Open visiting in adult intensive care units – A structured literature review

BackgroundOpen visitation in adult intensive care units report benefits such as reduced frequency and duration of deliriums, improved patient and family satisfaction, and reduced anxiety and depression of family members. ‘Being close’ is one of the most basic and important needs of family members of critically ill patients. Open visitation provides an increased opportunity of being at the bedside with the patient, however, it is not universally embraced by adult intensive care units worldwide.AimTo critically appraise the literature concerning open visitation in adult intensive care units.DesignA structured literature review.MethodThis review was guided by the methodology by Kable et al. (2012). Sixteen articles are included in the review.ResultsDespite the documented benefits, several challenges exist which hinder broad application of open visitation in adult intensive care units.ConclusionThis review acknowledged challenges faced in adopting an open visiting policy in adult intensive care units such as negative staff perceptions and attitudes; patient protection; family and cultural consideration, as well as organisational challenges. The lack of a clear and consistent definition of open visitation is problematic, and strategies are urgently needed to support staff to provide holistic patient- and family-centred care.     

Promoting family-centered visitation makes a difference

Promoting parental and sibling visitation of the critically ill child can positively influence the resolution of a crisis when a child is admitted to the pediatric intensive care unit. There are many benefits as well as barriers to incorporating family-centered visitation into the plan of care. Understanding the needs, stressors, and coping styles of the entire family will help the nurse provide a positive experience when parents or siblings visit the critically ill child.     

Open visitation policies and practices in US ICUs: can we ever get there?

Open visitation has been highly recommended by critical care groups but is not prevalent in practice. Here we discuss the present study on current visitation practices in US ICUs and discuss several factors affecting open visitation. We conclude with suggestions on achieving more liberal visitation practices.In a previous issue of Critical Care, Liu and colleagues embark upon a timely and important topic: visitation practices in US ICUs [1].There are many benefits to open visitation. Patients feel supported [2] and safe [3]. Families are more satisfied with care and are less anxious [4]. Healthcare providers have increased opportunities for communication and teaching [2]. Because of these benefits, open and unrestricted visitation in ICUs has been recommended by critical care groups [5,6]. However, Liu and colleagues report that almost all US ICUs (90%) have restrictive visitation policies, and most (62%) have three or more restrictions. What is disconcerting is that these findings are not all that different from those reported in 2007, where only 32% of ICUs had open visitation [7]. Even this statistic is misleading, because ''open'' referred only to the hours of visitation, and most ICUs considered open had restrictions on age and the number of visitors [7]. Liu and colleagues'' findings are also consistent with those from other countries where very few, if any, ICUs have open visitation policies [8,9]. With all of the evidence guiding practice toward open visitation, why is it that most ICUs continue to have restrictions on visitation? There are several factors to be considered before ICUs truly embrace open visitation.One factor is the ICU patient. Open visitation has been studied from the perspective of the family and the healthcare provider, but very few studies have focused on the patient''s perspective. Because ICU patients are often unable to communicate their preferences about visitation, they are often excluded from research studies. However, Olsen and colleagues interviewed 11 ICU patients to gain their perspective on visitation [10]. These patients stated that they felt supported when their families were present and were in favor of flexible visitation. Yet most patients wanted some limitations, such as having only close family members visit. In addition, these patients felt stressed when trying to communicate with visitors and when thinking about how upsetting this experience was for their families [10]. Recently, Hardin and colleagues surveyed 122 ICU patients on their satisfaction with unrestricted visiting hours [11]. Their results support those of Olsen and colleagues, since most patients wanted some restrictions and control over visitation. These two studies on the patient''s perspective indicate that the patient''s voice needs to be heard when developing visitation policies.Another factor is the potential contributions of visiting ICU family members to the well-being of their loved ones. Interviews of 25 family members of 24 high risk of dying ICU patients showed that families took on certain roles while in the ICU and that they were physically and actively present in their loved ones'' care [12]. These families reported that they were physically and actively present in their loved ones'' care. Families'' contributions included protecting the patient, facilitating information, providing necessary patient history, comforting and motivating the patient, and performing caregiving activities. As a result, families believed the patient felt safer and more supported if they were present. Others have found that families can contribute to patient care by keeping ICU diaries for the patient [13]. In families that kept diaries, researchers reported significantly lower post-traumatic stress symptoms in both patients and family members 12 months after the ICU stay [13]. Families can also contribute to patient care by participating in patient rounds. Investigators assessing this approach reported improved family satisfaction with communication and decision-making, both of which are important needs for families [14]. Families have much to offer, and allowing them open visitation could help them fulfill their roles, contribute to patient care, and decrease patient and family symptoms.One more factor is the healthcare provider. In a study comparing healthcare providers'' beliefs and attitudes toward open visitation, researchers found that nurses were generally not in favor of it [15]. Nurses feared losing control of their ICU room and felt that visits did not offer more comfort and support to the family. They also felt that open visitation hindered patient rest, infringed on patient privacy, and was an impediment to the nurses doing their job [15]. In addition, there is a great deal of inconsistency among healthcare providers in the level of comfort they have in communicating with families. For example, those who feel more comfortable working with families may favor open visitation, whereas those who do not may want stricter visitation policies. Liu and colleagues found this lack of consistency to be the case, with more restrictions in the Northeast and fewer restrictions in the Midwest and smaller hospitals [1]. This lack of consistency, along with varying beliefs and attitudes toward visitation, can lead to confusion and resentment to all involved (patient, family and healthcare provider) and may be another factor as to why open visitation policies in ICUs continue to be elusive.So how do ICUs embrace open visitation? First, it should be understood that open visitation is not a one-size-fits-all philosophy. Second, it should be clarified that open visitation does not mean a free-for-all, with visitors being on the unit whenever they like. Third, it is important to understand that addressing visitation is a complex process that means patient interests are accounted for, clinicians have improved communication skills, and families are supported and prepared for their visits. Fourth, changing the terms ''open'' and ''unrestricted'' to ''flexible'' and ''liberal'' could help alleviate some of the barriers that healthcare providers have toward open visitation. Finally, perhaps each ICU will need to have an individualized approach to open visitation policies that meet the needs of the patient, the family, and the healthcare provider. However ICUs choose to embrace open visitation, it needs to happen.     

