Sunday, February 10, 2008

My Latest Literature Review! Family Centered Care in the Intensive Care Unit Through Open Visiting Hours

Family Centered Care in the Intensive Care Unit Through Open Visiting Hours
Nurses today have a unique challenge and opportunity to effectively balance the provisions of critical care on the acutely ill patient while also striving to meet the needs of family members impacted by the patient’s critical illness. The concept of family has changed over the years and expanded to include blood relatives as well as people that are significant to the patient. It is a fact that many people will either personally experience a critical illness or be impacted by a critical illness by a friend or family member (Gavaghan & Carroll, 2002).
The concept of family centered care and open visiting hours in the intensive care unit (ICU) has recently come into light as health care professionals, family members and researchers seek to examine the benefits of a more liberal policy for visitation. According to Farrell, Joseph, & Schwartz-Barcott (2005), visitation regulation have largely gone unchanged since the U.S. Public Health Service published visitation recommendations for the intensive care unit in 1962. The research on the subject matter remains limited and far more research is necessary in an effort to acquire empirical data relating to patient responses to a more liberalized visitation policy that is focused on family centered care.
This paper seeks to examine the literature available to answer the compelling question as to whether open visitation policy within the critical care environment provides recovery benefits to the patient. Adjunctive to this question is the need to recognize the family as an extension of the patient and determine their needs and motivation. This paper will explore five comprehensive studies in an effort to develop information on the compelling question. Further, each study will be critically reviewed to determine commonalities among the research as well as differences. Finally, the results of the review will provide conclusions that support change in practice and provide strategies for hospitals to develop a visitation policy that is consistent with the research and focused on family centered care.
Literature Review
The first research article is a study conducted by Gavaghan & Carroll (2002) with a purpose to integrate current knowledge about family centered care as a means to develop nursing interventions that promote family centered approach to care in the ICU. The primary thrust of the research was focused on family centered care theory, where the family is viewed as a “social unit that has significant effect on the patient’s outcomes” (Gavaghan & Carroll, 2002, pg. 65). Gavaghan & Carroll (2002) hypothesized that family members have needs that must be recognized by nurses in the critical care environment. Further, the authors set out to clarify these needs through the development of the Critical Care Family Needs Inventory (CCFNI). The CCFNI focused on five conceptual areas that researchers felt were important to the family and included: proximity, assurance, information, support, and comfort. According to Gavaghn & Carroll (2002) psychometric testing of the CCFNI supported appropriate measurement of the data collected by the tool. The study sample consisted of forty family members that completed the CCNFI (N=40). The results of this inventory revealed that family members often felt that their needs for information as well as proximity were met. However, the study revealed that visiting hours, support and comfort were often inconsistently provided by nurses and medical staff. Of special interest is the notion that while the hospital had a posted policy for visitation, nurses were inconsistent in their application of the policy. This inconsistency often made the family feel a sense of distrust to the nurses.
The final conclusion of this survey provided for suggested recommendations to improve family relationships in the ICU and improved satisfaction. Nurses are the primary means of information and support because they are the health care professionals that have direct and constant access to the patient. The study suggests that as a means to improve satisfaction, hospitals develop a visitation policy that embraces family in the care of the patient. Further, the facility should develop a brochure about family centered care and visitation that provides the family with an orientation to the activities of the ICU. Lastly, the author suggested that the use of volunteers to engage families in the orientation process provided needed relief to the nurses and actively involves a group of people that have the time to spend nurturing the family needs.
Another research article written by Farrell, Joseph, & Schwartz-Barcott (2005), focuses on the need to balance patient, visitor and staff needs in terms of open visitation in the ICU. This phenomenological qualitative study was driven by the need to answer the question about nurse perceptions while working with visitors in the ICU. The study focused on a sample of nurses (N=8) that work in the ICU and have voiced concerns over balancing the care of the critically ill patient while attempting to meet the increasing needs of family members. The tools used for this research included observation, questionnaire and interviews with the sample participants. The measurement and analysis of the data included host verification, where the researcher validates the quotes from the sample participants and allows the participants to verify their answers (Polit & Beck, 2004).
The findings of the survey demonstrated that nurses are central to access of the patient. Nurses hold the key to the gateway and depending upon their needs for the day can deny or grant access to the patient by family members. The major concern with this responsibility is the general lack of consistency by the nurses. One nurse may grant family access while another nurse denies access creating a disparity in the nurse-family relationship (Farrell, Joseph, & Schwartz-Barcott, 2005). Central to the nurse-family relationship is for the nurse to understand that family members have a need for information, and access to the patient. Likewise, families need to understand that nurses must balance the critical care of the patient, safety and have the ability to complete the nurse’s work while the family is present. The study also focused on how nurses manage family visitation during the patient’s routine care and when it is appropriate to ask a family member to leave. Study participants overwhelming cited that they asked family members to leave during the provisions of personal care (Farrell, Joseph, & Schwartz-Barcott, 2005). Further, nurses were conflicted as to whether family members should be present during codes. The study suggested that family presence during a code is very individualized and should be left to the discretion of the health care team and the family members (Farrell, Joseph, & Schwartz-Barcott, 2005).
In comparison to the first study reviewed by Gallaghan & Carroll (2002), Farrell, Joseph, & Schwartz-Barcott (2005) suggest that the ICU appoint one individual that can effectively manage the complex needs of the family, thereby allowing the nurse time to care for the patient. While Farrell, Joseph, & Schwartz-Barcott (2005) do not suggest a volunteer can manage this function, it is interesting to note that both studies made this recommendation.
Another study conducted by Livesay, Gilliam, Mokracek, Sebastian & Hickey (2005) detail the experiences of nurses that work in a Neuroscience Intensive Care Unit (NICU). The purpose of this study was to examine nurse’s perceptions about open visitation, determine if the nurses believe the policy needs to be changed, and how the actual policy in place impacts their patient’s recovery. This quasi-experimental research design had a participant sample of registered nurses and patient care technicians (N=30). The measurement tools employed were questionnaires that were distributed to study participants. Of the thirty participants, twenty-six responded (Livesay, et al, 2005). According to the study, 85% of the sample were aware of the visitation policy and provided this information to family members when they inquired about visiting hours. Nurses were more likely to be liberal with the visitation policy (10 of 25) if the patient’s condition was serious. Most of the nurses in the sample indicated they would ask family members to leave the ICU during normal care routines. The majority of nurses would recognize caregiver fatigue on the part of the family member and would suggest that the family member take a break to get a cup of coffee or go for a walk (Livesay, et al, 2005). An interesting point to note here is that the nurses studied most often recognized the family members need for information concerning the condition of the patient. Many family members were reluctant to leave the bedside if there were not some assurances from the nurse that they would contact the family member if the patient’s condition were to change. Another point of interest is that fact that when nurses provided the family with assurance that they would monitor the patient closely; the family member would leave the unit for a rest period (Livesay, et al, 2005).
