the majority of the selected studies were found through searching CINAHL and the second largest numbers of articles were found through hand searching the reference lists of articles that had been reviewed.  24   Table 2 Number of Studies Selected by Database Database Number of Selected Studies  CINAHL 22 Hand Searched 16 Embase 11 PubMed 11 MedLine 2 Cochrane  0 Joanna Briggs 0  2.5.4 Selected Studies The following table, as referenced above, shows all of the studies that were finally chosen for inclusion in this REA.    Table 3 Selected Studies in Alphabetical Order of Author Agard, A.  S., & Maindal, H.  T.  (2009).  Interacting with Relatives in Intensive Care Unit.  Nurses' Perceptions of a Challenging Task.   Agard, A., & Lomborg, K.  (2010).  Flexible Family Visitation in the Intensive Care Unit: Nurses' decision-making.   Eggenberger, S.  K., & Nelms, T.  P.  (2007).  Being Family: The family experience when an adult member is hospitalized with a critical illness.   Eriksson, T., & Bergbom, I.  (2007).  Visits to Intensive Care Unit Patients - frequency, duration and impact on outcome.   Eriksson, T., Bergbom, I., & Lindahl, B.  (2011).  The Experiences of Patients and their Families of Visiting Whilst in an Intensive Care Unit - a hermeneutic interview study.   Farrell, M., Joseph, D., & Schwartz-Barcott, D.  (2005).  Visiting Hours in the ICU: Finding the balance among patient, visitor, and staff needs.   Fumagalli, S., Boncinelli, L., Lo Nostro, A., Valoti, P., Baldereschi, G., Di Bari, M., et al.  (2006).  Reduced Cardiocirculatory Complications with Unrestrictive Visiting Policy in an Intensive Care Unit: Results from a pilot randomized trial.   Garrouste-Orgeas, M., Philipart, F., Timsit, J., Diaw, F., Willems, V., Tabah, A., et al.  (2008).  Perceptions of a 24-hour Visiting Policy in the Intensive Care Unit.   Gonzalez, C., Carroll, D., Ellitott, J., Fitzgerald, P., & Vallent, H.  (2004).  Visiting Preferences of Patients in the Intensive Care Unit and in a Complex Care Medical Unit.    25 Table 3 Selected Studies in Alphabetical Order of Author Hardin, S., Bernhardt-Tindal, K., Hart, A., & Henson, A.  (2011).  Critical-Care Visitation: The Patients' Perspective. Hunter, J. D., Goddard, C., Rothwell, M., Ketharaju, S., & Cooper, H. (2010). A Survey of Intensive Care Unit Visiting Policies in the United Kingdom. Anaesthesia , 65, 1101-1105. Johansson, I., Fridlund, B., & Hildingh, C.  (2005).  What is Supportive When an Adult Next-of-kin is in Critical Care?  Marco, L., Bermejillo, I., Garayalde, N., Sarrate, I., Margall, A., & Asiain, C.  (2006).  Intensive Care Nurses' Beliefs and Attitudes Towards the Effect of Open Visiting on Patients, Family, and Nurses.   McAdam, J., Arai, S., & Puntillo, K.  (2008).  Unrecognized Contributions of Families in the Intensive Care Unit.   Olsen, K.  D., Dysvik, E., & Hansen, B.  S.  (2009).  The Meaning of Family Members' Presence During Intensive Care Stay: A qualitative study.   Roger, C., Mari, A., Bousquet, P.  J., Louart, G., Casano, F., Cuvillon, A., et al.  (2010).  Patient's Relatives Wishes Concerning the Visiting Hours in an Intensive Care Unit. Soury-Lavergne, A., Hauchard, I., Dray, S., Baillot, M., Bertholet, E., Clabault, K., et al. (2011). Survey of Caregiver Opinions on the Practicalities of Family-Centred Care in Intensive Care Units. Journal of Clinical Nursing , 21, 1060-1067. Williams, C.  M.  (2005).  The Identification of Family Members' Contribution to Patients' Care in the Intensive Care Unit: A naturalistic inquiry.    2.5.5 Excluded Studies The following 42 studies were excluded because they were found to not be relevant to the REA topic, their methodological quality was such as to disqualify them, or they simply did not match the selection criteria.    Table 4 Excluded studies in Alphabetical Order by Author Anzoletti, A.  B., Buja, A., Bortolusso, V., & Zampieron, A.  (2008).  Access to Intensive Care Units: A survey in North-East Italy.   Bergbom, I., & Askwal, a.  (2000).  The Nearest and Dearest: A lileline for ICU patients.   Berti, D., Ferdinande, P., & Moons, P.  (2007).  Beliefs and Attitudes of Intensive Care Nurses Toward Visits and Open Visiting Policy.      26 Table 4 Excluded studies in Alphabetical Order by Author Carlson, B., Riegel, B., & Thomason, T.  (1998).  Visitation: Policy Versus Practice.   Carter, A., & Lester, K.  (2008).  Family Presene at the Bedside.   Cooper, L., Gray, H., Adam, J., Brown, D., McLaughlin, P., & Watson, J.  (2008).  Open All Hours: A qualitative exploration of open visiting in a hospice.   Del Barrio, M., Lacunza, M., Armendiaz, A.  C., Margall, A., & Asiain, C.  (2004).  Liver Transplant Patients: Their experience in the intensive care unit.  A phenomenological study.   DeLeskey, K.  (2009).  Family Visitation in the PACU: The current state of practice in the United States.   Duran, C.  R., Oman, K.  S., Abel, J.  J., Koziel, V.  M., & Szymanski, D.  (2007).  Attitudes Toward and Beliefs About Family Presence: A survey of healthcare providers, patients' families, and patients.   Fisher, C., Lindhorst, H., Matthews, T., Munroe, D.  J., Paulin, D., & Scott, D.  (2008).  Nursing Staff Attitudes and Behaviours Regarding Family Presence in the Hospital Setting.   Frazier, S.  K., Moser, D.  K., daley, L.  K., McKinley, S., Riegel, B., Garvin, B.  J., et al.  (2003).  Critical Care Nurses' Beliefs About and Reported Management of Anxiety.   Fridh, I., Forsberg, A., & Bergbom, I.  (2007).  Family Presence and Environmental Factors at the Time of a Patient's Death in an ICU.   Giannini, A., Miccinesi, G., & Leoncino, S.  (2008).  Visiting Policies in Italian Intensive Care Units: A nationwide survey.   Gray, H., Adam, J., Brown, D., McLaughlin, P., Hill, V., & Wilson, L.  (2011).  Visiting All Hours: A focus group study on staff's views of open visiting in a hospice.   Halm, M.  A., & Titler, M.  G.  (1990, November).  Appropriateness of Critical Care Visitation: Perceptions of patients, families, nurses, and physicians. Henrich, N.  J., Dodek, P., Heyland, D., Cook, D., Rocker, G., Kutsogiannis, D., et al.  (2011).  Qualitative Analysis of an Intensive Care Unit Family Satisfaction Survey.   Hinkle, J., & Fitzpatrick, E.  (2011).  Needs of American Relatives of Intensive Care Patients: Perceptions of Relatives, Physicians and Nurses.   Hunter, J.  D., Goddard, C., Rothwell, M., Ketharaju, S., & Cooper, H.  (2010).  A Survey of Intensive Care Unit Visiting Policies in the United Kingdom.   Jager, A.  J., & Wynia, M.  K.  (2013).  Variance in Patient Access to Support Persons by Race/Ethnicity and Language Preference: An analysis of patient survey data.   Karlsson, C., Tisell, A., Engstrom, A., & Andershed, B.  (2011).  Family Members' Satisfaction with Critical Care: A pilot study. Kean, S.  (2010).  Children and Young People Visiting an Adult Intensive Care Unit.   Kirchoff, K.  T., & Dahl, N.  (2006).  American Association of Critical- Care Nurses' National Survey of Facilities and Units Providin Critical Care.   Kutash, M., & Northrop, L.  (2007).  Family Members' Experiences of the Intensive Care Unit Waiting Room.     27 Table 4 Excluded studies in Alphabetical Order by Author Lee, M.  D., Friedenberg, A.  S., Mukpo, D.  H., Conray, K., Palmisciano, A., & Levy, M.  M.  (2007).  Visiting Hours Policies in New England Intensive Care Units: Strategies for improvement.   Liu, V., Read, J.  L., Scruth, E., & Cheng, E.  (2013).  Visitation Policies and Practices in US ICUs. May, J., Ellis-Hill, C., & Payne, S.  (2001).  Gatekeeping and Legitimization: How informal carers' relationship with health care workers is revealed in their everyday interactions.   O'Halloran, R., Worrall, L., & Hickson, L.  (2011).  Environmental Factors that Influence Communication Between Patients and their Healthcare Providers in Acute Hospital Stroke Units: An observational study. Paavilainen, E., Salminen-Toumaala, M., Kurikka, S., & Paussu, P.  (2009).  Experiences of Counselling in the Emergency Department During the Waiting Period: Importance of family participation.   Pavlish, C., & Ceronsky, L.  (2009).  Oncology Nurses' Perceptions of Nursing Roles and Professional Attributes in Palliative Care.   Plowright, C.  I.  (1998).  Intensive Therapy Unit Nurses' Beliefs About and Attitudes Towards Visiting in Three District General Hospitals.   Prins, M.  M., Milton, D., & Shaver, J.  F.  (1989).  The Effect of Family Visits on Intracranial Pressure.   Quinio, P., Savry, C., Deghelt, A., Guilloux, M., Catineau, J., & de Tinteniac, A.  (2002).  A Multicenter Survey of Visiting Policies in French Intensive Care Units.   Schiller, W.  R., & Anderson, B.  F.  (2003).  Family as a Member of the Trauma Rounds: A strategy for maximized communication.   Simpson, T.  (1991).  The Famly as a Source of Support for the Critically Ill Adult.   Spreen, A.  E., & Schuurmans, M.  J.  (2011).  Visiting Policies in the Adult Intensive Care Units: A complete survey of Dutch ICUs.   Tanner, J.  (2005).  Visiting Time Preferences of Patients, Visitors and Staff.   Taylor, A.  (2008).  Exploring Patient, Visitor and Staff Views on Open Visiting.   Tschann, J.  M., Kaufman, S.  R., & Micco, G.  P.  (2003).  Family Involvement in End-of-Life Hospital Care.   Vandijck, D., Labeau, S.  O., Geerinckx, C.  E., De Puydt, E., Bolders, A.  C., Claes, B., et al.  (2009).  An Evaluation of Family-Centered Care Services and Organization of Visiting Policies in Belgian Intensive Care Units: A multicenter survey.   Whitis, G.  (1994).  Visiting Hospitalized Patients.   Williams, B.  R., Bailey, F.  A., & Woodby, L.  L.  (2012-2013).  A Room Full of Chairs Around his Bed: Being Present at the Death of a Loved One in Veterans Affairs Medical Centers.     28 2.5.6 Appraisal Tools The Civil Service website recommends analyzing studies based on three major qualities: Methodological quality, relevance of research design to the current REA, and the relevance of the study focus for the current REA (Bevan et al., 2010).  In order to ascertain the methodological quality and the relevance of the design and study focus I used several different tools depending on whether the study was quantitative, qualitative, or mixed methods.    2.5.7 The Government Social Research Score and Weight of Evidence Tool The GSRS WOE tool is a heuristic that enables a four-part evaluation of studies (Gough, 2007).  The purpose of this tool is to assist a reviewer in creating a final assessment of the evidence through the weighing criteria that are both generic (to all studies) and specific (to the current review) (Gough, 2007).  WOE A is the first step and is a generic evaluation of the quality of the work and is not specific to the review itself.  WOE B is review-specific: it focuses on whether or not the study design has relevance to this particular review.  Also, review-specific, WOE C focuses on the particular topic of the study and its relevance to the review being conducted.  Finally, WOE D takes all of the previous answers into account and is an overall judgment as to the extent that the study answers the review question(s) (Gough, 2007).   As described in the previous section the GSRS WOE tool was used for all of the studies regardless of their design and a score of low evidence, medium evidence, or high evidence was assigned to each study; see figure 2 below for the details of the tool.   29 Additionally, to see the entire GSRS EPPI-Centre data extraction and coding tool for education studies V2.0 please see Appendix A.    Figure 2.  Government Social Research Weight of Evidence Assessment Tool Government Social Research Service Weight of Evidence Assessment Criteria Questions Weight of Evidence A: Taking account of all quality assessment issues, can the study findings be trusted in answering all the study questions?  High Trustworthiness Medium Trustworthiness Low Trustworthiness Weight of Evidence B: Appropriateness of research design and analysis for addressing the question or sub-questions, of this specific REA  High Evidence Medium Evidence Low Evidence  Weight of Evidence C: Relevance of particular focus of the study (including conceptual focus, context, sample, and measures) for addressing the research question, or sub-questions, of this specific REA  High Evidence  Medium Evidence Low Evidence Weight of Evidence D: Overall weight of evidence  High Evidence Medium Evidence Low Evidence Government and Social Research Service (Civil Service, 2010) Retrieved from: http://www.civilservice.gov.uk/networks/gsr/resources-and-guidance/rapid-evidence-assessment/how-to-do-a-rea May 10th 2013  2.5.8 The Critical Appraisal Skills Programme The CASP tool for Qualitative evidence is a 10-question screening tool to help evaluate the quality of Qualitative studies.  The tool begins by asking if there is a clear statement of aims and if the chosen methodology is appropriate for the research question asked.  If the answer is ‘yes’ to the first two questions the reviewer can continue on with the  30 remaining questions which appraise the design of the research, recruitment strategy, data collection methods, relationship between the researcher and participants, ethical considerations, data analysis, and a clear statement of findings.  The final aspect of the tool is whether or not it is clear what value the research findings are contributing.  I used the CASP 10 Questions tool for all of the qualitative studies and the qualitative portions of the mixed methods studies; see Figure 3 below for the details of the tool.  To see the tool in its entirety please see Appendix B.   Figure 3.  CASP 10 Questions Qualitative Research Analysis Tool CASP 10 Questions tool for qualitative research  1. Was there a clear statement of the aims of the research?   2.  Is a qualitative methodology appropriate?  Is it worth continuing?  3. Was the research design appropriate to address the aims of the research?  4. Was the recruitment strategy appropriate to the aims of the research?  5. Were the data collected in a way that addressed the research issue?  6. Has the relationship between researcher and participants been adequately considered?  7. Have ethical issues been taken into consideration?  8. Was the data analysis sufficiently rigorous?  9. Is there a clear statement of findings?  10. How valuable is the research?   CASP 10 Questions Tool for Qualitative Research (Civil Service, 2010) Retrieved from: http://www.civilservice.gov.uk/networks/gsr/resources-and-guidance/rapid-evidence-assessment/how-to-do-a-rea May 10th 2013  2.5.9 Maryland Scale of Scientific Methods Sherman, Gottfredson, MacKenzie, Eck, Reuter, & Bushway created the Maryland Scale of Scientific Methods (1998).  This tool is used to evaluate Quantitative studies using a five point scale that ranks studies from weakest to strongest in terms of overall internal validity (Sherman et al., 1998).  Level 1 is considered the weakest type of study where there is only an observation intervention and outcome from a single point in time and there are  31 multiple threats to internal validity.  Level 2 is equivalent to a study with a before and after methodology.  Level 3 is a study with comparison between two or more groups: there is a control group and an intervention group as well as a before and after methodology.  Level 4 is a more complex study that uses multiple groups, control, and before and after comparison.  Level 5 is a study that uses all of the same as Level 4 but also includes randomisation in its design (Sherman et al., 1998).  Studies that simply use descriptive statistics cannot be evaluated using the Maryland Scale of Scientific Methods (Sherman et al., 1998).   Finally, the Maryland Scale of Scientific Methods was used to evaluate all of the quantitative studies and the quantitative portions of the mixed methods studies; please see Figure 4. for the details of this tool.      32  Figure 4.  Maryland Scale of Scientific Methods  Maryland Scale of Scientific Methods (Civil Service, 2010) Retrieved from: http://www.civilservice.gov.uk/networks/gsr/resources-and-guidance/rapid-evidence-assessment/how-to-do-a-rea May 10th 2013  2.5.10 Synthesis of Findings Throughout the process of this REA I used an iterative process to synthesize the findings.  This allowed me to tailor and rethink my approach as I progressed through the studies.  Further, this allowed me to identify patterns within the data and to refine my questions.  As a guide I followed the ‘stages of synthesis’ diagram from the Civil Service website (Bevan et al., 2010).  Please see Figure 5 below.      Maryland Scale of Scientific Methods Level Methodological Quality Level 1 Observed correlation between an intervention and outcomes at a single point in time.  A study that only measured the impact of the service using a questionnaire at the end of the intervention would fall into this level. Level 2 Temporal sequence between the intervention and the outcome clearly observed; or the presence of a comparison group that cannot be demonstrated to be comparable.  A study that measured the outcomes of people who used a service before it was set up and after it finished would fit into this level.   Level 3 A comparison between two or more comparable units of analysis, one with and one without the intervention.  A matched-area design using two locations in the UK would fit into this category if the individuals in the research and the areas themselves were comparable.   Level 4 Comparison between multiple units with and without the intervention, controlling for other factors or using comparison units that evidence only minor differences.  A method such as a propensity score matching, that used statistical techniques to ensure that the programme and comparison groups were similar would fall into this category. Level 5 Random assignment and analysis of comparable units to intervention and control groups.  A well conducted Randomised Controlled Trial fits into this category.  33 Figure 5.  Stages of Synthesis   Stages of Synthesis.  (Civil Service, 2010) Retrieved from: http://www.civilservice.gov.uk/networks/gsr/resources-and-guidance/rapid-evidence-assessment/how-to-do-a-rea May 10th 2013   2.5.11 Communicating the Findings The final stage of any REA is to communicate the findings.  I used the Civil Service website to provide a guideline for how to do this and they recommend utilizing one of three standard formats; either in a 1 page, 3 page or 25 page format (2010).  In order to convey the findings of this REA in a comprehensive manner I have chosen the 25-page format and this can be found in the subsequent chapter of this paper.  2.6 Chapter Summary Beginning in May 2013 an REA was begun with the goal of examining the existing literature on the topic of open visitation in adult critical care.  A search, to the point of saturation, was undertaken of the following search engines: CINAHL; Cochrane Database; EMBASE; Joanna Briggs Database; MEDLINE; and PubMed.  The search resulted in a total of 62 articles all of which were reviewed for the inclusion criteria and read.  Quantitative  34 articles were reviewed using the GSRS score and Maryland scores.  Quantitative studies were also evaluated for the quality of their design, methodology and bias risk.  Qualitative articles were reviewed using the GSRS score and the CASP 10 questions.  Studies with a qualitative methodology were also reviewed for their design and methodology and the rigour with which the data was coded and analyzed.  Mixed methods studies were appraised using the GSRS score, the CASP 10 questions (for the qualitative portions) and the Maryland Score (for the quantitative sections).  Design and methodology was also reviewed in a similar fashion for the mixed methods studies.  There were a final total of seven quantitative articles, eight qualitative articles, and three mixed methods articles included in the REA.    35 Chapter 3: Findings 3.1 Introduction The following chapter will present the findings of the REA.  These findings are organized into three categories based on the type of study: qualitative, quantitative, and mixed methods.  Within each of these categories the findings will be discussed with regard to their ranking in the WOE scoring system known as the GSRS score (Civil Service, 2010; Gough, 2007).  The scale for the GSRS score is high, medium, and low.  For the purposes of this REA studies with a low ranking were excluded.  The GSRS score was used as an exclusion factor because practice and policies should be based on the best possible evidence.  Therefore, only the findings from studies with a rank of high or medium were included.    3.2 Qualitative Studies Qualitative research is the investigation of phenomena where non-numerical data are collected in an in-depth manner that creates rich narrative information (Polit & Beck, 2012).  In this section qualitative studies that ranked high or medium on the GSRS score will be discussed.  The CASP 10 questions tool was used for the evaluation of the qualitative evidence and the results were entered into an Excel spreadsheet.  The findings from the CASP questionnaire helped to inform the reporting of the findings.  Eight qualitative studies were included for review in this REA: seven were considered high evidence and one was considered medium evidence.     36 3.2.1 Weight of Evidence: High The high score means that the study demonstrated high trustworthiness and high evidence in categories A, B, C and D (i.e., overall evidence) (Civil Service, 2010; Gough, 2007).  Trustworthiness refers to the dependability and quality of the study design and results  (Gough, 2007).  In order to receive a rank of A: high trustworthiness, the study demonstrated-that all the quality assessment pieces were well executed and rigorous (Civil Service, 2010).  Category B: High Evidence means that the research design and analysis were highly appropriate for addressing the question and or sub-questions of this particular REA.  Category C: High Evidence refers to the relevance of the study’s focus to the current REA; this includes the relevance of the conceptual focus, context, and sample and measures.  