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.     

The effect of video visitation on intensive care unit patients and family members outcomes during the COVID-19 pandemic: A randomised controlled trial

ObjectiveTo investigate the effect of video visitation on intensive care patients’ and family members’ outcomes during the COVID-19 pandemic.DesignThis is a randomised controlled trial.SettingAn adult intensive care unit in a tertiary hospital in Beijing, China.MethodsA total of 121 adults, who were >18 years of age, conscious, able to communicate verbally, and admitted to the intensive care unit for over 24 hours were randomised into the intervention (video visitation) (n = 65) and control (n = 56) Groups. A total of 98 family members participated. Patient primary outcomes included anxiety and depression, measured using the Hospital Anxiety and Depression Scale. Secondary outcomes included patient delirium and family anxiety assessed using the Confusion Assessment Method scale and Self-Rating Anxiety Scale, respectively; and patient and family satisfaction, measured using a questionnaire routinely used in the hospital.ResultsThere were no statistically significant differences between the groups in patients’ anxiety (t = 1.328, p = 0.187) and depression scores (t = 1.569, p = 0.119); and no statistically significant differences in delirium incidence between the groups (7.7 % vs 7.1 %, p > 0.05). There were no significant differences in changes in family members’ anxiety scores (t = 0.496, p = 0.621). A statistically significant difference in satisfaction was found between the two group patients (86.1 % vs 57.2 % of patients were satisfied with using video visitation, p < 0.05), and the result of family members’ satisfaction was also statistically significant (88 % vs 62.5 % of family members were satisfied with using video visitation, p < 0.05).ConclusionVideo visitation did not seem to influence anxiety, but the use of video visitation can improve the patient and their family members’ satisfaction. Future research is needed to determine the feasibility of embedding video visitation into routine practice, and the optimal frequency and length of video visitation in relation to patients’ and family members’ outcomes.Implications for clinical practiceVideo visitation improved patient and family members' satisfaction. Therefore, clinicians should consider using video visitation when face to face visit is restricted. Video visVitation did not reduce patient anxiety significantly in this study maybe because the average length of intensive care stay was too short. Future research is needed on its effect on long term intensive care patients.     

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.     

Critical care open visiting hours

To gain an understanding of and increased knowledge about the effects of open visiting hours on patients, their family members, and nurses within the intensive care unit environment, the author reviewed 10 empirical studies. Much has been debated about the essentials needed to create a healing environment that best promotes harmony of the mind, body, and spirit for the critically ill patient. Research indicates an open visiting policy may improve the quality of care and satisfaction of patients, family members, and nurses in the intensive care unit. The studies reviewed show that although most critical care nurses find that open visiting hours may impede patient care, the benefits to patients and family outweigh any negative impact to the patient.     

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.     

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.     

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.     

An evaluation of interventions for meeting the information needs of families of critically ill patients.

OBJECTIVE: To evaluate the effectiveness of two methods of meeting the information needs of families of critically ill patients: an open visiting hour policy and a family information booklet. SETTING: Medical intensive care unit of a university medical center. SUBJECTS: Family members (N = 147) of patients admitted to the medical intensive care unit. INTERVENTIONS: Implementation of an open visiting hour policy and information booklet. MEASUREMENTS AND MAIN RESULTS: Questionnaires were distributed to family members 24 to 48 hours after the patient's admission. The questionnaire addressed family satisfaction with having specific information needs met and posed questions that tested their knowledge of unit policies and personnel. The questionnaire was distributed to three groups: families who had restricted visiting hours and no booklet (group 1, n = 48), families who had open visiting hours but no booklet (group 2, n = 50), and families who had open visiting hours and an information booklet (Group 3, n = 49). Implementation of an open visiting hour policy increased family satisfaction. Families exposed to both the open visiting hours and the information booklet were more knowledgeable about specific details than were those exposed to only the open visiting hour policy. CONCLUSIONS: Flexible visiting hours and information booklets were two practical methods of meeting the information needs of families. Open visiting hours, as a singular intervention, significantly improved family satisfaction. The effectiveness of the booklet in assisting families to recall discrete pieces of information supports the further development and use of preprinted materials to assist in meeting family information needs.     

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.     

A family-centered critical care unit

Although care of the family has long been a focus of nursing, there has been an increased emphasis in recent years to provide opportunities for families to be an integral part of the hospitalization experience. This has been difficult for many nurses who perceive themselves as competent to care for a patient in "medical crisis" but feel unqualified to provide family care. This article will address issues related to implementing a family-centered philosophy of care in a critical care unit. Implementation strategies that will be discussed include: formulating a staff-led family support group and family committee, instituting a family visitation contract within open visitation parameters, and developing clinicians with expertise in family care. Tools such as a performance plan for a Clinical Nurse II specializing in family care and the family visitation contract will be shared.     

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.     