The conclusion of this study resembled the conclusions of the two other studies reviewed. This study recommended that clear policy be established on visitation and that nurses apply the policy consistently across the board. In addition, the development of educational material and perhaps a contract for care is made between the family member and the nursing staff. This study identified the educational material be used as a means to provide the family with education about the patient’s needs, the nurses responsibilities and ways in which the family can be engaged in the care of the patient. Finally, like the other studies, this study also recommended that support personnel be included in the units of staffing in an effort to relief the nurse from the responsibility of meeting the complex needs of the family. Support personnel can provide the family member with needed information and contact during the critical care stay and increase the family’s satisfaction with the hospital (Livesay, et al, 2005).
The next study reviewed was one conducted by White (1994) that randomly selected 125 hospitals that had an intensive care unit (N=125) and to compare and contrast visiting policies for each hospital. 40% of the sample responded to the survey conducted by White (1994) during the study period. Of this 40% all participants had a visiting policy in place for pediatric and adult ICU. Visiting hours ranged from 8 hours to 14 hours with few having any form of visiting hours after 9:00PM. The general premise of the study was to determine if there were physiological reasons for more liberalized visitation as well as to describe the legal and ethical considerations for a more liberalized visitation policy.
As has been true throughout this literature review, most of the studies, including this study by White (1994) speak to the fact that the nurse is considered the gatekeeper. Use of this term employs the understanding that nurses are often the professional responsible for applying the policy of visitation within the critical care environment. In addition, the nurse directly impacts the family’s ability to have access to the patient or be denied access to the patient (White, 1994). The major difference in this research is the focus on ethical and legal considerations for visitation. According to White (1994), patients and their families have the right to be together through an acute illness. White (1994) suggests that as patients are isolated and in some cases forced isolation, this can and often does cause a general sense of distrust with the staff and increases the recovery period of the patient. Patients need the support and nurturing of their family during times of acute crisis or illness.
The conclusion of this survey suggested that nurses need to have a wide depth of understanding about the policy of the hospital in terms of visitation. Nurses often denied access to visitors if the business of the unit required such actions. Most often cited was the increased acuity of the patient or the staff limitations (i.e. shortages of staff members) (White, 1994).
The final research study that was reviewed was conducted by Eriksson & Bergbom (2007) and was designed to answer the question of whether family visitation actually helps the patient during recovery. While there is much discussion about family visitation, there is very limited research to support or deny the claim that increased visitation by family actually is beneficial to the patient. Eriksson and Bergbom (2007) used a prospective, explorative observational study design to answer the referenced question. They surveyed a sample group of 198 patients and their families during the study period (N=198). The nature of the study was longitudinal because it provided a study review period of eight months. The primary thrust of the study was to examine the results of family visitation on the clinical manifestations of the patient and whether these clinical results were related to increase family support. Data was collected over an eight month span of time and reflected a total of 198 patients. The data was analyzed via the Statistical Package for Social Sciences, Version 12 and deemed reliable (Eriksson and Bergbom, 2007).
At the completion of the study, the data revealed that there is really no conclusive evidence that increased family visitation had a direct positive or negative impact on the patient’s overall clinical performance. In fact, the researchers suggested that more research and study is needed in an effort to provide further evidence on the subject. The authors made reference to the fact that patients in the study that had no visitation during their stay in the ICU had a better mortality rate than those that had visitations (Eriksson & Bergbom, 2007). This result might lead one to believe that family visitations do not have any correlational relationship to clinical performance and recovery.
Each study reflected a reasonable design and analysis methodology. Some studies reflected the perception of nurses with open visitation policies, while other studies focused on the patient’s clinical performance with increased family visitation. In each study, the data was compelling and revealed that family members have a need for close proximity (access) to the patient, a need for information, and a way to be engaged and involved in the patient’s care. Further, most of the studies reviewed suggested that educational material be developed in an effort to provide family members with an orientation to the critical care environment and the stated visitation schedule. Nurses were recognized as the gatekeeper for access to the patient and when there is disparity among nurses in terms of enforcement of vitiation policies it can negatively impact the nurse-family relationship. Some studies went so far to suggest that when visitation policies are not consistently enforced that it can cause a distrustful relationship between staff and family members and reduce overall family satisfaction with care.
Some inconsistency with the studies center around the overall influence open visitation has on the clinical performance of the patient. The study by Eriksson & Bergbom (2007) provided empirical data to refute the hypothesis that increased family visitation actually improve patient’s overall mortality and decreases the recovery process. Evidence from their study is contrary to the new age assumption that open visitation makes a real difference to the patient. While the results of their data may be true, the authors of the study suggest that more research be conducted to in an effort to analyze more data on the subject.
Open visitation in the critical care environment is being widely discussed as a means to improve patient outcomes and provide families with proper access. Research on the topic continues to be very limited. However, there is enough evidence to suggest that family-center care theory can be used as the corner stone of this foundational understanding into human dynamic. Families are evolving and changing and health care professionals must recognize that people who are important to the patient must be considered family members (Gavaghan & Carroll, 2002). While the industry adapts to the changing family unit, there are several strategies that nurses and hospitals can employ in an effort to better meet the needs of patients and their families. Some of these strategies include: the development of consistent and fair visitation policies designed to address the needs of the family, educating nursing staff about the need to fairly and consistently apply the visitation polices across the board without the need for disparity, and the development of educational material designed to orient the family member to the critical care environment as well as provide them with written information about stated visitation schedules. Further recommendations suggest that a member of the volunteer staff be appointed as a family liaison and conduct the family orientation. Also the development of a family engagement contract was suggested by one study in an effort to involve the family with the provisions of care. Finally, in an effort to provide ample access to the patient and allow fatigued caregivers the opportunity to take reasonable rest breaks, one study suggested that the hospital invest in beepers that can be assigned to family members that leave the ICU for breaks. Beepers provide the family member with a peace of mind that if they are needed or if the patient has a change in condition, the nursing staff will have ready access to alert them of these changes.
As hospitals and critical care environments develop their policies, they must keep in mind that nurses play a critical role as gatekeepers for the patient. The primary concern must always be for the well-being of the patient, but the family and their complex needs must be met as well. The challenge faced by today’s professional nurses is truly in the balance of these two different priorities.