Family visitation on special care units.

1 With placement of a family member with Alzheimer's disease on a SCU, the family does not relinquish the caregiving role, rather they take on different roles in relation to the residents. 2 Family visitation of the residents on the SCU is an integral part of family involvement in care of individuals with Alzheimer's disease, as well as SCU functioning. 3 Within the context of changing relationships with the residents, family members visited the residents as a sense of duty to "be faithful," to monitor care by "being their eyes and ears," and to foster a sense of family through ongoing relationships and family rituals. 4 Nurses have critical roles in promoting physical, emotional, and interactive environments which foster family visitation on SCUs.     

Visitation in the intensive care unit: impact on infection prevention and control

Evidence-based practice has shown that open visitation in the intensive care setting positively impacts patient outcomes. However, many intensive care units continue to strictly limit visitation hours. One concern for nurses is that open visitation will expose their vulnerable patients to an increased risk of infection. This fear is unfounded in professional literature as well as in the experience of a busy intensive care unit in San Antonio, Texas. Keeping our patients safe from hospital-acquired infections requires vigilant attention to infection prevention procedures. Meanwhile, what may actually be bugging our patients is a health care culture that is based on tradition and is blind to the many benefits provided by a more liberal visitation policy rooted in patient-centered care.     

The managed care contract: survival or closure?

The managed health care contract can be considered the most powerful tool in the health care environment today. Providers of care as well as insurers need to fully comprehend the legal and financial impact of these contracts. Too many organizations (providers and insurers) are getting caught in financial failure, resulting in bottom line-driven health care. It seems that the days of providing the most ethically appropriate health care are gone. Too much emphasis has been put on providers and administrators to provide the care that will result in positive income. The only way to "protect" oneself is in the creation, negotiation, and administration of the managed health care contract.     

A visit to the intensive cares unit: a family-centered culture change to facilitate pediatric visitation in an adult intensive care unit

To guide family adjustment, an effort was made to facilitate pediatric visitation in an adult intensive care unit (ICU). Goals were to improve customer satisfaction and to raise staff comfort level with child visitation. After implementing an open visitation policy, concerns around pediatric visitation in the ICU remained. Fears centered on risks to both patient and child. Literature was reviewed before a book was written entitled A Visit to the ICU. It contained information about what a child visiting the ICU would see, hear, and feel when visiting a loved one. The book provided reassurance for caregivers and children, informing them about what to expect when visiting. The goal of the book was to provide caregivers with a framework for age-appropriate education. Staff education was provided on developmental stages, including a child's understandings of illness and death. Nursing interventions were reviewed and resources provided. A survey demonstrated that the book increased staff comfort level with children visiting the unit, was a positive tool for patients and families, and eased fears among children while helping to facilitate coping mechanisms. The article will describe the practice change of pediatric visitation in an ICU and how it could be applied to other critical care settings.     

