GUEST EDITORIAL

Visitors in the intensive care unit

Patients are admitted to an intensive care unit (ICU) because their illness or injury may be life-threatening, requiring intense support and monitoring that cannot be given in the general wards. Critical illness is often sudden, unexpected and can change the lives of both the patient and family members in a matter of minutes. The everyday lives of family and close friends may come to an abrupt halt or be disrupted as they live in the uncertainty of not knowing whether the patient will survive. The ICU, a stressful, unfamiliar, alien and intimidating environment, often becomes the centre of people's lives as they wait desperately for any signs of alterations or progress in the lives of their loved ones. The lives of the patients admitted to ICU are often in danger, which can lead to anxiety, depression and post-traumatic stress disorder in their family members.

For many years, admission of a patient to the ICU followed what we might call a 'revolving door principle', i.e. when the patient came in, the family was sent out. However, this principle might be disadvantageous when caring for critically ill patients and their family members. Allowing family members access to the patient has been shown to alleviate much of this distress. Families describe the need to be near their loved ones as being of high importance, yet they are often excluded, except for brief interludes, without explanation.^[1,2] The needs of family members of ICU patients have been well-established, and instruments such as the Critical Care Family Needs Inventory (CCFNI) have been developed to determine these needs. The desire to be near the patient has consistently been ranked by family members as one of their most important needs.^[3] Family needs should be taken into consideration, because when a patient is critically ill in ICU, the traditional nurse-patient relationship is often replaced by a nurse-family member relationship.^[4]

Apart from the need to be close to the ICU, involvement of patient families in the ICU has been necessitated by the need for decision-making on behalf of critically ill and sedated patients. Families assist in end-of-life decisions, decisions about use of life-sustaining therapies and other important matters, and therefore play an important role in the ICU.^[5] Visiting loved ones in the ICU is thus an important and integral part of family care, especially since patient-centred and family-centred care has been increasingly encouraged to improve the quality of care and the satisfaction of patients and their families.

The time period of an ICU visit is described as either restrictive or open/liberal. A restrictive policy allows families to visit during certain periods of the day and restricts the number of visitors per period. An open visiting policy (OVP) allows access to family at all times (24 hours) with or without restricting the time or duration of the visits for the family members during any given period.^[6]

Visitation of an adult ICU patient has traditionally been restricted. However, in the past 2 decades, a push to liberalise ICU visitation has emerged in response to publicised studies in which visitation is demonstrated to be beneficial to patients, family members and nurses.^[71 Publications calling for flexible, open visitation have come from the American College of Chest Physicians,^[8] the Society of Critical Care Medicine,^[9] the American Association of Critical Care Nurses^[10] and the Institute for Medicine.^[11]

In Sweden 70% of the ICUs had unrestricted visiting hours, followed by the United States (32%), France (23%), the United Kingdom (22%) and Italy (0.4%).^[7] It is being increasingly recognised that unrestricted visiting by relatives of critically ill patients may be beneficial to both the patients and their relatives.^[6] Unrestricted visiting has also been reported to reduce cardiovascular complications in the critically ill. A randomised trial comparing the haemodynamic consequences of unrestricted and restricted visiting policies found that patients who had unrestricted visiting hours experienced a decreased risk of cardiocirculatory complications and a reduction in anxiety scores.^[121 The study revealed that there was a reduction in rates of anxiety and depression, and an improvement of satisfaction of care among family members when visiting times were unrestricted.

