National Patient Safety Goals for 2007 approved by the Joint Commission on Accreditation of Healthcare Organizations Board of Commissioners include "to encourage patients' active involvement in their own care as a patient safety strategy" and "to define and communicate the means for patients and their families to report concerns about safety and encourage them to do so."1 Undoubtedly, the lines of communication between nurses, physicians, patients, and their families must be open during hospitalization. Education programs that teach patients and their families should be created according to each patient's and family member's level of health literacy and the needs of special patient populations (eg, geriatric and limited-English-speaking patients).
In the United States, family involvement in inpatient care is increasingly emphasized to provide safe and error-free care. However, some studies have challenged this theme, for example, in effectively preventing inpatient falls2 and family members being the transmitters of nosocomial infection agents such as severe acute respiratory syndrome.3 The qualifications and roles of family members and family-paid aides and the economic burdens to families should be addressed, instead of simply replacing hospital nursing personnel and saving nursing costs for inpatient services (eg, see References 3 and 4). Before setting up an open visitation policy and generally inviting family members to participate in inpatient care in the US hospital systems, we need to understand the roles that family members are expected to play in inpatient care and what kinds of activities nurses expect them to perform.
Using Sitters or Volunteers as Companions to Prevent Patient Falls
Some hospitals in western societies use volunteers or pay US $18 per hour to have sitters-who are not trained as nurses or certified nurse assistants-to stay with patients who are at high risk for falls as a fall prevention strategy. A study was conducted on two 4-bed safety bays in medical wards in 2 Australian hospitals to evaluate the feasibility of using volunteers to prevent inpatient falls.5 No patients fell at these sites when such volunteers were present; however, there was no significant impact on the overall fall rates of these sites in this before/after comparative research. In contrast, another Australian study6 used volunteers to reduce falls in an acute aged care ward. Patients assessed as being at high risk for falls were cared for in an observation room staffed by volunteers. No patient falls were reported in this observation room when volunteers were present. In addition, there was a statistically significant reduction of 44% in the overall fall rate, compared with the rate before this program was implemented.
These hospital-paid sitters and volunteers in US and Australian hospitals do not ambulate patients and use the call bell to summon nurses if patients attempt to move from the bed or chair without assistance.5,6 The effectiveness of sitters or volunteers in preventing falls has been recognized by hospital administrators, but whether they decrease inpatient fall rates is still uncertain. Evidence-based intervention research is needed to further illustrate the cost-effectiveness of such fall prevention programs.
Patient Safety and the Culture of Family Involvement in Inpatient Care
The medical practice environment in the Confucianism value-based societies of east Asia (Taiwan, China, Korean, Japan, etc, excluding Hong Kong) is quite different from that in western/Christian societies, although most Asian hospitals adopt the western medicine model in practice. Family members are usually the primary informal care givers and are involved in inpatient care in acute care settings. Nurses, intentionally or not, delegate basic nursing activities (eg, ambulating, moving the patient from the bed to the toilet, feeding) to these people. Nurses claim that they teach family members how to perform these activities and routinely note this on patient charts (eg, fall prevention education).
Taiwan's Family Involvement Culture
Taiwan has a long-standing custom of allowing family members to stay with their hospitalized loved ones in acute care units for up to 24 hours per day. Although traditional Confucian values are impressed deeply on the minds of Taiwanese, hospitals in Taiwan have had issues related to family involvement in medical practice.3 For example, the roles of inpatient's family members, overcrowded patient units, and conflicts between families and medical staff have created concerns about quality care standards. Such a custom might (1) interfere with a patients' rest and the peace, safety, and operation of the ward (there is a high frequency of reported thefts in inpatient units); (2) result in social pressure on family members (accompanying sick parents during hospitalization is a way of being filial); and (3) contribute to the family's psychological and financial burdens.3,7
Hiring a Private Aide
In Taiwan's acute care hospitals-except in intensive care units-family members are allowed to stay with the patient all day. As a result of the recent changes in the structure of many Taiwanese families (a decrease in the number of large extended families living together), when a member of the household is hospitalized, family members are often busy working outside the home and cannot provide a companion for their sick one. According to traditional Taiwanese customs, hospital nurses usually expect to delegate some of their nursing activities such as morning care, emptying bedpans, and removing the covers of the intravenous insertions (for adding medications) to family members.
If all the adults in a household are employed, at least 1 family member in our society has to bear some of the social costs because someone has to take time off work. If the family members cannot spare someone to stay with the patient, they will usually hire a private aide (with minimal or no nursing training) to provide bedside care.3 The O-Ba-Sun system of hiring an aide-usually a middle-aged woman-to assist with bedside care has long been used in Taiwan's family involvement culture in acute care settings.