Category D: High Overall Evidence means that study execution, design and focus were all high quality and relevant to the REA (Civil Service, 2010; Gough, 2007).  For more information on the WOE scoring tool please see Appendix A.  The following table depicts all of the qualitative studies that received a Category D: overall high rank.  The findings from each study will be discussed in detail below.      37 Table 5 Qualitative Studies Weight of Evidence High by Author and GSRS Category Score Authors Category A Category B Category C Category D  Agard, S.A.; Lomborg, K.  High Trustworthiness High Evidence  High Evidence High Overall Evidence Eggenberger, S.; Nelms, T.  P.   High Trustworthiness High Evidence  High Evidence High Overall Evidence Farrell, M.  E.; Joseph, D.H.; Schwartz-Barcott, D.  High Trustworthiness High Evidence  High Evidence High Overall Evidence Johansson, I.; Fridlund, B.; Hidlingh, C.  High Trustworthiness High Evidence  High Evidence High Overall Evidence McAdam, J.; Arai, S.; Puntillo, K.A.  High Trustworthiness High Evidence  Medium Evidence High Overall Evidence Olsen, K.D.;  Dysvik, E.; Hansen, B.S.  High Trustworthiness High Evidence  High Evidence High Overall Evidence Williams, C. High Trustworthiness High Evidence  High Evidence High Overall Evidence *Please see Appendix A for full explanation of GSRS scoring system     38 Agard and Lomborg (2010) studied Danish ICU nurses’ decision-making regarding visitation using a grounded theory approach and semi-structured interviews.  They identified three themes: clarifying relations, defining the situation, and guiding relatives.   “Clarifying relations” referred to the process the nurse went through to get to know who the family is and what their relationship is to the patient.  This process helped to inform the nurses’ decision about whether this person should be allowed to visit.   “Defining the situation,” the second theme, related to what the nurse took into consideration when deciding whether a visit at the bedside was appropriate.  These included the safety of the patient, time of day, and the existing unit policy, though special exceptions were made for patients who were dying.  The final theme, “guiding relatives,” pointed to the role the nurses took in encouraging families to either stay or leave the unit.  Additionally, this sometimes meant that the nurses had to invite people to return to the unit if their loved one was no longer doing well.   The researchers found that nurses drew on multiple factors to aid their decision making: nurses assessed the current conditions of the unit, the needs of the neighbouring patients, the needs of the family, and the needs of other staff on the ward.  The authors described this decision making process as ‘clinical leadership’ (Agard & Lomborg, 2010).  They asserted that while negotiating family visitation is often seen as a simplistic nursing task, it is actually complex and required communication and assessment skills and the ability to put together a holistic picture of the patient, family, staff, and unit.  Further, the authors suggested that the training of critical care nurses should support the development of clinical leadership.   39 Farrell, Joseph, and Schwartz-Barcott (2005) used in-depth interviews and participant observation when they studied eight ICU nurses.  These nurses were chosen for the study because their charge nurse had identified them as ‘expert’ in working with families.  From these interviews the following four themes emerged: dealing with visitors in daily practice, gaining access, general approaches, and asking families to leave the unit.  Each theme will be described in brief detail in the subsequent paragraph. “Dealing with visitors in daily practice” referred to how nurses incorporated visitation into their workflow (Farrell et al., 2005).  The nurses agreed that each patient and visitor situation was unique; as such there was no way for them to easily incorporate the work associated with visitation into their workflow.  This feeling of being unable to prepare for the task of visitation contributed to the feeling that it was additional and burdensome work.   “Gaining access” referred to the process families went through to gain proximity to their loved ones.  Barriers to proximity included: requiring family to call prior to visiting, and admitting only people related by blood or marriage (Farrell et al., 2005).  These restrictions were not applied equally and were often suspended when the patient’s death was imminent.  Furthermore, the ICU visitation policy only allowed visitation 5 minutes every hour 24 hours a day.  Despite acknowledging the importance of family presence, the nurses in this study admitted to further restricting access if the unit was busy (Farrell et al., 2005).    “General approaches,” described the nurses’ different approaches to family visitation.  The nurses in this study acted as advocates for the patient, for instance, they discouraged visitation if the patient felt tired (Farrell et al., 2005).  In addition this theme encompassed the concerns nurses had regarding how to safely administer medication with  40 visitors present.  This theme also included how nurses explained the technical aspects of the ICU.   The final theme, “Asking families to leave the unit,” described when nurses requested privacy during their care of patients, for example, during a procedure such as a cardiac arrest, or personal care (Farrell et al., 2005).  These decisions were based on the patient’s physical comfort and the nurses’ willingness to have a family member present.  The researchers recommended the implementation of a new nursing role to answer family questions and address their needs during visit.   Williams (2005) explored family member contributions to the care of patients in the ICU using a naturalistic inquiry methodology with in-depth interviews and videotaping the nurses in their practice environment.  The purposive sample was comprised of 14 British ICU nurses.  The three themes were: Getting to know the patient through the family, family's contribution to patient care, and nurses' role in supporting families.  These themes will be discussed next.   “Getting to know the patient through the family” addressed the challenge in the ICU of getting to know patients who are typically sedated or intubated: families can help in this regard.  The nurses understood their patients better when they interacted with the family.  Often this meant picking up on subtle cues about the family’s relationship to the patient.  Gaining these insights helped the nurses feel more connected with their patients.   “Family’s contribution to patient care” referred to the vital role that families played in providing emotional support to the patient.  Further, the author suggested that emotional support helped to reduce anxiety and improve weaning from ventilation (Williams C. M.,  41 2005).  Finally, the researcher discussed the important social contribution of families, which helped provide some normality and structure to the patient’s day. The final theme, “The nurses’ role in supporting families,” highlights how the nurses facilitated communication between the non-verbal patient and the family by sharing communication techniques such as: inviting families to touch the patient (Williams C. M., 2005).  This helped to reduce confusion and frustration on behalf of both parties.  This was important because in the critical care environment families needed that permission in order to feel safe to have physical contact with the patient (Williams C. M., 2005). Eggenberger & Nelms (2007) conducted a phenomenological study with eleven families (41 participants total) that was grounded in family systems theory.  The researchers conducted in-depth semi-structured group interviews with each family and analyzed the data using a hermeneutic method.  The goal was to understand the experience of the family when one of their adult members was critically ill.  The authors found four themes: lived space, lived relation, lived body, and lived time, each will be discussed below.    “Lived space” referred to the physical space families occupied.  Although families felt that the ICU was a confusing and foreign place they still had a strong urge to be in close proximity with their loved one.  The families’ temporary “lived space” was occupied by technology and feelings of vulnerability and helplessness.  Many families described the psychological space as ‘hell’ (Eggenberger & Nelms, 2007). “Lived relation” described the nature of relationships between family members, nurses and doctors.  Relationships between family members strengthened as a result of “suffering through this hell” (Eggenberger & Nelms, 2007).  Nurses played a pivotal role in supporting and uplifting the families when they spent time with the family, shared of  42 themselves, and treated the patient with dignity.  Furthermore, when nurses shared information with families, family members felt more connected to the nurse and trusted them.  Families experienced distress when they were discouraged from participating in the care of their loved ones, or when they were not acknowledged as important.   The second theme “lived body” explored the incredible amount of physical and emotional strain that families experienced when they had a critically ill loved one.  “Lived body” related to the families experience of anxiety, guilt, sadness, fear, and uncertainty when they were trying to be physically present with their loved one.  The authors also noted that families experienced strain due to travelling between hospital and home and from spending long periods at the bedside. The final theme “lived time” related to the importance of proximity and how they felt that this ranked over anything else, the families called this effect ‘suspended time’ (Eggenberger & Nelms, 2007).  The families’ time was constantly filled with uncertainty and much was also spent waiting.  Finally, the researchers noted the profound power of nurses to influence the experience of the patient and family (Eggenberger & Nelms, 2007).   Johansson, Fridlund, & Hildingh (2005) used a grounded theory methodology to conduct a secondary analysis in order to understand the support needs of families of critically ill adults.  The sample consisted of twenty-nine adult relatives of adult ICU patients in Southwest Sweden.  Five themes emerged: the situation of the relatives, the generated theoretical understanding of what relatives found supportive, to trust oneself, to encounter charity, to encounter professionalism.     43 “The situation of the relatives” described the chaotic and shocking situation that families of critically ill patients find themselves in.  Most of the families had been warned that their loved one would not likely survive.  The families experienced powerlessness and profound uncertainty.  They felt unable to help their loved one and reliant on the healthcare professionals.   “The generated theoretical understanding of what the relatives found supportive” discussed the experience of support in the ICU.  Family members of critically ill patients found empowerment through internal and external resources.  Internal resources were described as cognitive functions such as trust in oneself and supporting oneself.  External resources were described as both emotional and intellectual such as to be supported as a person and as a relative.   The third theme was “To trust oneself” and as mentioned above was identified as an internal resource.  Families’ devised strategies to help themselves cope better and in doing so were better able trust their ability to confront the challenges of having a critically ill family member (Johansson et al., 2005).   “To encounter charity” meant that families felt supported by the nurses.  The families described this as being accepted for who they were and how they acted by the nurses.  Families reported that caring behaviour demonstrated by the nurses had a powerful impact on their experience (Johansson et al., 2005).  Caring behaviours encompassed actions such as everyday pleasantries to deeper more meaningful conversations.  Families interpreted displays of caring for them as also caring for the patient.   44 The final theme, “to encounter professionalism”, meant to be supported by nurses as a family member.  The families defined professionalism as being given the opportunity to participate in care for, or the invitation to be at the bedside of their loved one.  The researchers determined visiting to be therapeutic for both the family and the patient (Johansson et al., 2005).  Finally, families felt secure when nurses demonstrated overt commitment to the care of the patient (Johansson et al., 2005).   McAdam, Arai & Puntillo (2008) utilized a purposive sample of 25 family members to conduct in-depth interviews, the findings of which were analyzed using an exploratory methodology.  The study aimed to determine the support that families provide when they have a loved one in the ICU.  The researchers identified six themes: Active presence, protector, facilitator, historian, coach, and voluntary caregiver.  These themes will be discussed in the subsequent paragraphs. “Active presence” discussed the importance that families placed on the need for proximity to their loved ones.  Families described sitting at the patient’s bedside to maintain a vigil.  Most, families, believed that being present made their loved one feel safer and more comfortable (McAdam et al., 2008).   “Protector” related to the idea that families’ felt they had to advocate for their critically ill loved one.  This meant that the family, while they were present at the bedside, attempted to defend and protect their loved-one.   The third theme “facilitator” described the role of families when they translated, explained, and interpreted the information for the patient.  Sometimes, this meant that the family also restated information for the healthcare team.     45 “Historian” described how the family acted as the source for all collateral information about the patient both before their illness and during.  The family then shared this intimate knowledge about the patient with the healthcare team.   “Coach” was identified as the role where family members worked to encourage, comfort, and motivate the patient during their critical illness.  The support offered by the family inspired hope in the patient.   The final theme, “voluntary caregiver,” described the importance of the family providing care to the patient.  The family wanted permission to provide personal care such as massage, repositioning, and daily needs.  Family members felt safer and less anxious when they enacted these six themes (McAdam et al., 2008).   Olsen, Dysvik, & Hansen (2009) conducted semi-structured interviews with eleven Norwegian ICU patients in order to understand what the presence of family meant to them during their stay in the ICU.  The researchers identified six themes: who the participants sought visits from, statements about the visits, support of the patient, stress for the patient, stress for the patient and family, and support of the family.  These themes will be discussed in the ensuing paragraphs.   “Who the participants sought visits from,” described the type of people that patients felt were most appropriate to visit them.  The participants sought visits from those they considered close or family. Patients wanted to be involved in the decision and were explicit about who they did not want to visit them.   “Statements about the visits” showed that many participants expressed ambivalence about visits but overall felt that they were valuable.  The authors indicated that this conflict  46 could be because the patients were sedated, intubated and not fully aware during visits but after they recovered they appreciated the value of knowing loved ones were with them.   “Support of the patient” referred to how the patient felt during visits from family – even when patients could not remember details of their ICU stay.  This ICU had flexible visiting hours that facilitated the presence of family.  The patients in this study valued the fact that their family was present not just for the support they provided but also for their ability to maintain the narrative of the patients illness (Olsen et al., 2009). “Stress for the patient” concerned the patients’ challenge to communicate verbally due to being intubated.  Participants felt that it was challenging to receive visitors when they felt unwell—particularly when too many visitors made it difficult for them to cope or manage these visits. “Stress for the patient and the family,” described the concern that patients had about their illness impacting their loved ones negatively.  They were worried that seeing them in this state could cause their family long-term distress.   The final theme was “support of the family. ” This theme represented the t patients’ belief that their families benefited from being present during their stay.  Patients felt that having their family present allowed the family to witness and engage with the care provided.  Despite the stress, patients said they felt supported by their family (Olsen et al., 2009).  This is the last qualitative study with a high category D rank.  3.2.2 Weight of Evidence: Medium The following section describes the single qualitative study that received the rank of medium in category D.    47  Table 6 Qualitative Studies Weight of Evidence (WOE) Medium by Author and GSRS Score Author Category A Category B Category C Category D  Eriksson, T.; Bergbom, I.; Lindahl, B.  High Trustworthiness High Evidence  Low Evidence Medium Overall Evidence *Please see Appendix A for full explanation of GSRS scoring system  Eriksson, Bergbom, & Lindahl (2011) conducted in-depth interviews using a hermeneutic approach with twelve people; seven previous ICU patients and five family members.  The findings of this study were broken into two main categories with two sub-themes each: the experiences of the patients – recalling real and unreal life experiences; and the experiences of the family – being on and off stage.  These themes will be examined in the next paragraphs.   “Experiences of patients- recalling real life experiences” described patients’ memories of real events that took place during their ICU stay.  Some patients described the experience as a dream-like state but were able to recall some specific events that occured.  Further, Patients described that they felt they had to show that they were strong and fighting for their lives (Eriksson et al., 2011).  Interestingly, none of the patients had any negative memories of the ICU.   The second sub-theme of “The experiences of patients” is “recalling unreal life experiences” which described the memories of patients that were not based on real events.  The patients explained elaborate journeys and what they experienced– such as being on a boat and feeling a cold wind blowing over them.  Many of the unreal experiences detailed by  48 patients had to do with escaping or taking trips.  Some of the participants recalled these unreal experiences as so frightening that they were unable to describe them in words.   “The experiences of family” sub-theme “being on stage” referred to the role of the family at the bedside.  “Being on stage” meant that the family felt they had to show strength and courage.  In addition, they also felt that they had to ask questions and seek information about their loved one.  The participants described that they felt good when they were present because they were engaged with the patient and the staff (Eriksson et al., 2011).  This allowed them to build relationships with the staff.   “The experiences of family” sub-theme “being backstage” was described as any time the family were outside of the patients room.  “Being backstage” meant that families felt isolated and alone (Eriksson et al., 2011).  In the following section studies that utilized a quantitative methodology will be described.    3.3 Quantitative Studies Quantitative research is the investigation of phenomena that are easily quantified and measured.  This form of data collection is rigorous and can use a controlled design (Polit & Beck, 2012).  The following section focuses on quantitative studies that ranked high or medium in category D.  The Maryland Score tool was also used for the evaluation of the quantitative evidence and the results were entered into an Excel spreadsheet.  The Maryland Score was useful in scoring the studies design and quality but could not be used to evaluate studies with descriptive statistics.  For more information on the details of the Maryland Scoring tool please see Appendix C.  Seven quantitative studies were included: four were  49 considered high evidence and three were considered medium evidence, each will be discussed below.    3.3.1 Weight of Evidence: High This section describes the quantitative studies that ranked high in category D.  The table below lists all of the included quantitative studies and the scores they received from each tool.    50 Table 7 Quantitative Studies by Authors, Weight of Evidence (WOE) and Maryland Score Authors Category A Category B Category C Category D Maryland Score  Ericksson, T.; Bergbom, I.  Medium Trustworthiness Medium Evidence High Evidence High Overall n/a Fumagilli, S.; Bocinelli, L.; Lo Nostra, A.; Valoti, P.; Baldereschi, G.; Di Bari, M.; Ungar, A.; Baldasseroni, S.; Geppetti, P.; Masotti, G.; Pini, R.; Marchionni, N.  High Trustworthiness High Evidence  High Evidence High Overall Evidence Level 5 Garrouste-Orgeas, M.; Philipart, F.; Timsit, J.F.; Diaw, F.; Willems, V.; Tabah, A.; Bretteville, G.; Verdavainne, A.; Misset, B.; Carlet, J.   Medium Trustworthiness Medium Evidence High Evidence High Overall Level 1 *Please see Appendices A & C for full explanation of GSRS scoring system and Maryland Score.  Please also note that a Maryland Score of n/a was applied when the statistics used were limited to descriptive statistics  Eriksson and Bergbom (2007) used a prospective, explorative, observational design to investigate the frequency and duration of visits for 198 mechanically ventilated patients in an ICU in Western Sweden.  