Facing challenges to family-centered care. I: Conflicts over visitation

Policies and practices related to parental presence and participation in the care of a hospitalized child can be a source of tension between nurses and families. Tensions often revolve around "visiting" hours, who may visit, the number of visitors allowed at the bedside at a time, and inconsistent enforcement of existing visitation policies. A family-centered framework for evaluating these policies and practices can provide direction that will help reduce these tensions. Visitation policies that are flexible and offer guidelines, not rules, will usually best meet the needs of families. Some nurses may need education, mentoring, skill-building, and role-playing opportunities to work comfortably with flexible guidelines and increased family presence and participation.     

Contracting for visitation with families

Visitation in adult critical care units is an important aspect of patient care, and thus should be incorporated into the patient's plan of care. There is no longer a question as to whether visitation should be liberalized or restricted; instead, visitation is individualized in each situation to best meet the patient's needs. One method of incorporating visitation into the care plan is by contracting with patients and family members.     

Implementation and sustainment strategies for open visitation in the intensive care unit: A multicentre qualitative study

ObjectiveOpen visitation in adult intensive care units has been associated with improved family and patient outcomes. However, worldwide adoption of this practice has been slow and reasons for this are unclear. This study documents barriers and strategies for implementing and sustaining open visitation in adult intensive care units in the United States experienced by nursing leadership.Research designQualitative approach using grounded theory.ParticipantsNurse leaders in adult intensive care units with open visitation.SettingMagnet® or Pathway to Excellence® designated hospitals in the United States.MethodsSemi structured interviews were conducted with 19 nurse leaders from 15 geographically dispersed hospitals. Interviews were recorded, transcribed and imported into Atlas.ti qualitative software for analysis. Grounded theory constant comparison analysis was used for coding and category development.FindingsThe analysis revealed three barriers; nursing attitudes and clinical and nonclinical barriers. Strategies to overcome these barriers were empathy, evidence-based practice, models of care, shared governance, nurse discretion, security and family spaces.ConclusionIntensive care nursing leadership experienced distinct barriers and strategies during pre-implementation, implementation and sustainment of open visitation. Other nursing leaders interested in open visitation can use these findings as they plan this transition in their intensive care units.     

Challenging restricted visiting policies in critical care

The need for family members to visit their loved ones when they have been admitted into the critical care unit was identified in 1979 by Molter in the critical care family needs inventory (CCFNI). This need has been the centre of controversy for critical care units for many years. This article provides an overview of literature that refutes some of the rationales that have been used to restrict family visiting in the critical care unit. An overview of a liberalized (open, contract, inclusive or structured) visiting policy is discussed as an option to the restricted visiting policy.     

Visitation in critical care: processes and outcomes of a performance improvement initiative

When family members became dissatisfied with a restrictive visiting policy in a combined coronary and medical intensive care unit, this situation was seen as an opportunity to better meet patient and family needs. A review of the literature indicated that open visitation policies enhance patient and family satisfaction, while a survey of patients, families, and health care team members revealed a desire for a more open visitation policy. Nursing staff, with input from other disciplines, developed and implemented a less restrictive visitation policy. Post-intervention surveys revealed higher patient and family satisfaction and a marked decrease in formal complaints.     