The cost of hiring a personal aide who cares for only 1 patient is about US $75 for a 12-hour shift or about US $120 for a straight 24-hour shift. (A privately hired aide is equivalent to a paid care giver in Korea.) Thus, more than 50% of the nurse aides available for hire through agencies in Taiwan have only an elementary or junior high school education and have been certified after some basic nursing training. The nurse aide training programs are usually sponsored by the Taiwan Department of Labor and offered by hospitals, nursing schools, or training centers.
Patients' Physical and Psychological Needs
The O-Ba-Sun system or family members can support patients with their physical and emotional needs but, because they lack professional training, cannot replace nurses for responsibilities such as effectively preventing inpatient falls. When medical needs or discomforts arise, patients should always send their family members or aides to summon a nurse for help or medical attention. From the perspectives of hospitals, inpatient falls have presented challenges in acute care settings, where someone with physical and cognitive limitations is exposed to unfamiliar and potentially hazardous surroundings. Family members may provide additional pairs of eyes to watch for and prevent hazardous situations. Our observation of the current practice environment suggests that family members and private aides often only alleviate the patients' apprehension. However, no evidence-based studies have investigated the effects on patients' psychological wellness and physical recovery of having family members and private aides involved in inpatient care.
Korean Family Involvement Culture in Inpatient Care
Cho and Kim4 claim that, according to the reports of the Ministry of Health and Welfare (written in Korean), as early as November 1999, the South Korean national health insurance system had differentiated nursing fees for inpatient care based on the nurse staffing levels of hospitals. This public policy aimed to prevent hospitals from delegating nursing care to family members or privately paid care givers (aides), which might ultimately deteriorate the quality of nursing care services.
Following this public policy announcement, a study in Korea used the data from the 2001 Seoul Citizens' Health Survey, which was a community-based interview survey with more than 3,000 previously hospitalized patients in Seoul, to investigate patients' needs for family and paid care givers during hospitalization.4 Eighty-seven percent of participants claimed they needed care givers during hospitalization. Family members were the primary care givers, but 3% employed private paid care givers. The average paid care-giver expense per day was US $38.50, which accounted for 35% of the total out-of-pocket expenses for a full hospital day. The total paid care-giver expense for the entire hospital stay was US $1,264 on average (median, US $667), and 73% of participants perceived this cost as burdensome.4 This study illustrates the financial burden to patients and family members during hospitalization but lacks a link to patient safety measures.
Inpatient Falls in Taiwan's Medical Environment
Tzeng et al2 analyzed the incident reports of falls and the activities of the accompanying family members when patients fell in a Taiwanese medical center in Taipei. Data on the patient fall cases were collected for 95 days, and all the information was reported by the staff nurses who dealt directly with these patients. There were 239 patient falls, 228 of which occurred in acute care settings (excluding emergency room and outpatient clinics). Among these 228 cases, 87 (38.2%) had no company, and 141 (61.8%) had at least 1 family member or aide present when the fall occurred. When the patients fell, 38 (27.0%) of accompanying family members were sleeping in the patient unit, 22 (15.6%) were not in the ward at that moment, 5 (3.5%) were using the bathroom in the patient unit, 26 (18.4%) were nearby but not watching the patient, 41 (29.1%) were watching the patient but unable to prevent the fall, and 9 (6.4%) were improperly supporting the patients when the fall was occurring or patients were losing their balance.
These findings suggest that family members may not always be dependable in assisting with inpatient care (eg, using the toilet, moving patients in and out of bed), and they often only alleviate their hospitalized loved one's and their own apprehension. If nurses and physicians consider family members to be part of the inpatient care team, these people need to be taught to assist patients effectively. Nurses have to repeat fall prevention health education to patients and family visitors as often as needed.2
Design of the Study
The purpose of this study was to illustrate the activities and roles of family members in their most recent experiences of accompanying their hospitalized loved ones in acute inpatient care. This cross-sectional survey design study was held in May 2006 in Taiwan, a Confucianism value-based society.
A convenient sampling method was used to collect data in the senior nursing class (51 students) of a private university in southern Taiwan. The human subjects review committee of this university approved the project proposal, ensuring human subject protection. Each student was instructed to invite a family member (excluding himself or herself) and a neighbor to fill out a survey. Participation was voluntary, and participants had to be at least 21 years old. However, participants were not required to sign the informed consent form because return of the completed questionnaires indicated consent.
The authors developed a 1-page questionnaire, including the informed consent form. One expert in Chinese history and culture and one in healthcare management and sociology were responsible for reviewing the content validity of this instrument. The instrument (in Mandarin) was pretested on 10 nursing students in this studied senior nursing class for clarity of wording and was finalized without any modifications.