Eriksson, T. & Bergbom, I. (2007). Visits to intensive care unit – frequency, duration and impact on outcome. British Association of Critical Care Nurses 12(1). 20-26.
Farrell, M., Joseph, D., & Schwartz-Barcott, D. (2005, January). Visiting hours in the ICU: finding the balance among patient, visitor and staff needs. Nursing Forum, 40(1), 18-28. Retrieved January 29, 2008, from CINAHL Plus with Full Text database.
Gavaghan, S., & Carroll, D. (2002, March). Families of critically ill patients and the effect of nursing interventions. Dimensions Of Critical Care Nursing: DCCN, 21(2), 64-71. Retrieved January 29, 2008, from MEDLINE database.
Livesay, S., Gilliam, A., Mokracek, M., Sebastian, S., & Hickey, J. (2005, April). Nurses' perceptions of open visiting hours in neuroscience intensive care unit. Journal of Nursing Care Quality, 20(2), 182-189. Retrieved January 29, 2008, from CINAHL Plus with Full Text database.
Polit, D. F., & Beck, C. T. (2004). Nursing research: Principles and methods (7th ed.). Philadelphia: Lippincott Williams & Wilkins.
Verhaeghe, S., Defloor, T., Van Zuuren, F., Duijnstee, M., & Grypdonck, M. (2005, April). The needs and experiences of family members of adult patients in an intensive care unit: a review of the literature. Journal Of Clinical Nursing, 14(4), 501-509. Retrieved January 29, 2008, from MEDLINE database.
Whitis, G. (1994, January). Visiting hospitalized patients. Journal Of Advanced Nursing, 19(1), 85-88. Retrieved January 29, 2008, from MEDLINE database.