Visiting hospitalized patients

Visiting policies in acute care institutions affect patients and families. The study sought to answer these questions: What are current hospital visiting policies and accompanying provisions for families? How are nurses implementing these policies? A questionnaire was developed, and reliability and content validity were established. The questionnaire was mailed to a randomly selected, stratified sample of 125 approved hospitals in 10 US states, with a 40% return rate. Consent and anonymity were explained in an accompanying covering letter. Results indicated that there was a wide range of general hospital visiting hours. Limitations on general visiting hours were primarily due to hospital policy (age, children, number of visitors) and nursing judgement (visitor illness, length of visit). General visiting hours and intensive care area visiting hours for paediatric patients were more extensive than for adult patients. Factors which influenced exceptions to visitation policies in intensive care areas focused on patient acuity and patient needs. Recovery room visiting was limited. If the patient was in a private room, visiting hours and provisions for family members were extensive. Provisions for family members of intensive care patients were minimal. Nursing judgement significantly influenced implementation of. visitation policies.     

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.     

Visitation policies and practices in US ICUs

Introduction

Prior reports suggest that restrictive ICU visitation policies can negatively impact patients and their loved ones. However, visitation practices in US ICUs, and the hospital factors associated with them, are not well described.

Methods

A telephone survey was made of ICUs, stratified by US region and hospital type (community, federal, or university), between 2008 and 2009. Hospital characteristics were self-reported and included the hospitals'' bed number, critical care unit number, and presence of ICU leadership. Hospital and ICU visitation restrictions were based on five criteria: visiting hours; visit duration; number of visitors; age of visitors; and membership in the patient''s immediate family. Hospitals or ICUs without restrictions had open visitation policies; those with any restriction had restrictive policies.

Results

The study surveyed 606 hospitals in the Northeast (17.0%), Midwest (26.2%), South (36.6%), and West (20.1%) regions; most were community hospitals (n = 401, 66.2%). The mean hospital size was 239 ± 217 beds; the mean percentage of ICU beds was 11.6% ± 13.4%. Hospitals often had restrictive hospital (n = 463, 76.4%) and ICU (n = 543, 89.6%) visitation policies. Many ICUs had ≥ 3 restrictions (n = 375; 61.9%), most commonly related to visiting hours and visitor number or age. Nearly all ICUs allowed visitation exceptions (n = 474; 94.8%). ICUs with open policies were more common in hospitals with < 150 beds. Among restrictive ICUs, the bed size, hospital type, number of critical care units, and ICU leadership were not associated with the number of restrictions. On average, hospitals in the Midwest had the least restrictive policies, while those in the Northeast had the most restrictive.

Conclusion

In 2008 the overwhelming majority of US ICUs in this study had restrictive visitation policies. Wide variability in visitation policies suggests that further study into the impact of ICU visitations on care and outcomes remains necessary to standardize practice.     

Outcomes of care from the professional's perspective.

Patient satisfaction is considered an important indicator of the quality of care provided by a home healthcare agency. Increased emphasis is now placed on patient outcomes of care by certification and accreditation standards. This detailed analysis of the outcomes of care by the patient, the family, and the professionals through the use of unsolicited patient letters of commendation and the clinical record did not reveal any specific pattern. The visiting nurse association's home care services are available on a nondiscriminatory basis. This fact is noted in the agency's literature and policy manual. The data analysis for this project supports this policy statement. Patients, family members, and a physician wrote letters of commendation regardless of the LOS, payer source, total charges, time spent with the patient, and personnel who provided the care.     

Family satisfaction in Egyptian adult intensive care units: A mixed-method study

ObjectivesTo examine family members’ satisfaction in adult intensive care units.MethodologyThis is mixed-method research. Family members of critically ill patients responded to a structured questionnaire and then were interviewed using semi-structured interviews. Quantitative and qualitative data were analyzed separately and integrated during the discussion.SettingsSix adult intensive care units in university hospitals in Egypt.Main outcome measuresFamily satisfaction was assessed using the Critical Care Family Satisfaction Survey and field notes of the interviews.ResultsThe mean total satisfaction score was 12.8 ± 3.5, and comfort has the lowest subscale mean score: 2.07 ± 0.96. Multivariate regression analysis showed that family members’ satisfaction was positively associated with their ability to communicate with patients (B [95% confidence interval]: 2.1 [1.19 to 3.02]) and negatively with daily purchasing of medications and supplies (−2.41 [−3.23 to −1.59]), low economic status (−1.57 [−2.47 to −0.67]), and perceiving patient condition to be deteriorating (−0.99 [−1.93 to −0.04]). Content analysis of qualitative data revealed four themes: aspects of family care, aspects of patient care, organizational and administrative issues and environment.ConclusionsIn Egyptian adult intensive care units, regular family meetings, flexible visiting hours, shared decision-making, increasing staff-to-patient ratio and ensuring comfortable waiting rooms are promising strategies to enhance family satisfaction.     

