Open visiting in the ICU: a debate

Application of a flexible visitation system in critically ill patients: A randomized clinical trial

OBJECTIVE

To determine the feasibility of a flexible visitation system in the intensive care unit (ICU).

METHODS

A randomized, open-label, parallel group clinical trial was conducted. All patients admitted to the ICU of the Lanzhou University Second Hospital from April to June 2022 were enrolled. The enrolled patients were randomly divided into an experimental group and a control group according to a computer-generated random sequence table.

RESULTS

A total of 410 patients were admitted. According to the inclusion and exclusion criteria, 140 patients were included in the experimental group (flexible visitation group) and 140 in the control group (normal visitation group). The average number of visitation minutes per day between the experimental group and the control group was 24.7 versus 23.9 min (p > 0.05).Among the outcome indicators, delirium occurred in 8 (5.7%) patients in the intervention group and in 24 (17.1%) patients in the control group (p = 0.003). Five complaints (mainly pressure ulcers) were received, with one in the experimental group and the others in the control group. There were 28 cases of nosocomial infection in the experimental group and 29 cases in the control group; therefore, the incidence of nosocomial infection was 20% versus 20.7% (p = 0.882). A total of 280 questionnaires were collected, with a retrieval rate of 100%. The satisfaction of patients in the experimental group and the control group was 98.6% and 92.1%, respectively (p = 0.011). The flexible visiting system reduced the ICU length of stay (LOS). The ICU LOS of the experimental group was 6 versus 8 days for the control group (p = 0.041). However, the flexible visiting system did not reduce the hospital stay (17 vs. 19 days, p = 0.923).

CONCLUSION

Conducting a flexible visitation system in ICUs could reduce the incidence of delirium in critically ill patients and improve the quality of nursing care; furthermore, the rate of nosocomial infections was not increased. These findings need to be further verified by a multicentre, large-scale clinical trial.

Association Between Clinical Nurse Specialist's Presence and Open Visitation in US Intensive Care Units

BACKGROUND

Current evidence shows that an open visitation policy can benefit patients and families during intensive care unit (ICU) stays. Therefore, an unrestricted visitation policy in the ICU has been proposed as part of patient-centered care.

PURPOSE

The purpose of this secondary analysis is to explore the likelihood of an ICU with a clinical nurse specialist (CNS) having an open visitation policy when compared with an ICU without a CNS.

DESIGN

This is a secondary analysis of a survey conducted between 2008 and 2009, describing the ICU visitation practices in more than 600 hospitals across the United States.

METHODS

χ Analysis was performed comparing the presence of CNS in the ICU with visitation policies, with P < 0.05 considered statistically significant.

RESULTS

There were data from 347 hospitals used in the analysis, with 47 hospitals (13.5%) having open visitation policies. There were 108 hospitals (31%) that had a CNS present in the ICU; 14 of the hospitals (13%) had open visitation policies. No significant correlation was found between a CNS being present in the ICU and open visitation policy (odds ratio, 0.93; P = .83), regardless of hospital geographic regions.

CONCLUSIONS

Although CNS presence was not associated with open visitation in this study, given the strong evidence to support the benefits to patients and the CNS role as a change agent in the hospital system, liberalization of visitation in the ICU is an area that could benefit from CNS advocacy.

Open intensive care units: a global challenge for patients, relatives, and critical care teams

AIM

The aims of this study were to describe the current status of intensive care unit (ICU) visiting hours policies internationally and to explore the influence of ICUs' open visiting policies on patients', visitors', and staff perceptions, as well as on patients' outcomes.

METHODS

A review of the literature was done through MEDLINE, EMBASE, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. The following keywords were searched: "visiting," "hours," "ICU," "policy," and "intensive care unit." Inclusion criteria for the review were original research paper, adult ICU, articles published in the last 10 years, English or Italian language, and available abstract.

RESULTS

Twenty-nine original articles, mainly descriptive studies, were selected and retrieved. In international literature, there is a wide variability about open visiting policies in ICUs. The highest percentage of open ICUs is reported in Sweden (70%), whereas in Italy there is the lowest rate (1%). Visiting hours policies and number of allowed relatives are variable, from limits of short precise segments to 24 hours and usually 2 visitors. Open ICUs policy/guidelines acknowledge concerns with visitor hand washing to prevent the risk of infection transmission to patients. Patients, visitors, and staff seem to be inclined to support open ICU programs, although physicians are more inclined to the enhancement of visiting hours than nurses.