They sought to investigate the impact that these visits had on patient survival and length of stay.  Seventy-five percent of participants had visitors; a quarter of who were spouses.  This study found that patients who were not partnered had  51 fewer visits, and were older.  Further, male patients had more visitors than did female patients.  The researchers found that there was no statistically significant difference between the mortality and hospital length of stay between those with visitors and those without visitors (Eriksson & Bergbom, 2007).   Fumagalli et al. (2006) conducted a single center randomized pilot study in a six-bed ICU in Italy.  They compared the complications associated with unrestricted visiting and restricted visiting.  There were 226 participants; 115 belonged to the unrestricted visiting policy group (UVP) and 111 belonged to the restricted visiting policy group (RVP).  Those analyzing the data were blinded to the study group from which the data were collected.  The researchers evaluated the microbial contamination of the environment, septic and cardiovascular complications, emotional profile, and the stress hormone response of each patient.  In the paragraphs that follow the findings of this study will be discussed.   Each group had one visitor per day but in the RVP the nurses chose the visitor and when they could visit.  In the UVP group the patient chose the visitor and when they could visit.  This resulted in 1 additional visitor per day and longer visits for those in UVP group. The researchers conducted multiple tests for bacterial contamination of the air and surfaces.  For both groups there were similar amounts of air contamination but the bacterial contamination of surfaces was significantly higher in the UVP group.  Despite the increased surface contamination no significant difference between the two groups for pneumonia, urinary tract infections, generalized sepsis or overall septic complications were shown (Fumagalli, et al., 2006).   The researchers also examined mortality rates and cardiovascular complications.  They found a significant reduction in the mortality rate of the UVP group.  Further, there was  52 a statistically significant finding for the RVP group: they were nearly twice as likely to have developed cardiovascular complications (Fumagalli, et al., 2006).   Emotional profile and stress-indicating hormones were also measured for both groups.  Both groups had a similar emotional profile on admission but there was a significant decrease in the anxiety profile of the UVP group.  Interestingly, there was no significant difference in the depression score of either group.  There was also no significant difference between the two groups with regard to the stress-indicating hormones but there was a clinically significant reduction in the hormones of the UVP group.  Although, the researchers recognized that more study was needed, they proposed that the increased visits reduced the patients’ anxiety and could have accounted for the improved cardiovascular outcomes of the UVP group.   Garrouste-Orgeas et al. (2008) conducted a single centre study in France with 192 people: 149 family members, 13 doctors and 30 nurses.  The researchers used self-administered surveys to evaluate the perceptions of a 24-hour visiting policy in the ICU, measure visiting times and determine the prevalence of anxiety and depression in families.   The main finding is that the unrestricted ICU visitation policy was associated with 1-2 hour visits by family per day.  The families in this study had high family satisfaction, and moderate symptoms for anxiety and depression.   The researchers also investigated the nurses’ and doctors’ perceptions of interference with the care they provided.  Interestingly, they reported a low perception of interference with their delivery of care.  However, nurses did report that they altered their behaviour when a family member was present.  The subsequent section will discuss those studies had a ranking of medium.  53 3.3.2 Weight of Evidence: Medium This section will describe the three studies that were ranked medium in category D.  The table below shows each study and the score achieved.    Table 8 Quantitative Studies Weight of Evidence Medium by Authors, GSRS Score, and Maryland Score Authors Category A Category B Category C Category D Maryland Score Hardin, S.; Bernhardt-Tindal, K.; Hart, A.; Stepp, A.; Henson, A.  Low Trustworthiness Medium Evidence High Evidence Medium Overall Evidence n/a Hunter, J.D.; Goddard, C.; Rothwell, M.; Ketharaju, S.; Cooper, H.  High Trustworthiness Low Evidence Medium Evidence Medium Evidence n/a Roger, C.; Mari, A.; Bousquet, P.-J.; Louart, G.; Casano, F.; Cuvillon, F.; Muller, L.; Zoric, L.; Saissi, G.; Leffrant, J.-Y.               High Trustworthiness Medium Evidence Medium Evidence Medium Overall Evidence Level 1  54 Table 8 Quantitative Studies Weight of Evidence Medium by Authors, GSRS Score, and Maryland Score Soury-Lavergne, A.; Hauchard, I.; Dray, S.; Baillot, M.; Bertholet, E.; Clabault, K.; Jeune, S.; Ledroit, C.; Lelias, I.; Lombardo, V.; Maetens, Y.; Meziani, F.; Reignier, J.; Souweine, B.; Tabah, A.; Barrau, K; Roch, A. High Trustworthiness Medium Evidence Medium Evidence Medium Overall Evidence n/a *Please see Appendices A & C for full explanation of GSRS scoring system and Maryland Score.  Please also note that a Maryland Score of n/a was applied when the statistics used were limited to descriptive statistics  Hardin, Bernhardt-Tindal, Hart, & Henson (2011) used a convenience sample of 122 English speaking patients in an American ICU to determine the satisfaction of critically ill patients with the current visiting policy, their preference for visit times and frequency.  The existing visitation policy allowed for two visitors at 30-minute intervals four times per day.  The researchers utilized a descriptive correlational design and distributed a non-validated 11-item questionnaire.   Overwhelmingly, patients wanted more time with their loved ones.  Over half wanted unlimited visitors or at least visitation more than four times per day.  Nearly all wanted no restriction on the time of day for visits and most reported that visitors did not increase their feelings of fatigue (Hardin et al., 2011).  There were significant correlations between liking visitation, length of preferred visitation time, number of visits in a day, and number of visitors allowed at any one time.  There were also significant correlations between age and  55 the number of visits that were desired – younger patients wanted more visitors more often.  Overall, the participants in this study wanted more control over visitation.   Hunter, Goddard, Rothwell, Ketharaju, and Cooper (2010) conducted a descriptive study of 271 British ICU nurse leaders.  They mailed self-administered surveys to determine the current visiting practice and what was provided for families within British ICUs.   The findings of this study revealed the type of visitation policy, how families accessed the ICU, and how information was shared with families.  The authors found that most ICUs had a formal visiting policy but only a small number had an open policy.  Nearly all made exceptions if the patient was dying (Hunter et al., 2010).  Further, over half of the ICUs had a ‘quiet period’ where no visitors were allowed in the unit so that ICU staff could work uninterrupted.  Families were asked to wash their hands before entering the patient room in all of the ICUs surveyed but some also asked that they don personal protective equipment (gown, gloves, and mask).  The vast majority provided written information to families regarding the unit and half also scheduled a meeting with the family and medical team on admission.  Information was rarely conveyed over the telephone.  The researchers concluded that not enough information was shared and that there was a conservative traditional model for visiting in most British ICUs and suggested a revision of the policies for both information sharing and visitation (Hunter et al., 2010).   Roger et al. (2010) conducted a single center observational cross-sectional prevalence in France to understand the wishes of relatives with regards to visiting hours in the ICU.  The researchers drew on a small sample of 64 family members who had a critically ill loved one in the ICU for 48 hours or more.  They utilized a validated questionnaire that was  56 administered by one of three nurses involved in the study.  This ICU allowed for two 1-hour visits per day except on weekends when family could visit for four hours in the afternoon.   The researchers had several salient findings regarding the needs and wants of family members of adult ICU patients.  Interestingly they found that over half of participants were satisfied with the current visiting hours but that nearly the same amount also stated they would like longer visiting hours.  Further, nearly half reported that they desired 24 hour per day visiting hours.  Family members indicated they would like to help with personal care but do not want to upset the nurses by doing so (Roger, et al., 2010).  Many family members also wanted to be able to be present at meal times in order to help their loved one eat.  The key finding was that most families wanted to be present with their loved one but did not want to interfere with the care they received.   Soury-Lavergne et al. (2011) led a descriptive study of ICU visitation policies in France with a sample of 722 caregivers (472 nurses, 175 doctors, and 75 allied health professionals).  They utilized a 49-item validated questionnaire created by The Board of the Nurses’ Congress of the French-speaking Society of Intensive Care.  The researchers aimed to determine caregiver opinion regarding visitation policy, information sharing with families and family participation in care.   Caregivers had several different opinions regarding their units’ visitation policies.  More than half of the adult ICUs had a restrictive visiting policy but many indicated they were in favour of increasing the visiting times available to families.  Additionally, those caregivers that already worked with open visiting hours were more likely to think that the policy improved the relationship with the patients and family.  However, more than half of  57 respondents felt that increased visiting hours in their unit would be disruptive to their ability to provide patient care (Soury-Lavergne, et al., 2011).   The way that families received information varied but nearly all respondents thought that information should be shared with families in the presence of their nurse.  Doctors were less likely to indicate that it was useful to have the nurse present during these discussions.  In addition to face-to-face meetings, information was also shared over the phone in nearly all of the ICUs.  The authors noted that adult ICUs were more likely to have restricted visiting and that there is evidence to suggest that a change in policy would be beneficial to patients, families and staff.  This is the final study in the quantitative section and the following section will describe the studies that utilized a mixed-methods design.    3.4 Mixed-Methods Studies Mixed-Methods design is a research process that utilizes both qualitative and quantitative design.  This research approach allows different but similar questions to be answered by the different types of data (Polit & Beck, 2012).  The following section describes the findings of the three included mixed-methods studies.  All of the studies ranked medium in category D.  It should also be noted that none of the studies in this section were described as mixed methods designs, although they all included both quantitative and qualitative components.     58 3.4.1 Weight of Evidence: Medium The category D score was applied to each of the studies with the Maryland score applied to the quantitative sections and the CASP 10 questions tool applied to the qualitative sections.  The table below lists the studies and their respective scores.    Table 9 Mixed Methods Studies Weight of Evidence Medium by Author, GSRS Score, and Maryland Score Authors Category A Category B Category C Category D Maryland Score Agard, A.S.; Maindal, H.T.   Medium Trustworthiness Medium Evidence Medium Evidence Medium Overall Evidence n/a Gonzalez, C.; Carroll, D.; Elliott, J.; Fitzgerald, P.; Vallent, H.  Medium Trustworthiness Medium Evidence High Evidence Medium Overall Evidence n/a Marco, L.; Bermejillo, I.; Garayalde, N.; Sarrate, I.; Margall, M.; Asiain, C.  High Trustworthiness Medium Evidence Medium Evidence Medium Overall Evidence Level 1 *Please see Appendices A & C for full explanation of GSRS scoring system and Maryland Score.  Please also note that a Maryland Score of n/a was applied when the statistics used were limited to descriptive statistics  Agard and Maindal (2009) used a cross-sectional, mixed methods design with a sample of 68 Danish ICU nurses.  They investigated their perceptions of participants’ personal knowledge and skills and outcome expectations in interacting with families.  The participants completed self-administered questionnaires and the quantitative findings were  59 analyzed using non-parametric statistics and linear regression models.  The questionnaire included open-ended questions that provided the qualitative data.  The findings of this study will be detailed in the ensuing paragraphs with the quantitative results presented first and the qualitative results presented second.   The quantitative findings showed that nurses recognized family work as part of their nursing duties.  There was a statistically significant relationship between the nurses’ perceived outcome expectations and their willingness to involve relatives in care activities (Agard & Maindal, 2009).  The majority of nurses felt they should allow relatives to participate in the minor care activities of the patient.   There was a small amount of qualitative data from open-ended questions that added some context regarding the nurses’ perceptions.  Nurses felt that family members benefited from seeing the amount of care the patient received; this assisted their understanding of the gravity of their loved ones illness.  The nurses felt strongly that it was within their professional boundaries to be involved in the families’ psychosocial issues.  Further, when they communicated with families they gained valuable information about the patient.  Some nurses still questioned whether or not family members should be allowed to witness certain situations and felt they could practice more freely without the presence of relatives.  Overall, the researchers concluded those nurses’ perceptions of personal knowledge and skills with interacting with families did not always equate with actual knowledge and skills.  However, those with a high degree of self-efficacy and positive expectations did indicate a high ability to cope with the demands of family presence (Agard & Maindal, 2009).     60 Gonzalez, Carroll, Elliott, Fitzgerald, and Vallent (2004) conducted a mixed methods study in two American ICUs using a validated survey tool, Patient’s Perceptions of Visiting in Hospital, and a structured interview.  Sixty-two patients participated in the study (Gonzalez et al., 2004).  The researchers aimed to describe patient preferences for family visiting.   The researchers found that the patients were not unanimous in their preferences towards visiting hours.  Less than half of the patients in this study wanted visiting hours to be unlimited, and some wanted to have visitors only once per day.  Half of the patients wanted visitors to come in the afternoon and less than half wanted visiting over by 8pm.  Many patients worried about their loved ones travelling to visit them but they valued the visit and found that their family helped with the interpretation of information.  Visiting was not perceived as stressful or an impediment to rest by the subjects in this study.   The qualitative findings from interviews with patients helped to add some context to the quantitative data.  The study participants also felt that the presence of their loved ones indicated that they were loved and cared for.  Patients wanted the ability to indicate when they did not want visitors; such as if they were feeling particularly unwell or the dynamic in their family was not optimal.  Patients suggested creating visitation guidelines that were flexible and allowed for the individual needs of patients and the authors endorsed this recommendation (Gonzalez et al., 2004).   Marco et al. (2006) conducted a mixed-methods descriptive correlational study with 45 ICU nurses in Spain using self-administered questionnaires.  This study aimed to analyze the relationship between nurses’ beliefs and attitudes about open visitation and the impact on patients, families, and nurses’ work (Marco et al., 2006).  61 The authors used the quantitative findings to present the correlation between nurses’ attitudes and beliefs about open visitation.  They found that most nurses felt positively about open visitation and believed that there was a positive impact on the patient and family.  One interesting demographic variable found that nurses with children were more likely to be in favour of open visitation.  Nurses also felt that open visitation reduced family anxiety and increased their satisfaction.  Finally, many nurses stated they felt that visiting did not exhaust their patients.  The qualitative data were derived from open-ended questions attached to the self-administered surveys. Ten themes were identified: adaptation of the condition of the patient and the family characteristics, influence of the structural characteristics of the unit, effect that open visiting has on the patient, timetable and length of visit, effects of the visit on the family, effects of open visiting on nurses, repercussion of open visiting on nursing care, visiting as a means of obtaining information about the patient, preparing the family for the visit, number of people in each visit.  Without detailing the findings of each category I will discuss some of the key qualitative findings.  The researchers found that nurses felt that open visiting was a good system for patients and that it helped them remain in contact with the outside world.  Nurses were also in favour of longer family visits even if it meant increased workload for them.  Further, nurses felt that close proximity with the patient helped the families to feel more satisfied and intensified the bond between the family members.  The researchers found some negative attitudes regarding increased workload, potentially not being able to meet all of the families’ demands, and fear of negatively impacting the family through exposure to a critical event such as a cardiac arrest (Marco et al., 2006).  This is the  62 last study in the mixed methods section and next a short summary of the chapter will be presented.    3.5 Chapter Summary The findings from nineteen research studies were presented in this chapter.  Qualitative studies made up the majority of the studies (8) and seven of them scored high on the GSRS scale while the remaining study rated a Medium.  The seven quantitative studies were split, three rated High and three rated Medium on the GSRS scale.  Finally, the three mixed methods studies all scored Medium on the GSRS scale.   The collective findings from these research studies shows the overarching impact of visiting policies and nursing practice on the patients, families, and nurses in the critical care environment.  There were noted benefits and drawbacks to patients, families and nurses with visitation.  In the following chapter I will go into depth regarding the themes that emerged from the studies included in this review and then in the final chapter, chapter 5, I will discuss strategies and recommendations for practice and policy to help meet the needs of both patients and families.  63 Chapter 4: Identifying Key Themes 4.1.1 Introduction The previous chapter presented the findings from 18 studies: seven quantitative, eight qualitative, and three mixed methods.  Based on the findings from these studies one overarching global theme and five organizational sub-themes emerged.  This chapter will present an overview of the approach I used to identify key themes in the REA studies.    4.1.2 Identifying Themes The themes from this REA were extracted using a systematized approach, referred to as creating a thematic network, which separated the themes into three categories: Global themes, organizing themes, and basic themes (Attride-Stirling, 2001).  Global themes are those themes that encapsulate the predominant idea that is found in the literature; in this case the global theme is proximity.  The middle-order category contains the organizing themes which help to summarize the more abstract concepts presented in the studies regarding this REA.  The organizing themes are: communication, control, empowerment, outcomes, and workload.  Basic themes are the lowest order of themes and represent the ideas that are evident in the literature: basic themes often represent actual words or phrases from the literature.  I have placed the basic themes in Table 10 with their corresponding organizing themes.     64 Table 10 Rapid Evidence Assessment Themes from the Literature Organized by Type of Theme Global Theme Proximity  Organizing Basic  Communication • Improved understanding of patient condition  • Patient history shared with team  • Improved communication with health care team   Control • Nurses desire control over visiting  • Patient desires more control over visitation   Empowerment • Trust and relationships improve  • Patients fight for their lives  • Families coach patient  • Nurses support the family   Outcomes • Improved cardiovascular outcomes  • Reduced anxiety for patients and families  • Reduced depression for patients and families   Workload • Families want to help with care giving  • Increased psychosocial work for nurses     65 Figure 6.  