Sleepless nights in the ICU: the awaken family

Having a loved-one in the ICU is a traumatic experience for family members that can lead to a cluster of psychological complications, recently defined as post-intensive care family syndrome. In a previous issue of Critical Care, Day and colleagues stressed the severe sleep disturbance and fatigue experienced by a majority of ICU patient family members. However, despite this burden being well characterised, the best preventive coping strategy remains undetermined.In a previous issue of Critical Care, Day and colleagues [1] investigated sleep, anxiety and fatigue in family members of patients admitted to the ICU. Using validated self-report tools, the majority of family members of ICU patients reported moderate to severe sleep disturbance and fatigue. This newly recognized family burden may have dramatic consequences as sleep deprivation may interfere with their decision-making and care-taking abilities. These findings emphasize the immense turmoil experienced by family members and suggest that surrogate decision makers could be temporarily incompetent, raising issues about the shared decision-making model [2].Perhaps, more so in intensive care than in other medical disciplines, relatives of critically ill patients playa key role during the long ICU course. They frequently play both caregiver and surrogate decision maker roles. Thus, the patient-physician relationship moves to a family-patient-physician-nurse relationship, making the ICU environment quite unique. Among stakeholders, each party may suffer from stress. Neglected for too long, the damaging psychological consequences of an ICU stay on physicians [3] and on relatives are now better characterized [4]. As underlined by Day and colleagues [1], family members of ICU patients have frequent intense sleep deprivation and are exposed to symptoms of anxiety and depression that could lead to psychiatric diseases such as panic disorder, post-traumatic stress disorder [5], or complicated grief [6].As the aging population requires more critical care and ICU mortality decreases, family members will increasingly have opportunities to share in the care of their loved one [7]. Managing a relative''s burden remains the main issue. We advocate that our ICUs have enough resources to prevent post-ICU burden. This requires communication strategies and improved behaviours. For instance, seeing family members sleeping in the waiting room is, unfortunately, a frequent occurrence for night shift clinicians [8]. We have to admit that most of our ICUs do not offer accommodation for family members, and a change in ICU design that integrates night accommodation for family members is warranted and unrealistic at the same time. Instead, several simple measures, mostly based on improving communication strategies and on family-centred ICU organization, have shown an ability to improve family burden. To be effective, interventions must be feasible, easy to reproduce, accessible, resource minimising, and easily integrated at the bedside. Informative hand-outs for educating families about critical illness and intensive therapies, as well as proactive and effective communication strategies fulfil these requirements [9]. As suggested by 25% of the respondents in the study of Day and colleagues [1], improving the frequency and the quality of the information related to their loved ones could allow them to leave the hospital during the night and improve the quality of their sleep. Simple changes in ICU structure, including but not limited to open visitation policies for families and rooms dedicated to family conferences, could also possibly have a beneficial impact on family anxiety and satisfaction. Additionally, flexible visitation in the ICU setting provides the family with opportunities to maintain social links (child care, professional activities, social commitments, and soon). These changes could enable them to manage daily life while allowing them breathing space. Free visitation policies are also an opportunity to alleviate their guilt. This is particularly true for families with ICU patients with lengthy ICU stays.Multiple risk factors of family burden have been identified, and preventative strategies rest on multifaceted programs. Thus, rather than a single intervention, we believe implementing multiple simple and accessible interventions (that is, family information leaflets, routine family conferences, daily family rounds, structured information, unrestricted visiting hours, regular nurse-family-physician meetings, family care specialist nurses, and so on) may prove effective in preventing post-intensive care family syndrome. We are at a time where a qualitative ''care bundle'' for family members has to be implemented in our daily practice. In addition to reducing sedation intensity in critically ill patients, we should find ways to provide healing information to family members and encourage them to safeguard their sleeping time. Studies to improve sleep quality in family members are warranted.     

A look at critical care visitation: the case for flexible visitation.

The topic of critical care visitation has been researched and discussed over the past 25 years and still remains controversial. There still remain many concerns over the benefits of open or flexible visitation. A review of some research conducted in the past several years, perceived barriers to open visitation, and the benefits will be presented in this article.     

La visita flexible en las unidades de cuidados intensivos: beneficios para los familiares del paciente crítico

AimTo identify, analyze and summarize the main effects that may be related to flexible visitation policies for the relatives of critically ill adults.MethodA review of the literature was conducted in the following databases: PubMed, CINAHL, PsycINFO, Cochrane Library and CUIDEN. Thematic content analysis was used to evaluate selected articles.ResultsFifteen articles were included in this review. Four main themes emerged from the thematic content analysis. Themes included the main effects of flexible visitation policies for the family of the critical patients such as: improvement of satisfaction, reduction of anxiety and stress, satisfaction regarding their own family needs, and the role of the family in the patient's care.ConclusionAccording to the existing evidence, flexible visitation policies appear to be both beneficial and decisive. It seems to be necessary to favor the participation of the family in the care of the intensive patient as well as the acquisition of a more prominent role the visitation context and in their relationship with the patient.     