DISCUSSION

The percentages of open ICUs are very different among countries. It can be due to local factors, cultural differences, and lack of legislation or hospital policy. There is a need for more studies about the impact of open ICUs programs on patients' mortality, length of stay, infections' risk, and the mental health of patients and their relatives.

Nurses? and physicians? viewpoints regarding children visiting/not visiting adult ICUs

Allowing children to visit adult intensive care units (ICUs) has been an area of controversy. There is a lack of recent research dealing with visits by children and physicians' views and whether differences exist between the views held by nurses and physicians regarding visits by children. The aim of this study was to describe and compare reasons given by nurses and physicians for restricting visits by children to a relative hospitalized in an adult ICU. This was a quantitative, descriptive multicentre study. Nurses and physicians (n = 291) at 72 general adult ICUs participated, each completing a questionnaire. A majority of the nurses and physicians were positive to children visiting patients in ICU, but they also imposed restrictions. The most common reasons were: severity of the patient's injury (50%); the environment was frightening for the child (50%); the infection risk for the child (36%) and the patient (56%). Children <7 years were restricted more than those >7 years. Nurses were more positive than physicians to visits by younger children. Physicians were more positive to visits if the patient was tired and critically ill/injured or was a friend/cousin. More physicians refused visits due to the fact that children are too noisy for the staff. Risks of negative effects on the children's health by visiting patients were also stated. Nurses and physicians still restrict children's visits to adult ICUs for a number of reasons, and nurses' and physicians' views on children visiting differ and so also the views within each professional group. The differences in views show that the dynamics are complicated and this could be attributed to a lack of a common view of care, which prevents family-centred care that includes children from being practised.

Intensive care nurses' beliefs and attitudes towards the effect of open visiting on patients, family and nurses

The policy of family visits to patients admitted into intensive care units (ICUs) has been liberalised in recent years. This change has been progressive in our unit from a restricted to an open visiting policy. We have carried out this study based on Ajzen and Fishbein reasoned action theory. The aim of this study is to analyse the relationship between nurses' beliefs and attitudes towards the effect of an open visiting policy on patients, family and nurses. A descriptive correlational design was used. The sample included 46 intensive care nurses from a teaching hospital in Spain, who completed two self-administered anonymous questionnaires. One of them, derived from empirical results of Kirchhoff et al. (1993) and Simpson et al. (1996) studies, was a Likert-type scale including 26 items divided in three subscales (patient, family and nurses). This scale was used to obtain the nurses' beliefs regarding the effects of open visiting. The second questionnaire was a differential semantic scale (used by the previous authors), which analysed nurses' attitudes towards visiting on the patient, family and nurses. Nurses' beliefs about the effect of visiting were positive, achieving a mean value of 3.001 (patient 3.04, family 3.23 and nurses 2.78) on a scale with a maximum value of 4. The mean score obtained on the scale of attitudes toward an open visiting policy was 6.005 (patient 6.41, family 6.37 and nurses 5.22), with a maximum of 7. The correlation between beliefs and attitudes was significant and positive (r = 0523, p < 0.0001). Comparison of sociodemographic variables with beliefs and attitudes disclosed no statistically significant differences, except for the two following variables: attitude and having children (t = -2.254, p = 0.03) which obtained a higher score. There is a correlation between nurses' beliefs and attitudes regarding the positive effects of open visiting on patients, family and nurses.

Visits of children to patients being cared for in adult ICUs: policies, guidelines and recommendations

Little is known about the frequency of children visiting their nearest relatives in adult ICUs or if there are any policies/guidelines or recommendations regarding these. The aims of this multi-centre descriptive study were to survey Swedish ICUs policies/guidelines or recommendations, and examine the reasons given both for and against restricting child visits; if parents/guardians sought advice in connection with such visits, and if any differences in demographic data could be ascertained. Fifty-six Lead Nurse Managers (LNM), representing as many general adult ICUs, participated by answering a questionnaire. Only one ICU had written policy/guidelines concerning child visits; most ICUs (70%) had no policies/guidelines at all. All LNMs reported that their ICU was positive to child visits, but only two actively encouraged these. Nineteen (34%) of the ICUs restricted child visits. More than 50% of the LNMs reported that only about half of their patients ever had visits from children. Seventy percent of the ICUs had no restrictions on visiting hours, but 30% imposed some form of restriction. Twenty LNMs reported that 75% of the parents/guardians of children 0-6 years old asked for advice about child visits. However, those responsible for children >12 years of age seldom asked for any advice at all.

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.