Family satisfaction with care provided by nurse practitioners to nursing home residents with dementia at the end of life

The purpose of this study was to examine family satisfaction with care provided by nurse practitioners (NP) to nursing home (NH) residents with dementia. A survey was mailed to 239 family members of nursing home residents who died with dementia. One open-ended question was added to provide comment about the care provided by the NP. A total of 131 surveys were returned (response rate 55%). The study revealed that 98% of family members agreed that they were satisfied with the end-of-life care provided by the NP. Survey responses were used to analyze the associations of communication, comfort, and satisfaction with NPs to total satisfaction with end-of-life care. Pearson's correlations demonstrated that overall satisfaction was significantly associated with NP-family communication, resident comfort, and satisfaction with NP care. Findings suggested that NPs using a model of care that emphasizes advance care planning, communication, and comfort results in high satisfaction of family members.     

急诊危重患者家属需求的满足情况调查

目的了解急诊危重患者家属需求的满足情况。方法在中文版危重患者家属需求量表（critical care family needs inventory,CCFNI）的基础上应用自行设计的需求满足量表,采取分层整群抽样的方法,对下“病危”或“病重”医嘱后24h内的急诊患者家属进行调查。结果急诊危重患者家属需求的满足程度较低,满足较好的是病情保证的需求和与探视有关的需求,满足较差的是希望在医院能进行特殊宗教信仰活动和有人协助解决经济问题;不同健康状况组家属之间的需求满足得分差异有统计学意义（P〈0．05）。结论急诊医护人员应重视评估和满足急诊危重患者家属的需求,提高这一特殊群体的身心健康和家庭满意度。     

Family satisfaction with care in the intensive care unit: results of a multiple center study

OBJECTIVE: To determine the level of satisfaction of family members with the care that they and their critically ill relative received. DESIGN: Prospective cohort study. SETTING: Six university-affiliated intensive care units across Canada. METHODS: We administered a validated questionnaire to family members who made at least one visit to intensive care unit patients who received mechanical ventilation for >48 hrs. We obtained self-rated levels of satisfaction with 25 key aspects of care related to the overall intensive care unit experience, communication, and decision making. For family members of survivors, the questionnaire was administered while the patient was still in the hospital. For family members of nonsurvivors, the questionnaire was mailed out to the family member 3-4 wks after the patient's death. MAIN RESULTS: A total of 891 family members received questionnaires; 624 were returned (70% response rate). The majority of respondents were satisfied with overall care and with overall decision making (mean +/- sd item score, 84.3 +/- 15.7 and 75.9 +/- 26.4, respectively). Families reported the greatest satisfaction with nursing skill and competence (92.4 +/- 14.0), the compassion and respect given to the patient (91.8 +/- 15.4), and pain management (89.1 +/- 16.7). They were least satisfied with the waiting room atmosphere (65.0 +/- 30.6) and frequency of physician communication (70.7 +/- 29.0). The variables significantly associated with overall satisfaction in a regression analysis were completeness of information received, respect and compassion shown to the patient and family member, and the amount of health care received. Satisfaction varied significantly across sites. CONCLUSIONS: Most family members were highly satisfied with the care provided to them and their critically ill relative in the intensive care unit. Efforts to improve the nature of interactions and communication with families are likely to lead to improvements in satisfaction.     

Clinician statements and family satisfaction with family conferences in the intensive care unit

OBJECTIVES: The quality of family-clinician communication in the intensive care unit is often inadequate, but little is known about specific clinician communication behaviors that might improve family satisfaction. In this exploratory analysis, we hypothesized that clinicians' communication behaviors providing emotional support to families during intensive care unit conferences would be associated with increased family satisfaction. DESIGN: We audiotaped 51 intensive care unit family conferences in which withholding or withdrawing life support was discussed or bad news was delivered. Emotional support techniques used by clinicians during each conference were identified and coded using grounded theory. SETTING: Four Seattle hospitals. SUBJECTS: Family members of critically ill patients. INTERVENTIONS: Questionnaires rating satisfaction with communication were completed by 169 family members. MEASUREMENTS AND MAIN RESULTS: Linear regression with generalized estimating equation methods was used to analyze the association between the frequency of clinicians' emotionally supportive statements and family satisfaction. Increasing frequency of three types of clinicians' statements during family conferences was associated with increased family satisfaction: a) assurances that the patient will not be abandoned before death (p=.015); b) assurances that the patient will be comfortable and will not suffer (p=.029); and c) support for family's decisions about end- of-life care, including support for family's decision to withdraw or not to withdraw life-support (p=.005). CONCLUSIONS: Most family members participating in this study were quite satisfied with the communication in the family conferences. Specific clinician communication behaviors are associated with increased family satisfaction during family conferences among family members who are willing to have a family conference recorded. Our results suggest that clinicians in the intensive care unit may improve the experiences of families of critically ill patients by providing explicit support for decisions made by a family with regard to end-of-life care and by assuring families continuity of high-quality care with particular attention to the patient's comfort.