The tendency towards restricted visiting policies could be attributed to a variety of reasons, such as cultural factors, lack of space, inadequate waiting areas, attitudes of ICU staff, communication issues and a lack of tools, such as information pamphlets for family members.^[5,12] Furthermore, an unrestricted or OVP might cause an increase in the workload for ICU workers and also create some delays in the performance of duties. Nurses could be more skeptical about an OVP despite recognition of the possible benefits to the patient. Restricted visiting policies are preferred by ICU staff, especially by nurses, because according to them opening an ICU to visitors could interfere with their care processes. OVP can make nurses and doctors feel controlled by the family's presence or afraid to make an error, and also may interfere with direct nursing or medical care. Healthcare practitioners feel that even though the family has a perception that their relatives are receiving the best care, many more requests may be made by the family, which creates a burden of stress for the ICU team. This may sometimes lead to minor conflicts between ICU workers and families.^[13]

The debate surrounding open visitations in the adult ICU has persisted for decades. It has been well established that families and patients desire open visitation, and that open visitation is beneficial and generally not harmful. Nonetheless, only about a third of ICUs have OVPs. Traditional and ritualistic practices are difficult to change, and in our technology-driven, efficiency-orientated healthcare system, the simplest interventions are often the hardest to initiate. Nevertheless, visiting in the ICU is a primary objective in caring for the critically ill, which cannot be deferred. Critical care practitioners must never forget that they are visitors in the patient's life, not the other way around.

PJ Jordan

School of Clinical Care Sciences, Nelson Mandela Metropolitan University

References

1. Berwick DM, Kotagal M. Restricted visiting hours in the ICU: Time to change. JAMA 2004;292(6):736-737. [http://dx.doi.org/10.1001/jama.292.6.736]        [ Links ]

2. Sims JM, Miracle VA. A look at critical care visitation: The case for flexible visitation. Dimens Crit Care Nurs 2006;25(4):175-179.         [ Links ]

3. Molter N, Leske JS. Critical Care Family Needs Inventory. Unpublished manuscript, 1983.         [ Links ]

4. Langley G, Schmollgruber S. End-of-life care in intensive care units. Southern African Journal of Critical Care 2006;22(2):58-65.         [ Links ]

5. Brysiewicz P, Bhengu R. The experiences of nurses in providing psychosocial support to families of critically ill trauma patients in intensive care units: A study in the Durban metropolitan area. Southern African Journal of Critical Care 2010;26(2):68-76.         [ Links ]

6. Da Silva Ramos FJ, Lumis RRL, Azevedo LCP, Schettino G. Perceptions of an open visitation policy by intensive care workers. Ann Intensive Care 2013;3(1):34. [http://dx.doi.org/10.1186/2110-5820-3-34]        [ Links ]

7. Glannini A, Miccinesi G, Leoncino S. Visiting policies in Italian intensive care units: A nationwide survey. Intensive Care Med 2008;34(7):1256-1262. [http://dx.doi.org/10.1007/s00134-008-1037-4]        [ Links ]

8. Sesler CN. The Critical Care Family Assistance Programme: Caring for those who care. Chest 2005;128(3):1101-1103. [http://dx.doi.org/10.1378/chest.128.3.1101]        [ Links ]

9. Kleinpell RM. Visiting hours in the intensive care unit: More evidence that open visitation is beneficial. Critical Care Med 2008;36(1):334-335. [http://dx.doi.org/10.1097/01.CCM.0000295266.17378.BD]        [ Links ]

10. Duran CR, Oman KS, Abel JJ, Koziel VM, Szymanski D. Attitudes towards and beliefs about family presence: A survey of healthcare providers, patients' families and patients. Am J Crit Care 2007;16(3):270-282.         [ Links ]

11. Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. Washington DC: National Academies Press, 2001.         [ Links ]

12. Fumagali S, Bonecinelli L, Lo Nostro A, et al. Reduced cardiocirculatory complications with unrestrictive visiting policy in an intensive care unit: Results for a pilot, randomised trial. Circulation 2006;113:946-952. [http://dx.doi.org/10.1161/CIRCULATIONAHA.105.572537]        [ Links ]

13. Biancofioire G, Bindi LM, Barsotti E, Menichini S, Baldini S. Open intensive care units: A regional survey about the beliefs and attitudes of healthcare professionals. Minerva Anestesio! 2010;76(2):93-99.         [ Links ]