Intensive therapy unit nurses' beliefs about and attitudes towards visiting in three district general hospitals

The beliefs and attitudes of intensive therapy unit (ITU) nurses regarding visiting of critically ill patients are believed to be influenced by many factors, such as the need to promote patient rest, the need to prevent physiological and psychological complications to the patient and the need to improve communications between all parties. In this paper, some of the factors are examined with attempts to establish whether there are any correlations between such factors as the length of time individual nurses have worked in the area, their professional qualifications, their job satisfaction and their perceptions of visiting and visitors. Sixty-eight nurses from three general ITUs situated in district general hospitals were interviewed. The conclusion was that nurses still have many negative beliefs and attitudes towards visiting and visitors. ITU nurses in this study generally appeared to consider the effects of visiting pessimistically, suggesting they believe they are doing so in the best interests of the patients, themselves and the ITU itself.

Preliminary testing of a proposition from the Roy Adaptation Model

OBJECTIVE

To test a framework based on a proposition of the Roy Adaptation Model predicting the relationships of severity of illness, perceived control over visitation (PCV), hardiness, state anxiety, and length of stay in an intensive care unit (ICU).

DESIGN

Descriptive-correlational.

POPULATION, SAMPLE, SETTING

Convenience sample was 60 general medical-surgical ICU patients admitted to one regional medical center in the Southeastern U.S.A. Patients completed data collection instruments after a minimum of 20 hours in the ICU during January-March 1994.

METHODS

Instruments included the PCV Scale, the State Anxiety Inventory, the Health Related Hardiness Scale, and the Acute Physiologic and Chronic Health Evaluation II. Model testing and path analysis were done.

FINDINGS

The study variables explained 18% of the variance in length of stay in the ICU, with anxiety and hardiness being the major contributing variables. The path between hardiness and PCV was the only path in the model supported by the data.

CONCLUSIONS

The proposed model had inadequate support in this preliminary testing. However, interventions that increase a patient's feelings of control and hardiness could decrease length of stay in ICU's.

Revisiting visiting in intensive therapy units

The aim of this study is to investigate whether, 2 years after the study by Biley et al (1993), visiting in intensive therapy units (ITU) remains restricted. The study was conducted over the summer months of 1995, and ITUs in southern England were contacted. It revealed more favourable results regarding some aspects of visiting practices, but not others.

Time series analysis of physiological response during ICU visitation

Time series analysis (TSA) is an important statistical procedure for clinical nursing research. The current paucity of nursing research reports using TSA may be due to unfamiliarity with this technique. In this article, TSA is compared with the ordinary least squares regression model; validity concerns of time series designs are discussed; and concomitant and interrupted TSA of data collected on the effects of family visitation on intracranial pressure (ICP), heart rate, and blood pressure of patients in ICUs are presented. The concomitant TSA of the effect of family on ICP suggested that family presence tended to be associated with decreased ICP. Interrupted TSA indicated the effect of family on heart rate and blood pressure was not as consistent: The overall effect on blood pressure appeared to be negligible, and heart rate may increase overall. Restrictive visiting policies, once typical of intensive care units, should be reconsidered.

Nurses' attitudes to visiting in coronary care units

In many coronary care areas there are still restricted visiting times (Shaw 1989). This investigative study describes some relevant research in this area, and documents a small study of 14 nurses in two coronary care units (CCUs). A semi-structured interview was used to obtain information regarding nurses' attitudes to visiting. The results showed that the majority of these nurses are flexible when it comes to visiting, and expressed a relaxed attitude to it. Although in the area investigated visiting times are specified, some nurses consider and act on the concept of individualised patient care. However, there are still some nurses who insist on doing everything for the patient in the morning and only allow relatives access in the afternoon. These nurses also believe visiting times are precious to the patients and relatives and will not intrude on them, which may limit communication.

Issues in intensive care visiting

In order to obtain a contemporary view of the visiting hour regimes in intensive care units (ICUs) in the UK, a national telephone survey was performed. 122 geographically representative units were contacted, representing 42% of the total number of units in the UK. 107 units gave consent to participate in the study, of which 66 units allowed visiting at any time of the day. Many of these units however restricted the number or kind of visitors and only 19% could be regarded as having 'true' open visiting, that is, visiting at any time of the day for any age of child, any member of the family, or friends. Several of the topics arising from the study are discussed in more detail, for example the childhood risk of infection and/or psychological trauma and the needs of the family. Based on the available research evidence, a more liberated view of hospital visiting is necessary, with relaxation of what often amount to restricted visiting regimes. Several recommendations for further research are made.