Thematic network organized from global theme to organizing theme to basic theme   Proximity	  Communic-­‐a?on	  Pa?ent	  history	  shared	  with	  team	  Improved	  communica?on	  with	  health	  care	  team	  Improved	  understanding	  of	  pa?ent	  condi␫n	  Empower-­‐ment	  Pa?ents	  fight	  for	  their	  lives	  Families	  coach	  pa?ent	  Trust	  and	  rela?onships	  improve	  Nurses	  support	  the	  family	  Outcomes	  Reduced	  anxiety	  for	  pa?ents	  and	  families	  Reduced	  depression	  for	  pa?ents	  and	  families	  Improved	  cardiovascular	  outcomes	  Workload	  Increased	  psychosocial	  work	  for	  nurses	  Families	  want	  to	  help	  with	  caregiving	  Control	  Pa?ent	  desires	  more	  control	  over	  visita?on	  Nurses	  desire	  control	  over	  visi␦g	  	   66 4.2 Global Themes The global theme is the theme that captures the most prevalent or comprehensive idea from the body of the literature.  For the purposes of this chapter there was only one global theme identified: proximity.    4.2.1 Global Theme: Proximity Proximity refers to the desire of families to be close to their critically ill loved ones and the desire of the critically ill patient to have their family close to them during their illness (Eggenberger & Nelms, 2007; Eriksson et al., 2011; Hardin et al., 2011; McAdam et al., 2008; Olsen et al., 2009; Roger, et al., 2010; Soury-Lavergne, et al., 2011).  As the global theme, proximity represents the conceptual thread that was woven throughout each piece of literature as an overarching theme.  It is an idea that was present in each study regardless of the population of the study..  Within this section of this chapter I will briefly explore the theme of proximity and how it relates to patients, families, and nurses.  Following this section I will discuss each of the organizing themes and how they relate back to proximity. Patients are unique individuals and as such they have unique needs.  Intensive care units that have standardized rules or restrictions regarding family presence negate this individuality and limit the ability of the family to meet the needs of the patient.  There was noted variation within the REA studies regarding the proximity needs of patients (Gonzalez et al., 2004; Eriksson et al., 2011).  This variation was wide and would make it challenging for any one static restrictive policy to capture and meet the needs of each patient.  For instance, patients of different ages and martial status had different needs for visitation.  It was suggested that those ICUs that offer a 24 hour visitation policy, or one that is determined to  67 collaborate with the patient, actually facilitated the family visiting their loved one (Garrouste-Orgeas, et al., 2008; Roger, et al., 2010). Families felt that their presence was beneficial to their loved ones and themselves; this act of being present was absolutely necessary.  Families wanted to be close to the patient for a number of reasons including: concern for the well-being of their critically ill loved one, guilt about not being close by, and the feeling that their presence was important to the patient.  Families described their presence as being active in their loved ones care and they felt that this made the patient feel safer and more comfortable (McAdam et al., 2008).  Proximity allowed the family to act as advocate and protector, their self-identified roles.  Being at the patient's bedside also allowed families to feel a sense of control in a critical situation where the outcomes were largely outside of the realm of their control.  In a time when families were filled with uncertainty it was critical for them to have ready access to their loved-ones.  Patients echoed similar sentiments regarding the value of the presence of their family during their illness.  Having their family present with them increased their feelings of safety and security, improved their knowledge of the plan of care, and inspired them to keep fighting for their lives.    4.3 Organizing Themes Organizing themes are the themes that help to capture the concepts that are closely linked to the global theme of proximity.  For this REA the organizing themes are: communication, control, empowerment, outcomes, and workload.  The basic themes are discussed within each of the organizing themes.  Basic themes are most closely associated  68 with the actual content (e.g., words, phrases) from the literature.  There are two to four basic themes within each of the organizing themes.  4.3.1 Organizing Theme: Communication Communication was an important theme associated with proximity because it facilitated communication between all parties.   In healthcare nurses play a major role coordinating care between different team members, and communication is a huge part of their work.  Communication also plays a large role in the relationship between the nurse, the family, and the patient and attitude can often impact how that communication resonates with the receiver (Marco et al., 2006).  When faced with challenging family behaviours, nurses in the REA studies were more likely to discourage family presence in the ICU than if their behaviours were easy and pleasant.   Nurses leveraged the family’s intimate knowledge of the patient through communication (Johansson et al., 2005; Williams, 2005).  When this occurred the nurses were able to gain insightful details about the patient’s history and the events that led to the ICU.  Further, by engaging with the family regarding the patient’s history, nurses were able to learn more about the patient as a person and their pre-ICU lifestyle.  This helped the nurses to build a strong relationship with the family and assisted in making treatment easier for the patient, their family, and the nurses.   Families also played important communication roles.  Within the REA studies, families shared important details that helped guide the course of treatment for the patient.  At the beginning of the ICU admission families typically assumed protector and advocacy roles (Eriksson et al., 2011; McAdam et al., 2008).  After building relationships with the ICU  69 team, they felt more comfortable, established trust with the team, and facilitated and maintained discussions with the multitude of nurses and doctors rotating through the unit.  In this way, families served as a persistent and consistent source of information about the patient.  Due to the level of their illness, sedation or intubation patients in the REA studies had unreal or dream-like experiences in the ICU that clouded their ability to distinguish between what really happened and what did not happen.  The proximity of their family throughout their stay and their capacity to hear their stories from family members post-ICU helped them make sense of what happened.    4.3.2 Organizing Theme: Control Visitation has historically been at the discretion of the nurse and thus within their control to change or adapt (Agard & Maindal, 2009; Agard & Lomborg, 2010; Gonzalez et al., 2004; Marco et al., 2006).   ICU nurses work in a fast paced and demanding area and are required to multi-task in order to complete their work throughout the day.  Visitation from families is one of the many things they are balancing and nurses said that they felt it could add to their workload.  For this reason the REA studies showed that nurses were reluctant to relinquish control over visiting and preferred to maintain restrictive policies or increase restrictions (Hunter et al., 2010;Marco et al., 2006; Soury-Lavergne, et al., 2011).  It was the exception that nurses wanted to increase the visiting hours or loosen their control.  Some nurses felt concern that if the patient had more control they would be impeded by the family from carrying out their nursing duties, such as medication administration (Marco et al., 2006).  One study recommended that nurses relinquish some control over visitation and collaborate with  70 patients and families to better assess their needs and tailor visitation to these needs.  Having families available to nurses, and in close proximity to patients, enhanced the opportunities for collaboration (Hardin et al., 2011).   The REA studies indicated that patients often had no control over when, who, and for how long their family could be with them, and they wanted this to change (Eriksson et al., 2011; Gonzalez et al., 2004; Hardin et al., 2011).  When discussing the desire to have more time with their families many patients stated that they simply wanted an increase in the allowable visiting hours.  There was however, a wide variability in what patients felt were acceptable times to visit.  Hardin et al. (2011) highlighted the need for individuality and increased control over the timing and duration of visits.    4.3.3 Organizing Theme: Empowerment Empowerment is the third organizing theme and it represents the impact that nurses and families have on each other and on the patient.  To empower someone means to provide them with the agency to act and to enable them to do so (Johansson et al., 2005).   In the REA study, nurses played a fundamental role in empowering or disempowering both the family and the patient.  In the REA studies, nurses used their formal authority or power to promote or restrict proximity based on their own beliefs and biases (Agard & Lomborg, 2010).  When nurses welcomed family presence they empowered the family by engaging them in the care of their loved one (Johansson et al., 2005).  This simple act increased the trust that the family had for the nurse and improved their overall relationship.     71 Critically ill patients are extremely vulnerable socially, emotionally, and physically.  Families are typically the most invested in helping their loved ones overcome their vulnerabilities and heal (Eggenberger & Nelms, 2007; McAdam et al., 2008).  In the REA studies, when the nurse supported the family, the family members were able to enact their role as a coach: this form of external empowerment helped them to support and motivate the patient.  This positive energy was found to be an excellent motivator for the patient (Johansson et al., 2005).   Patients were empowered by the proximity of their families, and family presence helped to maintain their connection to their lives outside of the hospital and the possibility of returning to their previous lifestyle (Olsen et al., 2009).  Even patients who were not conscious and not aware at the time of their family’s presence felt that it was an important factor in their recovery (Eriksson et al., 2011).    4.3.4 Organizing Theme: Outcomes This theme references the physical and emotional outcomes that patients experienced from the proximity or presence of their family.   Patients experienced improvements in both their emotional and physical health as a result of having their family close to them during their critical illness (Eriksson et al., 2011; Fumagalli, et al., 2006; Gonzalez et al., 2004; Olsen et al., 2009).  Emotional health refers to their levels of anxiety and depression.  Those patients who were able to have adequate access to their family had reduced experiences of anxiety that improved their healing trajectory in ICU.  A potential contributor to this reduction in anxiety was an improved sense of security and comfort that patients reported having when their family was present (Gonzalez et al.,  72 2004).  Finally, once they were through the critical phase of their illness, patients reported having a better understanding of the care they received if they had family who could contribute to filling in the gaps of their memory of the events (Eriksson et al., 2011).  Some patients did report feelings of stress regarding their family, such as concerns about the amount of travel or time their families had to dedicate to being in the hospital.  However, it was clear that these concerns were outweighed by the benefits of decreased anxiety.   Improved outcomes were not isolated to the patient group; there were also noted improvements in the families that were studied.  In one study, families with flexible visitation were compared to families who had restricted visitation: a validated anxiety and depression tool was given to both types of families.  Families with flexible visitation had lower anxiety/depression scores than those families who had restrictions (Garrouste-Orgeas, et al., 2008; Olsen et al., 2009). Patients also experienced improvements in their physiological status when proximity of their family was within their control.  Patients’ physiological improvements were noted in the cardiovascular performance and the presence of stress-inducing hormones in one study that investigated physiological outcomes associated with ICU patients when their families were present.  Fumagilli et al (2006) found that there was a significant reduction in poor cardiovascular outcomes of the patients in their study who had the ability to control who could visit them, when, and for how long.  They also noted a decrease, although not statistically significant, in the stress-inducing hormones of the patients in this group as well.     73 4.3.5 Organizing Theme: Workload Workload refers to the physical and emotional work of both the nurses and the family (McAdam et al., 2008; Williams, 2005).  In the REA studies the majority of nurses believed in the importance of including the family in their nursing care for patients, but many of them objected to a visitation policy that would allow families to be present at the discretion of the patient (Agard & Maindal, 2009; Hunter et al., 2010; Soury-Lavergne, et al., 2011).  This may be due to nurses’ perceived increase in their workloads during family presence in the ICU.  This perception of increased workload was true in other REA studies except the nurses in the Garrouste-Orgeas et al. (2008) study who said that they did not perceive a disruption in care.  The existing policy of the ICU seems to have had an impact on the nurses’ perceptions; those who worked in ICUs with an open policy were much more likely to be accepting of family presence than those who worked in ICUs with a restrictive policy (Garrouste-Orgeas, et al., 2008; Hunter et al., 2010; Soury-Lavergne, et al., 2011).   Nurses’ perception of increased workload was often associated with an increase in the psychosocial work that families required such as: emotional support, grief support, and communication assistance.  Further, nurses provided technical support such as: explaining the medical condition of the patient, the physicians’ plan of care, and explanation of the critical care environment including the monitors and machines (Agard & Maindal, 2009; Farrell et al., 2005; Hunter et al., 2010; Williams, 2005).  When families were present, nurses had to spend time to ensure that the above needs were met, and this meant stretching their capacity to accomplish the other tasks in the day.     74 The REA studies showed that the families of critically ill patients were faced with massive uncertainty and anxiety. Being in close proximity to their loved-ones helped them to feel connected and decreased their feelings of worry.  The families reported wanting to contribute to the physical and emotional care of their loved one but not wanting to interfere with the work of the nurses (Hardin et al., 2011; Johansson et al., 2005; Roger, et al., 2010; McAdam et al., 2008; Williams, 2005).  Families reported conflict between a feeling of helplessness and an obligation to care for their loved one.  They also expressed the desire to be asked or invited to participate at the level that they, and the patient, felt comfortable.  Family members who wanted to participate in care were able to assist with washing, massaging, feeding, and touching the patient.  When allowed to do so, they felt as though they were contributing to the patient’s improvement.  Further, families provided much needed emotional and psychological support because they could coach and encourage the patient to be positive and to survive.  When they were actively discouraged from participating with their loved ones’ care they were very distressed (Eggenberger & Nelms, 2007; Johansson et al., 2005).  Family members, as voluntary caregivers, reported feeling like part of the team; this level of participation helped them calm the chaos of their situation.    4.4 Chapter Summary I have provided evidence to support the six organizing themes from the REAs, and I have established their connection to the global theme of proximity.  Table 10 also provides examples of basic themes that I believe provide support for their respective organizing themes.  Nurses, families, and patients all agree that there are benefits to having families in close proximity to their critically ill loved ones.    75 Communication between the team and the family was enhanced when the family was able to be present, as was communication between the family and the patient.  The nurse played a facilitating role by giving the family tips on how to better communicate with their loved ones.  Nurses often desired maintaining or increasing their control over visitation while patients desired an increased amount of control over visiting.  Empowerment came in several forms, but proximity played a role in increasing the sense of empowerment—having the families there as sources of information and support.  Patients with more control over their visiting showed improved cardiovascular outcomes and decreased anxiety and depression.  Families also showed decreased anxiety when they were able to be present with their loved one.  Families wanted to contribute to the daily care of the patient and, when allowed to do so they reduced some of the nurses’ care burdens.  Families, however, needed a nursing invitation to participate because they were hesitant to take on these roles without nurse permission and guidance.  Nurses recognized the importance of family, but they were concerned about additional workload.  The themes of this REA illuminate the needs of patients, families and nurses.  In the next and final chapter I will describe how the findings from the included studies and these themes could be used to inform education, policy, and practice.     76 Chapter 5: Discussion and Implications 5.1 Chapter Introduction The purpose of an REA is to rapidly assess the existing evidence on a particular topic in order to inform the practice environment.  The focus of this REA was the visitation needs of patients, families, and nurses in the ICU.  The recommendations, that follow, are framed around suggestions for changes in practice, policy, education, and research that could help increase the proximity of families to patients in the ICU.  The beginning of this chapter will provide an application of the findings from Chapter 4 to the REA questions and sub-questions. Policy and practice recommendations encompass three key areas for change: amendment of visitation policies, enhancement of family participation in care, and enhancement of information sharing.  Education recommendations focus on the ongoing education needs of nurses and the needs of patients in the ICU.  The third area is the suggestions for nursing research including replication studies and future areas for research.    5.2 Applying the Findings to the Research Question and Sub-questions I will use the themes from Chapter 4 to answer the research questions identified in Chapter 1.  The global theme and organizing themes will be bolded in each section to demonstrate how these themes from the literature are associated with the answers to the REA questions.     77 5.2.1 Benefits and Drawbacks for Patients Overwhelmingly, patients wanted to have their families nearby (proximity) them while in hospital and felt that the family’s presence was important to their healing and well being (Eggenberger & Nelms, 2007; Eriksson et al., 2011; Gonzalez et al., 2004; Marco et al., 2006; McAdam et al., 2008; Olsen et al., 2005).  Gonzalez et al. (2004) showed that patients valued the fact that their families could act on their behalf to communicate with the healthcare team.  Patients also felt that having their family with them in hospital helped them to better understand the information relayed from the team.  The presence of family at the bedside improved the patient’s well being (outcomes) by helping them to feel more connected to their normal lives outside of the hospital (Marco et al., 2006; Williams, 2005).  An even more compelling benefit to critically ill patients was that the presence of their loved ones encouraged them to fight for their lives: patients wanted to get better and survive (Eriksson et al., 2011).  Family presence was important to patients once they regained consciousness and discovered that their families were there with them the whole time.  Nurses in Williams’ 2005 study identified that family members played a vital role in allaying the fear and anxiety of the patients.   A theme related to patient well being was their capacity to have some control over visitation.  The findings of Fumagilli et al. (2006) suggested that patients who were able to control when they had visitors showed improved cardiovascular outcomes.  They theorized that the reduction in the anxiety scores of the patients who had control over their visitation could have impacted the improved cardiovascular outcomes.     78 5.2.2 Benefits and Drawbacks for Families Several studies showed that families of critically ill patients wanted to be in close proximity to advocate for and to protect their vulnerable loved one (Eggenberger & Nelms, 2007; Eriksson & Bergbom, 2007; Johansson et al., 2005; Gonzalez et al., 2004; Olsen et al., 2009; Roger, et al., 2010).  Families preferred being at the bedside, but even being in the waiting room reduced their anxiety because they were nearby their loved-one (Eggenberger & Nelms, 2007; Olsen et al., 2009).  The reason proximity was so important to families is multi-faceted.  Having a critically ill loved one is very stressful, and one of the coping strategies families used to reduce their stress and anxiety was to be as close as possible to the patient.  