Family visitation in the PACU, 1984-2006.

Family visitation in postanesthesia care remains a controversial issue in North American hospitals. Historically, PACUs have been a closed and restricted area to the general public. Over the past 20 years, a growing body of nursing research has emerged challenging the restrictive practices of excluding family visitation in the immediate postoperative period. Because of the inconsistencies and gaps between current clinical practice and research, a review and analysis of past and present family visitation literature was conducted. Findings indicate that a further study of beliefs and workplace culture can contribute to a better understanding of impeding factors on a much needed change in policy.     

The invisible dimension: abuse in palliative care families

The family as the unit of care underpins the philosophy and practice of palliative care. Through this model of service delivery, palliative care professionals attempt to provide holistic, quality end-of-life care to terminally ill patients and their families. The research on palliative care families to date, however, constructs the family unit as functional, articulate, cohesive and, thus, able to adapt to the impact of a terminal diagnosis, albeit with professional intervention if required. This notion of the family as monolithic and unproblematic masks the existence of family issues that have the potential to impact negatively on the care that patients receive, and thus constrain the palliative health professional in facilitating quality end-of-life care. Through a review of current literature, this paper identifies such an issue--that of abusive family relationships--which has been hitherto neglected in palliative care research. It is suggested that the issue of abusive family relationships needs to be identified and responded to at some level if the goal of providing holistic care and facilitating a "good death" for all terminally ill people receiving palliative care is to be achieved. The continued invisibility of this issue does not resolve the problem of abuse and could result in the implementation or continuation of practices that may in fact be damaging.     

Provider continuity and quality of medical care. A retrospective analysis of prenatal and perinatal outcome

It is often assumed that family physicians are able to provide a higher quality of medical care because of the greater degree of continuity inherent in their practices. The authors attempted to measure the association between continuity and quality of medical care using pregnancy as a tracer condition. Using a retrospective cohort study design, two groups of pregnant women were identified--those cared for in the family practice (FP) centers and those cared for in the obstetric (OB) clinics. Process and outcome of medical care were measured along with patient satisfaction. Provider continuity, as measured by the SECON value, was much higher in the FP group, and was highly correlated with the presence of an "attitudinal contract" between patient and physician. Although not statistically significant, four times as many newborns from the OB group were admitted to the neonatal intensive care unit. FP group newborn weight averaged 220 grams more than the OB group (P less than 0.05). This difference remained after control for covariates. While not reaching statistical significance, patient satisfaction scores tended to be higher for the FP group in two of three categories measured. The results suggest that continuity of care was associated with better patient outcome and satisfaction. Directions for causal interpretation and future research are discussed.     

Decision making in the critically ill patient

In the preceding discussion we have attempted to set forth some realistic guidelines for the primary care physician in the critical care area. We feel that he is of utmost importance in setting the tone for his patient's care. He is the first physician to be called when his patient becomes critically ill. He decides whether or not consultation is needed immediately. He should choose appropriate consultants, trying to provide required expertise and compatible personalities to relate with his patient and the patient's family. His work does not end with establishing roles and delivering care. He is the single most important physician when difficult ethical and medicolegal decisions must be made. He is the physician who knows the patient and the patient's family best. They look to him for guidance and decision making about their health care. He is best able to discuss the wishes and desires of the patient if the patient becomes unable to decide for himself. The primary care physician can be extremely helpful when the appropriate medical decision is to withhold therapy. He can comfort and console the family and help them realize that the proper decisions have been made. His previous close relationship with the patient and family makes difficult decisions much easier to accept. He is also of primary importance when trying to provide care to a patient who ostensibly refuses such care. The trust he has earned in the past because of the care he was provided allows him to be much more forceful than the subspecialist who may have been on the case for 1 or 2 days. He can be the difference between survival and death merely by his presence and advice. Other difficult decisions are always made easier by a primary physician who can relate to the consultants as well as the patient and his family. In conclusion, we feel that the technologic advances of the past 30 years have tended to drive the primary care physician away from the critical care unit. This is mostly because of a need for particular expertise to run the machines of medicine. One cannot be expected to become or remain an expert in primary care and critical care medicine. The primary care physician should not feel or be excluded from the critical care area. His knowledge of general medicine and his expertise in interpersonal and family relationships allow him to provide the much needed "high touch" component of "high tech" critical care medicine.