  1. Patrick, this is a very interesting review. I work at a hospital that is a "universal bed". We have open visitation and to be honest with you, it makes it hard sometimes. We recover our patients in the room and the family is right outside the door waiting to come in. Many don't understand what we are doing and why they have to wait because after all they are "back in their room". Also, what do you do about no age limit. I've seen numerous babies crawling on the floor. These rooms are ICU rooms and even if they are mopped everyday, there are massive amounts of ick and babies shouldn't be crawling on the floors. Families don't get this. I've seen it work to the patient's advantage ~ for example, if you have a patient coming out of anesthesia combatively, often the family can help calm their loved one down. Anyways, that's my two cents based on an open ICU/PCU hospital. Crystal

  2. Hi Crystal - the literature speaks about setting an age limit for visitation, especially open visitation in the ICU. Most of the research studies suggested that kids under the age of 14 not be permitted in the ICU. However, there is some evidence to suggest that younger visiters may be welcome provided that the rules are followed (i.e. no crawling on the floor) and that visits be no longer than 10-15 minutes. The reason most studies do not promote kids visitation is becuase of the potential for tranmission of pathogens to the patient who is already compromised as well as reverse transmission to the kids. Thanks for your commnets.

  3. I write this in the ICU waiting room because it is not "time" to visit my critically ill mother.As a 20 plus year veteran critical care nurse, I find the restrictive visitation hours an archaic dinosaur that needs to be abolished. For an ICU nurse to throw out another critical care nurse breeds anger and mistrust. How is this still possible in 2009???
    Charyl from Colorado

  4. Bravo, what necessary words..., an excellent idea

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