Secondly, being in the same physical space as the patient allowed the families to fulfill what they felt was their role as protector, and advocate for the patient.  Families often felt that their loved-one was at risk of more harm and that they needed to be close to them to prevent this (Eggenberger & Nelms, 2007).  The need for proximity was especially important during the first stage of hospitalization; afterwards, the level of fear subsided as the family members grew to trust the staff.   Improved trust and relationships with the staff also benefited to the family.  Nurses felt that if families were able to witness the care and the attention that their critically ill loved one was receiving then they would have a better understanding of their loved one’s trajectory (Williams, 2005).  Finally, families felt positively about their experience when they were given permission to help with the care giving activities for their loved ones, such as hand holding, bathing, and feeding.  Although these are basic everyday activities families needed to be given permission to perform them in the critical care environment.     79 5.2.3 Benefits and Drawbacks to Nurses Communication, information sharing, and improved relationships were the key benefits for nurses from open visitation that supported family presence (Eggenberger & Nelms, 2007; Johansson et al., 2005; McAdam et al., 2008; Williams, 2005).  Nurses felt that they were better able to know their patient’s personalities when the family was present and that this helped them to plan their care more accurately (McAdam et al., 2008; Williams, 2005).  Families also helped nurses, who rotate, to create more continuity in care routines.  Also, of value to nurses, many families were interested in helping with the physical care of the patient (Soury-Lavergne, et al., 2011).  Families helped, in part, to reduce the burden of workload on the nurses, which freed them up to perform other tasks.  When nurses were able to effectively work with families and encourage them to be present and active in the care of the patient, families said they felt empowered.  Empowered families worked more collaboratively with the nurses, making the nurses’ work smoother, more effective and efficient.   In contrast to the above, some studies found that nurses’ felt that family presence increased the burden of their workload because of the high psychosocial needs of families in crisis (Agard & Maindal, 2009; Soury-Lavergne, et al., 2011).  An additional drawback for nurses was the perceived loss of control over their work environment when patients were allowed to decide who visited them and when (Marco et al., 2006).   Lack of policy or protocol to govern visitation and family presence, or a policy that is overly strict, resulted in nurses acting in ways that were detrimental (Agard & Lomborg, 2010; Farrell et al., 2005; Hunter et al., 2010; Roger, et al., 2010).  This typically occurred because each nurse arbitrarily decided for that shift whether they would allow family  80 presence or not.  This variability led to conflict between nurses, and nurses and families, and negatively impacted the unit culture.  When this occurred families behaviour could be challenging because they did not have clear expectations and they strongly wanted proximity to their loved one. The benefits and drawbacks of open visitation for nurses, families, and patients examined in these studies falls along the lines of the themes proximity, communication, control, empowerment, outcomes and workload.   5.3 Policy and Practice Recommendations The following section will discuss the policy and practice recommendations as understood from the findings of the REA studies.   The authors of the REA studies offered several suggested areas for substantive change in nursing policy and practice.  It is acknowledged that PFCC requires a multipronged approach to achieve its desired effects but the essential role of families in the health and well being of patients is one of the building blocks of PFCC.  Therefore, it is not surprising that the key areas for suggested change involve changes to existing restrictive visitation policies, the enhancement of family participation in care, and improved information sharing with families and patients.  This section will go through each of those areas and describe the potential avenues for which this change can occur.  5.3.1 Suggested Changes to Visitation Policy Each patient, and their respective family, is unique and during a time of critical illness it is vital that nurses promote family presence in a way that values individual needs.   81 Restrictive visitation policies are based on convention rather than evidence, and frequently act to control and limit the presence of families in the ICU.  Many authors called for a change to the visitation policy: either broadening hours to be less restrictive or creating a policy that allows for individualized visiting plans (Agard & Lomborg, 2010; Fumagalli, et al., 2006; Garrouste-Orgeas, et al., 2008; Hardin et al., 2011; Hunter et al., 2010; Olsen et al., 2009; Roger, et al., 2010; Soury-Lavergne, et al., 2011).   Regardless of the approach taken to change visitation policy, it is clear that there is little to no supporting evidence to maintain restrictive visiting.  Hunter et al. (2010) called for the removal of visiting hours all together, based on the rationale that families are highly adaptable to the routines of the ICU and their presence not only benefits the patient but also the nurses.  Fumagilli et al. (2006) provided a similar recommendation, demonstrating how flexible visitation did not increase risk of sepsis; and cardiovascular outcomes actually improved for ICU patients.  The recommendations of Soury-Lavergne et al. (2011) and Roger et al. (2010) also supported an increase in the flexibility of visiting hours, although they referred more to increasing the windows of time for visiting rather than removing restrictions altogether.  Shifting control from the nurse to the patient and family represents a paradigm shift in the ICU.  Several authors suggested a patient-controlled visitation policy that allows for an individualized visitation plan to be created between the patient, their family, and nurses (Agard & Lomborg, 2010; Hardin et al., 2011; Olsen et al., 2009).  These types of visitation plans are more in line with PFCC and can support the growth of that philosophy within the ICU (Garrouste-Orgeas, et al., 2008; Hardin et al., 2011).  Family members represent a source of important social support to patients and an individualized plan facilitates visitation that aligns to the wishes of the patient.    82 Agard and Lomborg (2010) suggested that the role of the nurse in collaborating with the patient and family regarding visitation is a role of clinical leadership.  They felt that this role was more complex in nature than previously thought, and that nurses must gain education and expertise to enact it appropriately.  Based on REA studies, my recommendations are to: a) institute flexible visiting hours in critical care areas; and b) tailor visitation hours and lengths of visitation based on patient and family needs and preferences.     5.3.2 Enhanced Family Participation The REA studies showed that families felt as though they were able to better advocate, coach and support the patient if they were physically close to them.  Further, when they were in close proximity to the patient, the opportunity to engage in physical care of the patient was enhanced: their participation, however, required a nurses’ invitation.   There were several ways that nurses enhanced family participation in the ICU. Strategies included: embrace family as integral to the health and well-being of the patient; demonstrate different ways to safely interact with the patient; and invite the family to participate (Eggenberger & Nelms, 2007; Johansson et al., 2005; McAdam et al., 2008; Williams, 2005). Nurses possess a profound power to influence the experience of the family and patient.  Eggenberger and Nelms (2007) found that nurses used their power to positively influence the family experience.  Nurses shared caring techniques with families, alleviating their fear of somehow injuring the patient. Nurses used their special knowledge to build relationships with families, and to include them in the care of the patient.  Further, it was  83 suggested that spending time with the family, to understand them and the patient, increased the family’s feelings of safety, security, and trust (Johansson et al., 2005). Families cope with a huge amount of fear and uncertainty when they have a critically ill loved one.  In one study, nurses showed them how to care for their loved one safely and effectively (Williams C. M., 2005).  Providing a gentle invitation to touch the patient, hold hands, or speak to the patient were ways of showing family members how to safely interact with their loved one.  ICU nurses are experts in dealing with critically ill patients, particularly communications.  For example, nurses showed the family the easiest way to communicate with an intubated patient.  Finally the nurse invited the family to assist with the provision of care; McAdam et al. (2008) described this role as the ‘voluntary caregiver’.   When there is a wider recognition of the therapeutic contribution of the family, then it becomes easier to identify other possibilities for family participation.  Some suggested ways to invite family participation in the care of their loved one is through unit activities such as medical rounding and nursing assessment (McAdam et al., 2008; Williams, 2005).  Both these activities provide opportunities to involve families in sharing their knowledge of the patient’s journey to the ICU; who they were as a person prior to hospitalization; and to advocate for their care while in ICU.  These types of family contributions have the potential to create trusting partnerships between the nurse and the family and improve the healthcare team’s knowledge of the patient as a person. Based on the REA studies, my recommendations are to work with the medical leadership to establish a program of medical rounding and to work with the nursing leadership to build a nursing assessment process that is inclusive of the family and patient. Both of these activities can demonstrate to the family that they are integral members of the team and beneficial to the health and well being of the  84 patient. I believe that formalizing opportunities for families to participate would clearly demonstrate a unit’s commitment to PFCC. In my opinion, these initiatives could act as catalysts to create a paradigm shift in ICU.   5.3.3 Enhanced Information Sharing Information sharing is one of the four core principles of PFCC, and it involves sharing information with patients and families in a timely, accurate, and affirming way (Institute for Patient and Family Centered Care, 2009).  Interestingly, this was one of the three main recommendations for practice and policy that emerged from the REA studies (Hunter et al., 2010; McAdam et al., 2008; Olsen et al., 2009; Roger, et al., 2010).  There were several ways of incorporating information sharing into the practice of the ICU healthcare team: planned daily times for information sharing, established meeting with family within 48 hours of admission, and an orientation to the policies and routines of the unit.  Each of these strategies will be discussed below.  During a time of medical crisis families crave consistent updates on the status and plan for their critically ill loved one.  The provision of frequent updates helps to relieve family anxiety and to empower them to engage in the patients’ care, as suggested in the previous section, one way to do this is to have them attend rounds (McAdam et al., 2008).  Attending medical rounds not only allows them to hear new information about their loved one, but it also invites them to contribute information for the team to learn about the patient. Hunter et al. (2010) suggested that there is a need for unrestricted family phone calls and planned, regular updates from the nurse, via telephone if necessary.  Similarly, Roger et al. (2010) recommended an established daily dialogue or meeting between the family and their  85 health care team.  Finally, having a standard procedure in place to set-p a meeting with the family within 48 hours of admission is critical in sharing important information about the patient’s status with the family.  This meeting sets the tone for continued participation and information-sharing between the team and the family (Hunter et al., 2010).   Information needs to be reinforced to ensure the families’ understanding.  On admission to the unit someone from the healthcare team needs to provide an orientation to the family.  This can be an informal orientation to the ICU’s policies regarding visitation and participation, as well as the routines of the unit (Olsen et al., 2009).  This is an excellent opportunity for the nurse to emphasize the importance of family presence and the interdependent role between family and patient.  Further, the nurse can help the family understand the patient’s need for rest and the potential for the patient to have very little memory of their ICU experience.  In doing so the nurse can encourage the family to be present and maintain an account of the patient’s experience which could assist them, post-ICU (Olsen et al., 2009).  All of the information provided verbally to the family or patient should be supported through written patient health education materials.  My key recommendations from these REA studies are to establish a clear information sharing policy to guide clinical practice.  I would suggest that this policy include guidelines for clinicians regarding a formalized family meeting within 48hours of admission and clear parameters for daily updates to the family whether these are in person or over the telephone.  Finally, I would endorse the creation of patient and family education materials that could act as an additional source of information.   86 5.4 Education Recommendations The ICU environment is fast-paced, busy, and challenging.  Nurses find that challenge increased, at times, when they have to work with families.  Education is the second overarching area of recommendations that materialized from this REA.  This section will describe the education recommendations for nurses, families, and patients.  5.4.1 Supporting Nurses to Work with Families Working with families is recognized as a specialized skill-set that requires additional training and preparation for nurses.  In order to be successful in enacting the complex nursing task of working with families and negotiating visitation, nurses must receive support and education (Agard & Maindal, 2009; Agard & Lomborg, 2010; Eggenberger & Nelms, 2007; Farrell et al., 2005; Eriksson, Bergbom, & Lindahl, 2011; Williams, 2005). The nurse must have a broad perspective of family and the ways in which families can participate in care and nurses need to include family contributions in their care plans.  Education should focus on increasing the nurse’s knowledge regarding the family experience.  This means deepening their understanding of what it is like to be a family with a loved one who is critically ill.  Story telling and in-depth discussion were two ways in which the nurses understanding could be deepened (Eggenberger & Nelms, 2007).  Nurses who have a strong understanding of therapeutic contributions of families are better able to acknowledge, document, and reward families for their role (Eriksson et al., 2011; Williams, 2005).  Working with families can be complex and nurses’ capacity to engage effectively with families may be a special form of leadership, clinical leadership (Agard and Lomborg, 2010).   87 Further critical care nurse education was recommended to teach clinical leadership competencies. Farrell et al. (2005) suggested the creation of the role of ‘Family Caregiver’.  This role entails working with the families in the ICU to help them better understand the plan for their loved ones.  The author suggested that a nurse in this formal, designated ‘caregiver’ role can ease the burden of other nurses. Further this role can increase the information sharing and provide regular, frequent emotional support to families. My suggestions, based on the REA studies, are to build in venues for nurses to be able to engage in in-depth discussion and story telling regarding the experiences of families to help them better understand the experience of families.  Nurses could share stories of families’ experiences from their perspective or families could actually come to a planned event and share their experiences directly. The REA studies’ findings supports the need for nurses to gain a deeper understanding.   5.4.2 Patient and Family Education Needs The recommendations for patient education from REA studies were different from traditional patient or family education.  Suggested, patient education focused on helping them to better understand their ICU experience and to separate the memories of real experiences from the memories of unreal experiences.  Eriksson et al. (2011) provided patients with diaries to document their memories. Nurses were encouraged to review patients' diaries with them, and to engage in story telling to help connect real events to memories.  This also provided an opportunity for the nurse to teach the family about the lack of memory and to offer strategies for the family to engage with the patient about their ICU experience.    88 Patients and families often have impaired processing due to the stress of the ICU experience, written materials can help reinforce verbal instructions or teaching.  This was the key recommendation for education for families and patients. My recommendations for this section, based on REA studies are to give patients and families journals and then create time for nurses to review their experiences with them on a regular basis.    5.5 Research Recommendations The major areas for research will be described as either replication studies or new areas for research   5.5.1 Replication Studies Replication studies repeat previous studies using the same methods but with a new population or other variable in order to see if the results are reproducible and valid (Polit & Beck, 2012).  Replication helps to ensure that the previous results are applicable in new situations.  One possibility would be to reproduce a single-centre study, such as Fumagilli et al. (2006), using multiple ICUs to provide more evidence for the impact of patient control over visitation on their physiological outcomes.  Johansson et al. (2005) recommended replicating their study in another centre or centres to see if families in comparative situations in other locations would place the same value on the need for control over visitation and access to patients.   89 5.5.2 Suggested Areas for Further Research The authors of the REA studies identified several areas for new research or additional research: work with families, communication and support, and patient healing with respect to patient control over visitation.   “Work with families” is an area that calls for research to look at family as a phenomenon (Eggenberger & Nelms, 2007; McAdam et al. , 2008; Olsen et al., 2009; Williams, 2005) This would mean further exploring the importance of families to patient well being and collecting information on the contribution of different types of families.  This area of research could also look at the decision-making process of families as they engage in the care of their loved ones.  Increasing the body of knowledge in this area could assist ICU staff in deepening their knowledge of the family experience and allow them to better engage the family in participating in the care of their loved one.  Further, this area of research could look at the nurses’ role in supporting patients who are not connected to family and what they might identify as their needs for support (Eriksson & Bergbom, 2007).   Communication and supports are influenced by the beliefs and attitudes of nurses. These attitudes and beliefs influence what is communicated and how it is delivered to families and patients (Agard & Maindal, 2009).  This area of research involves a deeper investigation of the attitudes and beliefs of nurses and how these impact their decision-making regarding visitation and family participation.  Another area for future potential research would be the content and processes of therapeutic communications between the health care providers, the patients, and the families (Agard & Lomborg, 2010).  This area could further assist in informing the nature of therapeutic communications between nurses and families and could also provide further insight into the experience of the patient.  Finally,  90 the area of support that families require from nurses should be explored to provide nurses with more guidance regarding the expectations of families (Williams C. M., 2005).  The final area of new research that was suggested for future investigation was the impact of family presence on patient healing.  To summarize, I recommend, on my REA topic, that further research in the area of the physiological outcomes related to family presence be explored and this could be done through a replication study based on Fumagilli (2006) initial findings. I would also suggest delving deeper into the area of nurses’ beliefs and attitudes and explore the ways that leadership strategies can impact those beliefs and attitudes.  5.6 Chapter Summary Recommendations for practice, policy, education, and research from the included studies in this REA were presented in this, the final chapter of this thesis.  Policy and practice recommendations encompassed the best practice for visitation, family participation, and information sharing.  Open and individualized visitation policies are the two key recommendations for best practices.  