Among the 102 family members, 99 (97.1%) had at least 1 experience of accompanying their hospitalized loved ones. Among these, the average age of the family participants was 42.04 years old, younger than the average age of the patients they attended to (mean, 55.81). Seventy-eight (78.8%) of family participants were women. In their most recent experience, 51 (51.5%) of the patients who had accompanying family members were women. About 85% of these patients had a hospital stay of 21 days or shorter (mean, 15.58 days). Based on the family visitors' perceptions, 54.1% (n = 53) of the patients' health problems for hospitalization were to be stabilized after a while, followed by expectations to "recover very soon" (n = 24, 24.5%) and then situations "being serious" (n = 21, 21.4%). It is also noted that 55(55.6%) participants had 2 generations living together, 26 (26.3%) had 3 generations, and 1 (1.0%) had 4 generations living in the same house.
As shown in Table 1, 40.4% of these family participants are the patient's children, and 9 (9.1%) indicated that there was a privately hired aide to assist the patient during hospitalization. Thirty-eight family members (40.4%) were employed full time, and 59 (59.6%) took turns keeping the patient company (Table 1).
As for the roles and involved activities of these participants, 87 (87.9%) attended to the patients' physical care, 80 (80.8%) offered psychological support, and 60 (60.6%) communicated with physicians and nurses about their loved ones' needs. The 4 most popular reasons for keeping the patient company during hospitalization were (1) it is perceived as "one of my responsibilities" (n = 76, 76.8%), (2) "coming to help voluntarily" (n = 66, 66.7%), (3) it is a way of "showing filial piety and devotion to my parent" (n = 43, 43.3%), and (4) "if no family member accompanied the patient, I would be afraid that the patient would not receive appropriate care" (n = 39, 39.4%). Five participants (5.1%) indicated that they were requested by nurses or physicians to keep their loved ones company during hospitalization.
As indicated in Table 1, 39 participants (39.4%) indicated that they were afraid that the patient would not receive appropriate care, and 9 (9.1%) said that they were requested by the patients to visit. The frequencies of these 2 reasons could reflect the public image toward Taiwan hospital systems, suggesting a lack of trust in medical care provided by the hospital and worry that loved ones would not receive good care if they were not present in the patient units.
Taiwanese hospitals were established based on the principle of western medicine. However, in clinical practice, physicians and nurses usually adopt the logic and common sense related to the values of Confucianism, where family involvement in inpatient care is expected. This way, hospital administrators can demand a higher ratio of patient to nurse, hire fewer nurses, and save human resource expenses, because some of the nursing hours can be transferred to family members or privately hired aides.
Family Visitors Cannot Replace Nurses
Involving family visitors in inpatient care and adopting the O-Ba-Sun system in Taiwan may provide psychological support to patients but cannot replace nurses in effectively preventing inpatient falls, for example, because they lack professional nurse training. The potential for fall-related injury is an important safety consideration and has been long considered as a nursing-sensitive quality indicator in the delivery of inpatient services.9 In trying to prevent inpatient falls, the quality, capabilities, and responsibilities of the companions contribute to different outcomes; a family companion who is a professional nurse or physician can most likely prevent a fall.
The Chinese phrase, "Three cobblers with their wits combined are a match for Chu-Ko Liang the genius," describes the attitude that wisdom of the masses exceeds that of the wisest individual. This Chinese phrase is simply intended to motivate and encourage people to work hard to be successful. In reality, 3 certified nurse assistants, family members, or sitters with their wits and efforts combined are not equivalent to a professionally trained nurse. Would it be feasible to pay the same amount of money to hire retired nurses as fall prevention care givers in inpatient units, instead of using sitters, volunteers, or family members? Would bringing in informal care givers to inpatient care be an effective way to ensure patients' safety? The answers are uncertain.
Given the nursing shortage, possible strategies to retain qualified nurses include ensuring safe working environments to minimize occupational hazards, providing flexible work arrangements to accommodate family considerations, and reducing incentives that encourage early retirement.9 Being a staff nurse in an acute care setting is physically demanding, and early retirement seems difficult to avoid. Using retired nurses as fall prevention care givers in inpatient units could be a win-win situation for retired nurses and to nursing executives to ensure patient safety and quality nursing care.
Frequent Communication With Patients and Family Visitors
Building a collaborative relationship and having frequent communication between staff nurses, patients, and companions (family members, privately hired aides, sitters) about an individual patient's risk for falls are the key to preventing fall-related injuries.10 Clinical nurses should patiently and constantly remind patients and their family visitors about fall prevention topics. Accompanying family members usually take turns, and the knowledge of fall prevention might not be passed from one person to the next. A guideline that includes written expectations about family members in acute care settings should be developed for patients, family members, hospital administrators, clinical nurses, and physicians. Different ethnic backgrounds and religions, as related to patients' family involvement, should especially be considered.
© 2007 Lippincott Williams & Wilkins, Inc.