This means that nursing practice should support and welcome family either all hours of the day or based on the specific desires or wishes of the patient.  Further, family participation should be promoted because it benefits everyone: the family, the patient, and the nurse.  Information sharing is vital to the experience of the family and patient.  Policies supporting this practice should include regular phone updates, meetings on admission, and regular conversations with the healthcare team.  Negotiating and working with families can be challenging for nurses and is considered a complex nursing task.  Therefore one of the main recommendations is that education be leveraged to support nurses  91 to work more effectively with families and deepen their understanding of the experience of the family.  Further, families can be educated on what to expect when their loved one is transitioning out of ICU and how to help support their loved one with their memory and narrative of their ICU experience.  As well it is important for the family to receive an orientation to the unit and education about the policies and routines of the unit so that they are clear on when and how to engage in the care and conversation concerning their loved one.  The final area of recommendations that were described in this chapter was research implications.  Authors highlighted the need for the replication of their studies to ensure that the results were valid and generalizable.  Additionally, they suggested research in four areas: the work of families, communication and support, and patient healing with respect to patient-controlled visitation.    5.7 Overall Summary: Knowledge Gained from REA I chose PFCC as the conceptual framework to guide my work as I conducted an REA of 18 studies.  Through a systematic process the studies were evaluated, analyzed, and themed.  Patients and families in ICU desire to have proximity to their loved ones and to have control over that process.  This can be challenging for the nurses despite their recognition that family is an essential part of the patient’s life and care.  There were several benefits, to patients, families, and nurses, identified in the literature.  Patients and families both showed a reduced amount of anxiety and depression when family presence was welcomed in the ICU.  Patients who had control over their visitation showed improvements in their cardiovascular outcomes.  Families also felt like they were better able to advocate for their loved one when they were present in the ICU with them.  Additionally, when nurses  92 gave family members permission, family were happy to participate and aid in the physical care of the patient.  Having that proximity and ability to touch and assist the patient improved the family’s perception of their experience. In order to move from the current paradigm to a PFCC paradigm policy and education are needed to help nurses relinquish control over visitation; and to work and collaboratively with patients and families to individualize family involvement in ICU care.  Research is needed to enlarge our knowledge base about the experiences of ICU patients and families: how visitation influences their perceptions and patient healing.  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An Evaluation of Family-Centered Care Services and Organization of Visiting Policies in Belgian Intensive Care Units: A multicenter survey. Heart and Lung , 39 (2), 137-146. Whitis, G. (1994). Visiting Hospitalized Patients. Journal of Advanced Nursing , 19, 85-88. Williams, B. R., Bailey, F. A., & Woodby, L. L. (2012-2013). A Room Full of Chairs Around his Bed: Being Present at the Death of a Loved One in Veterans Affairs Medical Centers. Omega , 66 (3), 231-263. Williams, C. M. (2005). The Identification of Family Members' Contribution to Patients' Care in the Intensive Care Unit: A naturalistic inquiry. Nursing in Critical Care , 10 (1), 6-14.   101 Appendices Appendix A    EPPI-Centre data extraction and coding tool for education studies V2.0 January 2007 Copyright of EPPI-Centre. Please do not reproduce or distribute without permission  EPPI-Centre data extraction and coding tool for education studies V2.0  Purpose and use of this tool This tool is designed to help those conducting systematic reviews on educational topics identify extract and code information about a particular research study that is to be included in a systematic review.  It is designed to help the reviewer obtain all the necessary information to  • Assess the quality of the study or its internal validity • Identify the relevant contextual information that may have affected the results obtained in the specific study • Identify the contextual information about a study that will be relevant to any assessment of the generalizability of findings in the individual study • Identify relevant information about the design , execution and context of a study for the purpose of synthesizing (bringing together) results from all the studies that are included in a particular review  The tool is designed to be used to extract data from a single primary study. That is the report(s) of a piece of research i.e. not a review (systematic or otherwise), a scholarly paper, treatise or opinion piece.  The study may be reported in more than one paper for which a single data extraction is completed  Each separate study included in a review will require a separate data extraction   For the purposes of producing a ‘map’ review groups will usually include questions from sections A, B, C, D, E (if relevant), G.  Questions B2 and G3 must be included in the coding questions for the map  Additional questions used will depend on the purpose of the map and the type of review.  The questions to be used should be agreed with the funder and the EPPI-Centre prior to starting coding  Other sections and questions are completed only on studies included in the ‘in-depth review’ 102 A.1 Name of the reviewer  A.1.1 Details A.2 Date of the review  A.2.1 Details A.3 Please enter the details of each paper which reports on this item/study and which is used to complete this data extraction. (1): A paper can be a journal article, a book, or chapter in a book, or an unpublished report.  A.3.1 Paper (1) Fill in a separate entry for further papers as required.  A.3.2 Unique Identifier: A.3.3 Authors: A.3.4 Title:  A.3.5 Paper (2)  A.3.6 Unique Identifier: A.3.7 Authors: A.3.8 Title: A.4 Main paper. Please classify one of the above papers as the 'main' report of the study and enter its unique identifier here. NB(1): When only one paper reports on the study, this will be the 'main' report.  NB(2): In some cases the 'main' paper will be the one which provides the fullest or the latest report of the study. In other cases the decision about which is the 'main' report will have to be made on an arbitrary basis.          A.4.1 Unique Identifier: A.5 Please enter the details of each paper which reports on this study but is NOT being used to complete this data extraction. NB A paper can be a journal article, a book, or chapter in a book, or an  A.5.1 Paper (1) Fill in a separate entry for further papers as required.  A.5.2 Unique Identifier: A.5.3 Authors: A.5.4 Title:      Section A: Administrative details Use of these guidelines should be cited as: EPPI-Centre (2007) Review Guidelines for Extracting Data and Quality Assessing Primary Studies in Educational Research. Version 2.0 London: EPPI-Centre, Social Science Research Unit.EPPI-Centre data extraction and coding tool for education studies V2.0 January 2007 Copyright of EPPI-Centre. Please do not reproduce or distribute without permission  103    unpublished report.  A.5.5 Paper (2) A.5.6 Unique Identifier: A.5.7 Authors: A.5.8 Title: A.6 If the study has a broad focus and this data extraction focuses on just one component of the study, please specify this here.  A.6.1 Not applicable (whole study is focus of data extraction)  A.6.2 Specific focus of this data extraction (please specify) EPPI-Centre data extraction and coding tool for education studies V2.0 January 2007 Copyright of EPPI-Centre. Please do not reproduce or distribute without permission  104 A.7 Identification of report (or reports) Please use AS MANY KEYWORDS AS APPLY.  A.7.1 Citation Please use this keyword if the report was identified from the bibliographic list of another report.  A.7.2 Contact Please use this keyword if the report was found through a personal/professional contact.  A.7.3 Handsearch Please use this keyword if the report was found through handsearching a journal.  A.7.4 Unknown Please use this keyword if it is unknown how the report was found.  A.7.5 Electronic database Please use this keyword if the report was found through searching on an electronic bibliographic database.  In addition, if the report was found on an electronic database please use ONE OR MORE of the following keywords to indicate which database it was found on:     aidsline For AIDSLINE  appsocscience For Applied Social and Abstracts EPPI-Centre data extraction and coding tool for education studies V2.0 January 2007 Copyright of EPPI-Centre. Please do not reproduce or distribute without permission  105  artscitation For the Arts and Humanities Citation Index  aei For the Australian Education Index  bei For the British Education Index  bibliomap For the EPPI-Centre's specialist register of research  cabhealth For CABhealth  cei For the Canadian Education Index  ceruk For CERUK  cinahl For the CINAHL  cochranelib For the Cochrane Library  dissabs For Dissertation Abstracts  dislearn For the Distance Learning Database  eduabs For Education Abstracts   EPPI-Centre data extraction and coding tool for education studies V2.0 January 2007 Copyright of EPPI-Centre. Please do not reproduce or distribute without permission  106 embase For EMBASE  eric For ERIC  healthplan For Health Planning  healthpromis For HealthPromis  educationline For Education-line  intbibsocsci For the International Bibliography of the Social Sciences langbehrabs For Linguistic and Language Behaviour Abstracts  medline For MEDLINE  psycinfo For PsycINFO  regard For REGARD  sigle For SIGLE socscicitation For the Social Science Citation Index  socservabs For the Social Services Abstracts  socioabs For Sociological Abstracts  spectr EPPI-Centre data extraction and coding tool for education studies V2.0 January 2007 Copyright of EPPI-Centre. Please do not reproduce or distribute without permission  107 For the Social, Psychological, Educational & Criminological Trials Register EPPI-Centre data extraction and coding tool for education studies V2.0 January 2007 Copyright of EPPI-Centre. Please do not reproduce or distribute without permission  108 A.8 Status Please use ONE keyword only  A.8.1 Published Please use this keyword if the report has an ISBN or ISSN number.  A.8.2 Published as a report or conference paper Please use this code for reports which do not have an ISBN or ISSN number (eg. 'internal' reports; conference papers)  A.8.3 Unpublished  e.g. thesis or author manuscript A.9 Language (please specify)  A.9.1 Details of Language of report Please use as many keywords that apply  If the name of the language is specified/known then please use the name as a keyword. For example: Dutch English French  If non-English and you cannot name the language:non English   Section B: Study Aims and Rationale   B.1 What are the broad aims of the study? Please write in authors’ description if there is one. Elaborate if necessary, but indicate which aspects are reviewers’ interpretation. Other, more specific questions about the research questions and hypotheses are asked later.  B.1.1 Explicitly stated (please specify) B.1.2 Implicit (please specify) B.1.3 Not stated/unclear (please specify) EPPI-Centre data extraction and coding tool for education studies V2.0 January 2007 Copyright of EPPI-Centre. Please do not reproduce or distribute without permission  109 B.2 What is the purpose of the study? N.B. This question refers only to the purpose of a study, not to the design or methods used.  A: Description Please use this code for studies in which the aim is to produce a description of a state of affairs or a particular phenomenon, and/or to document its characteristics. In these types of studies there is no attempt to evaluate a particular intervention programme (according to either the processes involved in its implementation or its effects on outcomes), or to examine the associations between one or more variables. These types of studies are usually, but not always, conducted at one point in time (i.e. cross sectional). They can include studies such as an interview of head teachers to count how many have explicit policies on continuing professional development for teachers; a study documenting student attitudes to national examinations using focus groups; a survey of the felt needs of parents using self-completion questionnaires, about whether they want a school bus service.        B.2.1 A: Description  B.2.2 B: Exploration of relationships  B.2.3 C: What works?  B.2.4 D: Methods development  B.2.5 E: Reviewing/synthesising research  110  B: Exploration of relationships Please use this code for a study type which examines relationships and/or statistical associations between variables in order to build theories and develop hypotheses. These studies may describe a process or processes (what goes on) in order to explore how a particular state of affairs might be produced, maintained and changed.  These relationships may be discovered using qualitative techniques, and/or statistical analyses. For instance, observations of children at play may elucidate the process of gender stereotyping, and suggest the kinds of interventions which may be appropriate to reduce any negative effects in the classroom. Complex statistical analysis may be helpful in modelling the relationships between parents' social class and language in the home. These may lead to the development of theories about the mechanisms of language acquisition, and possible policies to intervene in a causal pathway.  These studies often consider variables such as social class and gender which are not interventions, although these studies may aid understanding, and may suggest possible interventions, as well as ways in which a programme design and implementation could be improved. These studies do not directly evaluate the effects of policies and practices C: What works A study will only fall within this category if it measures effectiveness - i.e. the impact of a specific intervention or   111 programme on a defined sample of recipients or subjects of the programme or intervention.  D: Methods development Studies where the principle focus is on methodology.  E: Reviewing/Synthesising research Studies which summarise and synthesise primary research studies.  B.3 Why was the study done at that point in time, in those contexts and with those people or institutions? Please write in authors’ rationale if there is one. Elaborate if necessary, but indicate which aspects are reviewers’ interpretation.   B.3.1 Explicitly stated (please specify) B.3.2 Implicit (please specify) B.3.3 Not stated/unclear (please specify) B.4 Was the study informed by, or linked to, an existing body of empirical and/or theoretical research? Please write in authors’ description if there is one. Elaborate if necessary, but indicate which aspects are reviewers’ interpretation.   B.4.1 Explicitly stated (please specify) B.4.2 Implicit (please specify) B.4.3 Not stated/unclear (please specify) B.5 Which of the following groups were consulted in working out the aims of the study, or issues to be addressed in the study? Please write in authors’ description if there is one. Elaborate if necessary, but indicate which aspects are reviewers’ interpretation. Please cover details of how and why people were consulted and how they influenced the aims/issues to be addressed.  B.5.1 Researchers (please specify) B.5.2 Funder (please specify) B.5.3 Head teacher/Senior management (please specify)  B.5.4 Teaching staff (please specify)  B.5.5 Non-teaching staff (please specify) B.5.6 Parents (please specify) B.5.7 Pupils/students (please specify)  112  B.5.8 Governors (please specify) B.5.9 LEA/Government officials (please specify)  B.5.10 Other education practitioner (please specify) B.5.11 Other (please specify) B.5.12 None/Not stated B.5.13 Coding is based on: Authors' description  B.5.14 Coding is based on: Reviewers’ inference B.6 Do authors report how the study was funded?  B.6.1 Explicitly stated (please specify) B.6.2 Implicit (please specify) B.6.3 Not stated/unclear (please specify) B.7 When was the study carried out? If the authors give a year, or range of years, then put that in. If not, give a ‘not later than’ date by looking for a date of first submission to the journal, or for clues like the publication dates of other reports from the study.  B.7.1 Explicitly stated (please specify ) B.7.2 Implicit (please specify) B.7.3 Not stated/unclear (please specify) B.8 What are the study research questions and/or hypotheses? Research questions or hypotheses operationalise the aims of the study. Please write in authors'description if there is one. Elaborate if necessary, but indicate which aspects are reviewers' interpretation.   B.8.1 Explicitly stated (please specify) B.8.2 Implicit (please specify) B.8.3 Not stated/ unclear (please specify)     113   Section C: Study Policy or Practice Focus  C.1 What is/are the topic focus/foci of the study? C.1.1 Assessment (please specify) C.1.2 Classroom management (please specify)  C.1.3 Curriculum (see next question below)  C.1.4 Equal opportunities (please specify)  C.1.5 Methodology (please specify)  C.1.6 Organisation and management (please specify) C.1.7 Policy (please specify) C.1.8 Teacher careers (please specify)  C.1.9 Teaching and learning (please specify) C.1.10 Other (please specify) C.1.11 Coding is based on: Authors' description  C.1.12 Coding is based on: Reviewers' inference   114 C.2 What is the curriculum area, if any? C.2.1 Art  C.2.2 Business Studies  C.2.3 Citizenship  C.2.4 Cross-curricular  C.2.5 Design & Technology  C.2.6 Environment C.2.7 General C.2.8 Geography C.2.9 Hidden C.2.10 History C.2.11 ICT C.2.12 Literacy - first languages  C.2.13 Literacy – further languages  C.2.14 Literature C.2.15 Maths C.2.16 Music C.2.17 PSE C.2.18 Phys. Ed C.2.19 Religious Ed. C.2.20 Science C.2.21 Vocational C.2.22 Other C.2.23 Coding is based on: Authors' description C.2.24 Coding is based on: Reviewers' inference C.3 What is/are the educational setting(s) of the study?  C.3.1 Community centre C.3.2 Correctional institution C.3.3 Government department C.3.4 Higher education institution  C.3.5 Home  C.3.6 Independent school  C.3.7 Local education authority  C.3.8 Nursery school  C.3.9 Other early years setting  115  C.3.10 Post-compulsory education institution  C.3.11 Primary school C.3.12 Pupil referral unit C.3.13 Residential school C.3.14 Secondary school C.3.15 Special needs school C.3.16 Workplace C.3.17 Other educational setting C.3.18 Coding is based on: Authors' description C.3.19 Coding is based on: Reviewers' inference  C.4 In which country or countries was the study carried out? Provide further details where relevant e.g. region or city.  C.4.1 Explicitly stated (please specify)  C.4.2 Not stated/unclear (please specify) C.5 Please describe in more detail the specific phenomena, factors, services or interventions with which the study is concerned. The questions so far have asked about the aims of the study and any named programme under study, but this may not fuly capture what the study is about. Please state or clarify here.        C.5.1 Details  116 Section D: Actual sample If there are several samples or levels of sample D.1 Who or what is/ are the sample in the study? Please use AS MANY codes AS APPLY to describe the nature of the sample of the report. Only indicate a code if the report specifically characterises the sample focus in terms of the categories indicated below , please complete for each level D.1.1 Please use this code if a population focus of the study is on pupils, students, apprentices, or other kinds of learners  D.1.2 Senior management Please use this code if a sample focu of the study is on those with responsibility in any educational institution for the strategic leadership and the educational institution under study. In the school setting, there term 'headteacher' is typically used ('principal' in the U.S.A., Canada and Australia); the term 'principal' is often used in a college setting, the term 'vice management of a whole organisation. This will include the person with ultimate responsibility.  chancellor' in a  D.1.3 Teaching staff Please use this code if a sample focus of the study is on staff who teach (or lecture) in a classroom/lecture-hall setting  D.1.4 Non-teaching staff Please use this code if a population focus of the study is on staff who do not teach, but whose role within the educational institution is administrative/ organisational, e.g. equal opportunities coordinators, other support staff  D.1.5 Other educational practitioners Please use this code if the sample focus of the study includes representatives from other educational bodies, including interest/advisory groups; school govorning bodies and  117 parent support groups  D.16 Government  Please use this code if the sample focus of the study is on representatives from government or governing bodies e.g. from the DfES (Department for Education and Skills), BECTA (British Educational Communications and Technology Agency), LSDA (learning and Skills Development Agency, formerly FEDA - Further Education Development Agency) etc.  D.1.7 Local educaiotn authority officers  Please use this code if a sample focus of the study is people who work in a local education authority  D.1.8 Parents Please use this code if the sample focus of the study refers to the inclusive category of carers of 'children' and 'young people', which may include natural parents/mother/father/adoptive parents/foster parents etc   Please use this code if the sample focus of the study is on members of the governing body, which may include teachers or parents. They play a role in the management and vision of the educational institution  D.1.10 Other sample focus (please specify)  D.2 What was the total number of participants in the study (the actual sample)? if more than one group is being  D.2.1 Not applicable (e.g study of policies, documents etc)  D.2.2 Explicitly stated (please  118 compared, please give numbers for each group specify) D.2.3 Implicit (please specify) D.2.4 Not stated/ unclear (please specify) D.3 What is the proportion of those selected for the study who actually participated in the study? Please specify numbers and percentages if possible.  D.3.1 Not applicable (e.g. review)  D.3.2 Explicitly stated (please specify) D.3.3 Implicit (please specify) D.3.4 Not stated/unclear (please specify) D.4 Which country/countries are the individuals in the actual sample from? If UK, please distinguish between England, Scotland, N. Ireland and Wales, if possible. If from different countries, please give numbers for each.  If more than one group is being compared, please describe for each group.   D.4.1 Not applicable (e.g. study of policies, documents, etc.)  D.4.2 Explicitly stated (please specify) D.4.3 Implicit (please specify) D.4.4 Not stated/unclear (please specify) D.5 If the individuals in the actual sample are involved with an educational institution, what type of institution is it? For evaluations of interventions, this will be the site(s) of the intervention.  D.5.1 Not applicable (e.g. study of policies, documents, etc.)  D.5.2 Community centre (please specify)  D.5.3 Post-compulsory education institution (please specify)   Please give details of the institutions (e.g. size, geographic location mixed/single sex etc.) as described by the authors. If individuals are from different institutions, please give numbers for each. If more than one group is being compared, please describe all of the above for each group.  D.5.4 Government Department (please specify)  D.5.5 Independent school (please specify age range and school type)  D.5.6 Nursery school (please specify)  D.5.7 Other early years setting (please specify)  D.5.8 Local education authority (please specify)   119 D.5.9 Higher Education Institution (please specify)  D.5.10 Primary school (please specify)  D.5.11 Correctional Institution (please specify)  D.5.12 Pupil referral unit (please specify)  D.5.13 Residential school (please specify)  D.5.14 Secondary school (please specify age range)  D.5.15 Special needs school (please specify)  D.5.16 Workplace (please specify)  D.5.17 Other educational setting (please specify)  D.5.18 Coding is based on: Authors' description  D.5.19 Coding is based on: Reviewers' inference D.6 What ages are covered by the actual sample? Please give the numbers of the sample  D.6.1 Not applicable (e.g. study of policies, documents etc) that fall within each of the given categories. If necessary refer to a page number in the report (e.g. for a useful table).  If more than one group is being compared, please describe for each group if follow-up study, age of entry to the study  D.6.2 0-4  D.6.3 5-10  D.6.4 11-16  D.6.5 17 to 20  D.6.6 21 and over  D.6.7 Not stated/unclear (please specify)   120 D.6.8 Coding is based on: Authors' description  D.6.9 Coding is based on: Reviewers' inference D.7 What is the sex of the individuals in the actual sample? Please give the numbers of the sample that fall within each of the given categories. If necessary refer to a page number in the report (e.g. for a useful table).  If more than one group is being compared, please describe for each group.  D.7.1 Not applicable (e.g. study of policies, documents etc) D.7.2 Single sex (please specify) D.7.3 Mixed sex (please specify) D.7.4 Not stated/unclear (please specify)  D.7.5 Coding is based on: Authors' description  D.7.6 Coding is based on: Reviewers' inference D.8 What is the socio- economic status of the individuals within the actual sample? If more than one group is being compared, please describe for each group.  D.8.1 Not applicable (e.g. study of policies, documents etc)  D.8.2 Explicitly stated (please specify) D.8.3 Implicit (please specify) D.8.4 Not stated/unclear (please specify) D.9 What is the ethnicity of the individuals within the actual sample? If more than one group is being compared, please describe for each group.  D.9.1 Not applicable (e.g. study of policies, documents etc)  D.9.2 Explicitly stated (please specify)  D.9.3 Implicit (please specify) D.9.4 Not stated/unclear (please specify)  121 D.10 What is known about the special educational needs of individuals within the actual sample? e.g. specific learning, physical, emotional, behavioural, intellectual difficulties.  D.10.1 Not applicable (e.g. study of policies, documents etc)  D.10.2 Explicitly stated (please specify) D.10.3 Implicit (please specify) D.10.4 Not stated/unclear (please specify) D.11 Please specify any other useful information about the study participants.  D.11.1 Details  Section E: Programme or Intervention description E.1 If a programme or intervention is being studied, does it have a formal name?     E.1.1 Not applicable (no programme or intervention)  E.1.2 Yes (please specify) E.1.3 No (please specify) E.1.4 Not stated/ unclear (please specify) E.2 Content of the intervention package Describe the intervention in detail, whenever possible copying the authors' description from the report word for word. If specified in the report, also describe in detail what the control/ comparison group(s) were exposed to.      E.2.1 Details E.3 Aim(s) of the intervention  E.3.1 Not stated  E.3.2 Not explicitly stated (Write in, as worded by the reviewer)  E.3.3 Stated (Write in, as stated by the authors) E.4 Year intervention started Where relevant  E.4.1 Details E.5 Duration of the   122 intervention Choose the relevant category and write in the exact intervention length if specified in the report  When the intervention is ongoing, tick 'OTHER' and indicate the length of intervention as the length of the outcome assessment period E.5.1 Not stated E.5.2 Not applicable E.5.3 Unclear E.5.4 One day or less (please specify)  E.5.5 1 day to 1 week (please specify)  E.5.6 1 week (and 1 day) to 1 month (please specify)  E.5.7 1 month (and 1 day) to 3 months (please specify)  E.5.8 3 months (and 1 day) to 6 months (please specify)  E.5.9 6 months (and 1 day) to 1 year (please specify)  E.5.10 1 year (and 1 day) to 2 years (please specify)  E.5.11 2 years (and 1 day) to 3 years (please specify)  E.5.12 3 years (and 1 day) to 5 years (please specify)  E.5.13 more than 5 years (please specify)  E.5.14 Other (please specify) E.6 Person providing the intervention (tick as many as appropriate)  E.6.1 Not stated  E.6.2 Unclear  E.6.3 Not applicable  E.6.4 Counsellor  E.6.5 Health professional (please specify)  E.6.6 parent  E.6.7 peer  E.6.8 Psychologist  123   E.6.9 Researcher E.6.10 Social worker E.6.11 Teacher/lecturer E.6.12 Other (specify) E.7 Number of people recruited to provide the intervention (and comparison condition) (e.g. teachers or health professionals)  E.7.1 Not stated  E.7.2 Unclear  E.7.3 Reported (include the number for the providers involved in the intervention and comparison groups, as appropriate) E.8 How were the people providing the intervention recruited? (Write in) Also, give information on the providers involved in the comparison group(s), as appropriate.    E.8.1 Not stated  E.8.2 Stated (write in) E.9 Was special training given to people providing the intervention? Provide as much detail as possible  E.9.1 Not stated  E.9.2 Unclear  E.9.3 Yes (please specify) E.9.4 No Section F: Results and conclusions In future this section is likely to incorporate material from EPPI reviewer to facilitate reporting numberical results  F.1 How are the results of the study presented? e.g. as quotations/ figures within text, in tables, as appendices  Warning! Failure to provide sufficient data here will hamper the synthesis stage of the review.  Please give details and refer to page F1.1 Details  124 numbers in the report(s) of the study, where necessary (e.g. for key tables) F.2 What are the results of the study as reported by the authors?  Before completing data extraction you will need to consider what type of synthesis will be undertaken and what kind of 'results' data is required for the  F2.1 Details F.3 What do the author(s) conclude about the findings of the study? Please give details and refer to page numbers in the report of the study, where necessary  F.3.1 Details Section G: Study Method  G.1 Study Timing Please indicate all that apply and give further details where possible  -If the study examines one or more samples but each at only one point in time it is cross-sectional  -If the study examines the same samples but as they have changed over time, it is a retrospective, provided that the interest is in starting at one timepoint and looking backwards over time  -If the study examines the same samples as they have changed over time and if data are collected forward over time, it is prospective provided that the interest is in starting at one timepoint and looking forward in time    G.1.1 Cross-sectional G.1.2 Retrospective G.1.3 Prospective G.1.4 Not stated/ unclear (please specify) G.2 when were the measurements of the variable(s) used as outcome measures made, in relation to the intervention Use only if the purpose of the study is to measure the effectiveness or impact of an  G.2.1 Not applicable (not an evaluation)  G.2.2 Before and after  125 intervention or programme i.e its purpose is coded as 'What Works' in Section B2 - If at least one of the outcome variables is measured both before and after the intervention, please use the 'before and after' category.  G.2.3 Only after G.2.4 Other (please specify) G.2.5 Not stated/unclear (please specify) G.3 What is the method used in the study? NB: Studies may use more than one method please code each method used for which data extraction is being completed and the respective outcomes for each method.  A=Please use this code if the outcome evaluation employed the design of a randomised controlled trial. To be classified as an RCT, the evaluation must:  i). compare two or more groups which receive different interventions or different intensities/levels of an intervention with each other; and/or with a group which does not receive any intervention at all AND ii) allocate participants (individuals, groups, classes, schools, LEAs etc) or sequences to the different groups based on a fully random schedule (e.g a random numbers table is used). If the report states that random allocation was used and no further information is given then please keyword as RCT. If the allocation is NOT fully randomised (e.g allocation by alternate numbers by date of birth) then please keyword as a non- randomised controlled trial  B=Please use this code if the evaluation compared two or more groups which receive different interventions, or different intensities/levels of an intervention to each other and/or with a group which does not receive any intervention at all BUT DOES NOT allocate participants (individuals, groups, classes, schools, LEAs etc) or sequences in a fully random manner. This keyword should be used for studies which describe groups being allocated using a quasi-random method (e.g allocation by alternate numbers or by date of birth) or other non- random method         G.3.1 A=Random experiment with random allocation to groups  G.3.2 B=Experiment with non- random allocation to groups  G.3.3 C=One group pre-post test  G.3.4 D=one group post-test only  G.3.5 E=Cohort study  G.3.6 F=Case-control study G.3.7 G=Statistical survey G.3.8 H=Views study G.3.9 I=Ethnography  G.3.10 J=Systematic review  G.3.11 K=Other review (non systematic)  G.3.12 L=Case study  G.3.13 M= Document study G.3.14 N=Action research G.3.15 O= Methodological study G.3.16 P=Secondary data  126 C=Please use this code where a group of subjects e.g. a class of school children is tested on outcome of interest before being given an intervention which is being evaluated. After receiving the intervention the same test is administered again to the same subjects. The outcome is the difference between the pre and post test scores of the subjects.  C=Please use this code where a group of subjects e.g. a class of school children is tested on outcome of interest before being given an intervention which is being evaluated. After receiving the intervention the same test is administered again to the same subjects. The outcome is the difference between the pre and post test scores of the subjects.  D=Please use this code where one group of subjects is tested on outcome of interest after receiving the intervention which is being evaluated  E=Please use this code where researchers prospectively study a sample (e.g learners), collect data on the different aspects of policies or practices experienced by members of the sample (e.g teaching methods, class sizes), look forward in time to measure their later outcomes (e.g achievement) and relate the experiences to the outcomes achieved. The purpose is to assess the effect of the different experiences on outcomes.  F=Please use this code where   items in a sample or population e.g analysis  127 parents views on education  H= Please use this code where the the researchers try to understand phenonmenon from the point of the 'worldview' of a particular, group, culture or society. In these studies there is attention to subjective meaning, perspectives and experience'.  I= please use this code when the researchers present a qualitative description of human social phenomena, based on fieldwork  J= please use this code if the review is explicit in its reporting of a systematic strategy used for (i) searching for studies (i.e it reports which databases have been searched and the keywords used to search the database, the list of journals hand searched, and describes attempts to find unpublished or 'grey' literature; (ii) the criteria for including and excluding studies in the review and, (iii) methods used for assessing the quality and collating the findings of included studies.  K= Please use this code for cases where the review discusses a particular issue bringing together the opinions/findings/conclusions from a range of previous studies but where the review does not meet the criteria for a systematic review (as defined above)  L= please use this code when researchers refer specifically to their design/ approach as a 'case study'. Where possible further information about the methods used in the case study should be coded   128 M=please use this code where researchers have used documents as a source of data e.g newspaper reports  N=Please use this code where practitioners or institutions (with or without the help of researchers) have  used research as part of a process of development and/or change. Where possible further information about the research methods used should be coded  O=please use this keyword for studies which focus on the development or discussion of methods; for example discussions of a statistical technique, a recruitment or sampling procedure, a particular way of collecting or analysing data etc. It may also refer to a description of the processes or stages involved in developing an 'instrument' (e.g an assessment procedure).  P= Please use this code where researchers have used data from a pre- existing dataset e.g The British Household Panel Survey to answer their'new' research question.   Section H: Methods-groups   H.1 If Comparisons are being made between two or more groups*, please specify the basis of any divisions made for making these comparisons Please give further details where possible  *If no comparisons are being made between groups please continue to Section I (Methods - sampling strategy)  H.1.1 Not applicable (not more than one group)  H.1.2 Prospective allocation into more than one group e.g allocation to different interventions, or allocation to intervention and control groups   129 H.1.3 No prospective allocation but use of pre-existing differences to create comparison groups e.g. receiving different interventions or characterised by different levels of a variable such as social class  H.1.4 Other (please specify)  H.1.5 Not stated/ unclear (please specify) H.2 How do the groups differ?  H.2.1 Not applicable (not in more than one group)  H.2.2 Explicitly stated (please specify)    H.2.3 Implicit (please specify) H.2.4 Not stated/ unclear (please specify) H.3 Number of groups For instance, in studies in which comparisons are made between group, this may be the number of groups into which the dataset is divided for analysis (e.g social class, or form size), or the number of groups allocated to, or receiving, an intervention.  H.3.1 Not applicable (not more than one group)  H.3.2 One H.3.3 Two H.3.4 Three H.3.5 Four or more (please specify)  H.3.6 Other/ unclear (please specify)  130 H.4 If prospective allocation into more than one group, what was the unit of allocation? Please indicate all that apply and give further details where possible  H.4.1 Not applicable (not more than one group)  H.4.2 Not applicable (no prospective allocation)  H.4.3 Individuals  H.4.4 Groupings or clusters of individuals (e.g classes or schools) please specify  H.4.5 Other (e.g individuals or groups acting as their own controls - please specify)  H.4.6 Not stated/ unclear (please specify) H.5 If prospective allocation into more than one group, which method was used to generate the allocation sequence?  H.5.1 Not applicable (not more than one group)  H.5.2 Not applicable (no prospective allocation)  H.5.3 Random  H.5.4 Quasi-random  H.5.5 Non-random   H.5.6 Not stated/unclear (please specify) H.6 If prospective allocation into more than one group, was the allocation sequence concealed? Bias can be introduced, consciously or otherwise, if the allocation of pupils or classes or schools to a programme or intervention is made in the knowledge of key characteristics of those    H.6.1 Not applicable (not more than one group)  H.6.2 Not applicable (no prospective allocation)  H.6.3 Yes (please specify) H.6.4 No  131 allocated. For example, children with more serious reading difficulty might be seen as in greater need and might be more likely to be allocated to the 'new' programme, or the opposite might happen. Either would introduce bias. (please specify) H.6.5 Not stated/unclear (please specify) H.7 Study design summary In addition to answering the questions in this section, describe the study design in your own words. You may want to draw upon and elaborate on the answers already given.    H.7.1 Details Section I: Methods - Sampling strategy   I.1 Are the authors trying to produce findings that are representative of a given population? Please write in authors' description. If authors do not specify, please indicate reviewers' interpretation.  I.1.1 Explicitly stated (please specify) I.1.2 Implicit (please specify) I.1.3 Not stated/unclear (please specify)  I.2 What is the sampling frame (if any) from which the partipants are chosen? e.g.telephone directory, electoral register, postcode, school listings etc.  There may be two stages - e.g. first sampling schools and then classes or pupils within them.  I.2.1 Not applicable (please specify)  I.2.2 Explicitly stated (please specify) I.2.3 Implicit (please specify) I.2.4 Not stated/unclear (please specify) I.3 Which method does the study use to select people, or groups of people (from the sampling frame)?  I.3.1 Not applicable (no sampling frame)  I.3.2 Explicitly stated (please specify)  132 e.g. selecting people at random, systematically - selecting, for example, every 5th person, purposively, in order to reach a quota for a given characteristic. I.3.3 Implicit (please specify) I.3.4 Not stated/unclear (please specify) I.4 Planned sample size If more than one group, please give details for each group separately.  In intervention studies, the sample size will have a bearing upon the statistical power, error rate and precision of estimate of the study.  I.4.1 Not applicable (please specify)  I.4.2 Explicitly stated (please specify)  I.4.3 Not stated/unclear (please specify) I.5 How representative was the achieved sample (as recruited at the start of the study) in relation to the aims of the sampling frame? Please specify basis for your decision.  I.5.1 Not applicable (e.g. study of policies, documents, etc.)  I.5.2 Not applicable (no sampling frame)  I.5.3 High (please specify) I.5.4 Medium (please specify) I.5.5 Low (please specify) I.5.6 Unclear (please specify) I.6 If the study involves studying samples prospectively over time, what proportion of the sample dropped out over the course of the study? If the study involves more than one group, please give drop-out rates for each group separately. If necessary, refer to a page number in the report (e.g. for a useful table).  I.6.1 Not applicable (e.g. study of policies, documents, etc.)  I.6.2 Not applicable (not following samples prospectively over time)  I.6.3 Explicitly stated (please specify) I.6.4 Implicit (please specify) I.6.5 Not  133 stated/unclear (please specify) I.7 For studies that involve following samples prospectively over time, do the authors provide any information on whether, and/or how, those who dropped out of the study differ from those who remained in the study?  I.7.1 Not applicable (e.g. study of policies, documents, etc.)  I.7.2 Not applicable (not following samples prospectively over time)  I.7.3 Not applicable (no drop outs)  I.7.4 Yes (please specify) I.7.5 No I.8 If the study involves following samples prospectively over time, do authors provide baseline values of key variables, such as those being used as outcomes, and relevant socio- demographic variables?  I.8.1 Not applicable (e.g. study of policies, documents, etc.)  I.8.2 Not applicable (not following samples prospectively over time)  I.8.3 Yes (please specify) I.8.4 No    Section J: Methods recruitment and consent   J.1 Which methods are used to recruit people into the study? e.g. letters of invitation, telephone contact, face-to-face contact.  J.1.1 Not applicable (please specify)  J.1.2 Explicitly stated (please specify) J.1.3 Implicit (please specify) J.1.4 Not stated/unclear (please specify)  J.1.5 Please specify any other details relevant to recruitment and consent J.2 Were any incentives provided to recruit   134 people into the study? J.2.1 Not applicable (please specify)  J.2.2 Explicitly stated (please specify)  J.2.3 Not stated/unclear (please specify) J.3 Was consent sought? Please comment on the quality of consent, if relevant.   J.3.1 Not applicable (please specify)  J.3.2 Participant consent sought J.3.3 Parental consent sought J.3.4 Other consent sought J.3.5 Consent not sought  J.3.6 Not stated/unclear (please specify) Section K: Methods - Data Collection   K.1 Which variables or concepts, if any, does the study aim to measure or examine?  K.1.1 Explicitly stated (please specify)  K.1.2 Implicit (please specify) K.1.3 Not stated/ unclear K.2 Please describe the main types of data collected and specify if they were used to (a) to define the sample; (b) to measure aspects of the sample as findings of the study? Only detail if more specific than the previous question        K.2.1 Details K.3 Which methods were used to collect the data? Please indicate all that apply and give further detail where possible  K.3.1 Curriculum-based assessment  K.3.2 Focus group interview  K.3.3 One-to-one interview (face to face or by phone)  135  K.3.4 Observation  K.3.5 Self-completion questionnaire  K.3.6 self-completion report or diary  K.3.7 Examinations  K.3.8 Clinical test  K.3.9 Practical test  K.3.10 Psychological test (e.g I.Q test)  K.3.11 Hypothetical scenario including vignettes  K.3.12 School/ college records (e.g attendance records etc)  K.3.13 Secondary data such as publicly available statistics  K.3.14 Other documentation  K.3.15 Not stated/ unclear (please specify)  K.3.16 Please specify any other important features of data collection  K.3.17 Coding is based on: Author's description   136 K.3.18 Coding is based on: Reviewers' interpretation K.4 Details of data collection intruments or tool(s). Please provide details including names for all tools used to collect data, and examples of any questions/items given. Also, please state whether source is cited in the report  K.4.1 Explicitly stated (please specify) K.4.2 Implicit (please specify) K.4.3 Not stated/ unclear (please specify) K.5 Who collected the data? Please indicate all that apply and give further detail where possible  K.5.1 Researcher  K.5.2 Head teacher/ Senior management  K.5.3 Teaching or other staff  K.5.4 Parents  K.5.5 Pupils/ students  K.5.6 Governors  K.5.7 LEA/Government officials  K.5.8 Other educational practitioner  K.5.9 Other (please specify) K.5.10 Not stated/unclear K.5.11 Coding is based on: Author's description  K.5.12 Coding is based on: Reviewers' inference  137 K.6 Do the authors' describe any ways they addressed the repeatability or reliability of their data collection tools/methods? e.g test-re-test methods  (where more than one tool was employed, please provide details for each)        K.6.1 Details K.7 Do the authors describe any ways they have addressed the validity or trustworthiness of their data collection tools/methods? e.g mention previous piloting or validation of tools, published version of tools, involvement of target population in development of tools.  (Where more than one tool was employed, please provide details for each)          K.7.1 Details K.8 Was there a concealment of which group that subjects were assigned to (i.e. the intervention or control) or other key factors from those carrying out measurement of outcome - if relevant? Not applicable - e.g analysis of existing data, qualitative study.   No - e.g assessment of reading progress for dyslexic pupils done by teacher who provided intervention  Yes - e.g researcher assessing pupil knowledge of drugs - unaware of whether pupil received the intervention or not.     K.8.1 Not applicable (please say why)  K.8.2 Yes (please specify) K.8.3 No (please specify)  138 K.9 Where were the data collected? e.g school, home  K.9.1 Educational Institution (please specify) K.9.2 Home (please specify) K.9.3 Other institutional setting (please specify)  K.9.4 Not stated/ unclear (please specify) Section L: Methods - data analysis L.1 What rationale do the authors give for the methods of analysis for the study? e.g. for their methods of sampling, data collection or analysis.    L.1.1 Details L.2 Which methods were used to analyse the data? Please give details (e.g., for in-depth interviews, how were the data handled?)  Details of statistical analyses can be given next.  L.2.1 Explicitly stated (please specify) L.2.2 Implicit (please specify) L.2.3 Not stated/unclear (please specify)  L.2.4 Please specify any important analytic or statistical issues L.3 Which statistical methods, if any, were used in the analysis?   L.3.1 Details L.4 Did the study address multiplicity by reporting ancillary analyses, including sub-group analyses and adjusted analyses, and do the authors report on whether these were pre-specified or exploratory?  L.4.1 Yes (please specify)  L.4.2 No (please specify)  L.4.3 Not applicable L.5 Do the authors describe strategies used in the analysis to control for bias from confounding variables?  L.5.1 Yes (please specify) L.5.2 No L.5.3 Not applicable  139 L.6 For evaluation studies that use prospective allocation, please specify the basis on which data analysis was carried out. 'Intention to intervene' means that data were analysed on the basis of the original number of participants, as recruited into the different groups.  'Intervention received' means data were analysed on the basis of the number of participants actually receiving the intervention.     L.6.1 Not applicable (not an evaluation study with prospective allocation) L.6.2 'Intention to intervene' L.6.3 'Intervention received' L.6.4 Not stated/unclear (please specify) L.7 Do the authors describe any ways they have addressed the repeatability or reliability of data analysis? e.g. using more than one researcher to analyse data, looking for negative cases.     L.7.1 Details L.8 Do the authors describe any ways that they have addressed the validity or trustworthiness of data analysis? e.g. internal or external consistency, checking results with participants.  Have any statistical assumptions necessary for analysis been met?        L.8.1 Details L.9 If the study uses qualitative methods, how well has diversity of perspective and content been explored?  L.9.1 Details L.10 If the study uses qualitative methods, how well has the detail, depth and complexity (i.e. the richness) of the data been conveyed?     L.10.1 Details  140 L.11 If the study uses qualitative methods, has analysis been conducted such that context is preserved?    L.11.1 Details Section M: Quality of study - reporting  M.1 Is the context of the study adequately described? Consider your previous answers to these questions (see Section B):  why was this study done at this point in time, in those contexts and with those people or institutions? (B3)  Was the study informed by, or linked to an existing body of empirical and/or theoretical research? (B4)  Which groups were consulted in working out the aims to be addressed in this study? (B5)  Do the authors report how the study was funded? (B6)  When was the study carried out? (B7)             M.1.1 Yes (please specify)  M.1.2 No (please specify) M.2 Are the aims of the study clearly reported? Consider your previous answers to these questions (See module B):  What are the broad aims of the study? (B1)  What are the study research questions and/or hypothesis? (B8)     M.2.1 Yes (please specify) M.2.2 No (please specify)  M.3 Is there an adequate description of the sample used in the study and how the sample was identified and recruited? Consider your answer to all questions in sections D (Actual Sample), I (Sampling Strategy) and J (Recruitment and Consent).      M.3.1 Yes (please specify) M.3.2 No (please specify)  141 M.4 Is there an adequate description of the methods used in the study to collect data? Consider your answers to the following questions (See Section K)  What methods were used to collect the data? (K3)  Details of data collection instruments and tools (K4)  Who collected the data? (K5)  Where were the data collected? (K9)          M.4.1 Yes (please specify) M.4.2 No (please specify) M.5 Is there an adequate description of the methods of data analysis? Consider your answers to previous questions (see module L)  Which methods were used to analysis the data? (L2)  What statistical method, if any, were used in the analysis? (L3)  Did the study address multiplicity by reporting ancillary analyses (including sub-group analyses and adjusted analyses), and do the authors report on whether these were pre-specified or exploratory? (L4) Do the authors describe strategies used in the analysis to control for bias from counfounding variables? (L5)            M.5.1 Yes (please specify) M.5.2 No (please specify) M.6 Is the study replicable from this report?  M.6.1 Yes (please specify) M.6.2 No (please specify) M.7 Do the authors state where the  M.7.1 Yes (please specify) M.7.2  142 full, original data are stored? No (please specify) M.8 Do the authors avoid selective reporting bias? (e.g. do they report on all variables they aimed to study, as specified in their aims/research questions?)    M.8.1 Yes (please specify) M.8.2 No (please specify) Section N: Quality of the study - Weight of evidence  N.1 Are there ethical concerns about the way the study was done? Consider consent, funding, privacy, etc.  N.1.1 Yes, some concerns (please specify)  N.1.2 No (please specify) N.2 Were students and/or parents appropriately involved in the design or conduct of the study? Consider your answer to the appropriate question in module B.1  N.2.1 Yes, a lot (please specify) N.2.2 Yes, a little (please specify)  N.2.3 No (please specify) N.3 Is there sufficient justification for why the study was done the way it was? Consider answers to questions B1, B2, B3, B4   N.3.1 Yes (please specify) N.3.2 No (please specify) N.4 Was the choice of research design appropriate for addressing the research question(s) posed?  N.4.1 yes, completely (please specify)  N.4.2 No (please specify) N.5 Have sufficient attempts been made to establish the repeatability or reliability of data collection methods or tools? Consider your answers to previous questions:  Do the authors describe any ways they have addressed the reliability or repeatability of their data collection tools and methods (K7)  N.5.1 Yes, good (please specify)  N.5.2 Yes, some attempt (please specify)  N.5.3 No, none (please specify) N.6 Have sufficient attempts been made       143 to establish the validity or trustworthiness of data collection tools and methods? Consider your answers to previous questions:  Do the authors describe any ways they have addressed the validity or trustworthiness of their data collection tools/ methods (K6) N.6.1 Yes, good (please specify) N.6.2 Yes, some attempt (please specify)  N.6.3 No, none (please specify) N.7 Have sufficient attempts been made to establish the repeatability or reliability of data analysis? Consider your answer to the previous question:  Do the authors describe any ways they have addressed the repeatability or reliability of data analysis? (L7)      N.7.1 Yes (please specify) N.7.2 No (please specify) N.8 Have sufficient attempts been made to establish the validity or trustworthiness of data analysis? Consider your answer to the previous question:  Do the authors describe any ways they have addressed the validity or trustworthiness of data analysis? (L8, L9, L10, L11)     N.8.1 Yes, good (please specify) N.8.2 Yes, some attempt (please specify)  N.8.3 No, none (please specify)  144 N.9 To what extent are the research design and methods employed able to rule out any other sources of error/bias which would lead to alternative explanations for the findings of the study? e.g. (1) In an evaluation, was the process by which participants were allocated to, or otherwise received the factor being evaluated, concealed and not predictable in advance? If not, were sufficient substitute procedures employed with adequate rigour to rule out any alternative explanations of the findings which arise as a result?  e.g. (2) Was the attrition rate low and, if applicable, similar between different groups?            N.9.1 A lot (please specify) N.9.2 A little (please specify) N.9.3 Not at all (please specify) N.10 How generalisable are the study results?  N.10.1 Details N.11 In light of the above, do the reviewers differ from the authors over the findings or conclusions of the study? Please state what any difference is.   N.11.1 Not applicable (no difference in conclusions)  N.11.2 Yes (please specify) N.12 Have sufficient attempts been made to justify the conclusions drawn from the findings, so that the conclusions are trustworthy?  N.12.1 Not applicable (results and conclusions inseparable)  N.12.2 High trustworthiness N.12.3 Medium trustworthiness N.12.4 Low trustworthiness  145 N.13 Weight of evidence A: Taking account of all quality assessment issues, can the study findings be trusted in answering the study question(s)? In some studies it is difficult to distinguish between the findings of the study and the conclusions. In those cases, please code the trustworthiness of these combined results/conclusions.     N.13.1 High trustworthiness N.13.2 Medium trustworthiness N.13.3 Low trustworthiness N.14 Weight of evidence B: Appropriateness of research design and analysis for addressing the question, or sub-questions, of this specific systematic review.   N.14.1 High N.14.2 Medium N.14.3 Low N.15 Weight of evidence C: Relevance of particular focus of the study (including conceptual focus, context, sample and measures) for addressing the question, or sub-questions, of this specific systematic review     N.15.1 High N.15.2 Medium N.15.3 Low N.16 Weight of evidence D: Overall weight of evidence Taking into account quality of execution, appropriateness of design and relevance of focus, what is the overall weight of evidence this study provides to answer the question of this specific systematic review?    N.16.1 High N.16.2 Medium N.16.3 Low  146 Section O: This section provides a record of the review of the study O.1 Sections completed Please indicate sections completed.    O.1.1 Section A: Administrative details  O.1.2 Section B: Study aims and rationale O.1.4 Section D: Actual sample  O.1.5 Section E: Programme or intervention description  O.1.3 Section C: Study policy or practice focus  O.1.6 Section F: Results and conclusions  O.1.7 Section G: Methods - study method  O.1.8 Section H: Methods - groups  O.1.9 Section I: Methods - sampling strategy  O.1.10 Section J: Methods recruitment and consent  O.1.11 Section K: Methods - data collection  O.1.12 Section L: Methods - data analysis  O.1.13 Section M: Quality of study - reporting  O.1.14 Section N: WoE A: Quality of the study - methods and data  O.1.15 Section N: WoE B: Appropriateness of research design for review question  O.1.16 Section N: WoE C: Relevance of particular focus of the study to  147 review question  O.1.17 Section N: WoE D: Overall weight of evidence this study provides to answer this review question?  O.1.18 Reviewing record  148 O.2 Please use this space here to give any general feedback about these data extraction guidelines    O.2.1 Details O.3 Please use this space to give any feedback on how these guidelines apply to your Review Group's field of interest  O.3.1 Details   149 Appendix B   CASP 10 Questions tool for qualitative research 1.  Was there a clear statement of the aims of the research?   Yes   No Consider:  – what the goal of the research was  – why it is important  – its relevance   2.  Is a qualitative methodology appropriate? Yes    No  Consider:  – if the research seeks to interpret or illuminate the actions and/or subjective experiences of research participants   Is it worth continuing?  Detailed questions   Appropriate research design  3.  Was the research design appropriate to address the aims of the research?  Consider:  – if the researcher has justified the research design (e.g.  have they discussed how they decided which methods to use?)   Sampling  4.  Was the recruitment strategy appropriate to the aims of the research?  Consider:  – if the researcher has explained how the participants were selected  – if they explained why the participants they selected were the most appropriate to provide access to the type of knowledge sought by the study  – if there are any discussions around recruitment (e.g.  why some people chose not to take part)  Data Collection 5.  Were the data collected in a way that addressed the research issue?  Consider:  – if the setting for data collection was justified  – if it is clear how data were collected (e.g.  focus group, semi-structured interview etc)  – if the researcher has justified the methods chosen  – if the researcher has made the methods explicit (e.g.  for interview method, is there an indication of how interviews were conducted, did they used a topic guide?)  – if methods were modified during the study.  If so, has the researcher explained how and why?  – if the form of data is clear (e.g.  tape recordings, video material, notes etc)  – if the researcher has discussed saturation of data    150 CASP 10 Questions tool for qualitative research Reflexivity (research partnership relations/recognition of researcher bias) 6.  Has the relationship between researcher and participants been adequately considered?  Consider whether it is clear:  – if the researcher critically examined their own role, potential bias and influence during:  – formulation of research questions  – data collection, including sample recruitment and choice of location  – how the researcher responded to events during the study and whether they considered the implications of any changes in the research design  Ethical Issues 7.  Have ethical issues been taken into consideration?  Consider:  – if there are sufficient details of how the research was explained to participants for the reader to assess whether ethical standards were maintained  – if the researcher has discussed issues raised by the study (e.  g.  issues around informed consent or confidentiality or how they have handled the effects of the study on the participants during and after the study) - if approval has been sought from an ethics committee  Data Analysis 8.  Was the data analysis sufficiently rigorous?  Consider:  – if there is an in-depth description of the analysis process  – if thematic analysis is used.  If so, is it clear how the categories/themes were derived from the data?  – whether the researcher explains how the data presented were selected from the original sample to demonstrate the analysis process  – if sufficient data are presented to support the findings  – to what extent contradictory data are taken into account  – whether the researcher critically examined their own role, potential bias and influence during analysis and selection of data for presentation  Findings 9.  Is there a clear statement of findings?  Consider:  – if the findings are explicit  – if there is adequate discussion of the evidence both for and against the researcher’s arguments  – if the researcher has discussed the credibility of their findings (e.g.  triangulation, respondent validation, more than one analyst.)  – if the findings are discussed in relation to the original research questions  Value of the research  151 CASP 10 Questions tool for qualitative research 10.  How valuable is the research?  Consider:  – if the researcher discusses the contribution the study makes to existing knowledge or understanding (e.g.  do they consider the findings in relation to current practice or policy, or relevant research-based literature?)  – if they identify new areas where research is necessary  – if the researchers have discussed whether or how the findings can be transferred to other populations or considered other ways the research may be used  © Public Health Resource Unit, England (2006).  All rights reserved.     152 Appendix C   The Maryland Scale of Scientific Methods  Research Designs   Before-After Control Multiple Units Randomization Methods Score     Level 1 0 0 X 0 Level 2 X 0 0* 0 Level 3 X X X 0 Level 4 X X X 0 Level 5 X X X X  Maryland Scale of Scientific Methods Level Methodological Quality Level 1 Observed correlation between an intervention and outcomes at a single point in time.  A study that only measured the impact of the service using a questionnaire at the end of the intervention would fall into this level. Level 2 Temporal sequence between the intervention and the outcome clearly observed; or the presence of a comparison group that cannot be demonstrated to be comparable.  A study that measured the outcomes of people who used a service before it was set up and after it finished would fit into this level.   Level 3 A comparison between two or more comparable units of analysis, one with and one without the intervention.  A matched-area design using two locations in the UK would fit into this category if the individuals in the research and the areas themselves were comparable.   Level 4 Comparison between multiple units with and without the intervention, controlling for other factors or using comparison units that evidence only minor differences.  A method such as a propensity score matching, that used statistical techniques to ensure that the programme and comparison groups were similar would fall into this category. Level 5 Random assignment and analysis of comparable units to intervention and control groups.  A well conducted Randomised Controlled Trial fits into this category.  153 Threats to Internal Validity  Causal Direction History Chance Factors Selection Bias Methods Score     Level 1 X 0 X 0 Level 2 0 0 0* 0 Level 3 0 X X 0 Level 4 0 X X 0 Level 5 0 X X X Key: X=Present 0=Absent *Except where a comparison unit is employed without demonstrated comparability. Retrieved from (Sherman et al., 1998)  

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