Implementation and evaluation of a liberalized visiting policy

The beliefs and attitudes of intensive care unit nurses and patient families regarding an open visitation policy in China

AIMS

To investigate the beliefs and attitudes of intensive care unit (ICU) nurses and patients' family members towards an open visitation policy in the ICU in China and to explore the reasons that promote or hinder open visitation to improve visitation policy.

BACKGROUND

Open visitation policies are widely recommended in many countries. However, there are gaps between evidence and practice. Most ICUs in China still use a restrictive policy for family visits, which raises controversy. There are limited visiting times, and family visitors are not allowed to enter the ICU.

STUDY DESIGN

A multicentre survey was conducted in seven hospitals in China. The Beliefs and Attitudes towards Visitation in the Intensive Care Unit Questionnaire (BAVIQ) was administered to ICU nurses and patient families from 11 the ICUs of seven hospitals. A total of 275 questionnaires were completed and returned by ICU nurses and 139 by patients' family members.

RESULTS

Among nurses, the belief scale score was 2.87 ± 0.33 (range 2-4), and the attitude scale score was 5.53 ± 1.12 (range 2.33-7). The belief scale was divided into three subscales: nurses, patients, and patients' families. The subscale score for patients' families was the highest, and the nurses' subscale score was the lowest. Most (84.0%) of the nurses were satisfied with the current ICU visitation policy. The belief and attitude scores were 3.13 ± 0.39 (range 1.96-4) and 6.18 ± 1.20 (range 1.67-7), respectively, for family members. The scores of the three subscales, that is, patients, patients' families and nurses, were 3.13 ± 0.40, 3.26 ± 0.43, and 3.04 ± 0.49, respectively.

CONCLUSION

Nurses' beliefs and attitudes towards implementing an open visitation policy in China are at a less positive level than those of patient family members.

RELEVANCE TO CLINICAL PRACTICE

The beliefs and attitudes of nurses towards open visitation policy in China need to be improved. The question of how to mobilize nurses' enthusiasm for an open visitation policy poses a challenge for ICU management.

Perspectives of intensive care nurses on open visits in an ICU

OBJECTIVE

To determine the attitude of the nursing professionals of an Intensive Care Unit regarding the effects of open visiting on the daily activities of the patient, their family and professionals, and also to determine their contribution to the current open visiting policy.

METHOD

A cross-sectional descriptive study was performed, with a non-probabilistic discretionary sampling. The sample comprised nursing professionals of the aforementioned Unit. They were given a questionnaire with 26 items and an open question to evaluate their suggestions.

RESULTS

101 nursing professionals took part in the study, of the 120 working in the Unit under study. Seventy-five point two percent state that the nursing team has to postpone or modify their work due to the presence of the family and 89.9% that their presence produces a physical and psychological burden on the staff. Eighty percent think that the visit exhausts the family and 84.2% that the family feels obliged to remain with the patient. Ninety-four percent think that the effect of the presence of the family depends on the patient and the family.

CONCLUSIONS

Most of professionals have a negative opinion about the policy of open visits, showing some reluctance when it comes to flexible visiting hours, although they admit that an unrestricted schedule in this type of units implies some benefit for the patient and the family.

Association between visitation restriction during the COVID-19 pandemic and delirium incidence among emergency admission patients: a single-center retrospective observational cohort study in Japan

Aim

This study aimed to identify the association between total visitation restriction because of the coronavirus 2019 (COVID-19) pandemic and the incidence of delirium for emergency inpatients.

Methods

This was a single-center, retrospective, observational cohort study conducted at a tertiary critical care center in urban Kyoto, Japan. Adult emergency patients hospitalized between January 1, 2019, and June 30, 2020, were recruited. In response to the COVID-19 pandemic, the authors' hospital began restricted visitation on March 28, 2020. This study defined before visitation restriction as January 1, 2019, through March 31, 2020, and after visitation restriction as April 1, 2020, through June 30, 2020. We did not restrict emergency services, and there were no changes in the hospital's routine, except for visitation restrictions. The primary outcome was the incidence of delirium. The adjusted odds ratio (AOR) with 95% confidence interval (CI) for delirium incidence was calculated to compare the before and after visitation restriction periods, and the logistic model was used to adjust for seven variables: age, sex, ward type on admission, primary diagnosis, ventilator management, general anesthesia surgery, and dementia.

Results

Study participants were 6264 patients, median age 74 years (56-83), and 3303 men (52.7%). The total delirium incidence in entire research period was 2.5% (158 of 6264 patients), comprising 1.8% (95/5251) before visitation restriction and 6.2% (63/1013) after visitation restriction. The AOR for delirium incidence was 3.79 (95% CI, 2.70-5.31) after visitation restriction versus before visitation restriction. Subgroup analysis showed no apparent interaction for delirium incidence.

Conclusion

Visitation restriction was associated with an increased incidence of delirium in emergency inpatients.

Perspectives of intensive care nurses on open visits in an ICU

OBJECTIVE

To determine the attitude of the nursing professionals of an Intensive Care Unit regarding the effects of open visiting on the daily activities of the patient, their family and professionals, and also to determine their contribution to the current open visiting policy.

METHOD

A cross-sectional descriptive study was performed, with a non-probabilistic discretionary sampling. The sample comprised nursing professionals of the aforementioned Unit. They were given a questionnaire with 26 items and an open question to evaluate their suggestions.

RESULTS

101 nursing professionals took part in the study, of the 120 working in the Unit under study. Seventy-five point two percent state that the nursing team has to postpone or modify their work due to the presence of the family and 89.9% that their presence produces a physical and psychological burden on the staff. Eighty percent think that the visit exhausts the family and 84.2% that the family feels obliged to remain with the patient. Ninety-four percent think that the effect of the presence of the family depends on the patient and the family.

CONCLUSIONS

Most of professionals have a negative opinion about the policy of open visits, showing some reluctance when it comes to flexible visiting hours, although they admit that an unrestricted schedule in this type of units implies some benefit for the patient and the family.

Rationales of restricted visiting hour in Iranian intensive care units: a qualitative study

BACKGROUND

Today, critical care visitation is considered an important aspect of patient-centred care and its positive effects on patients and their relatives have been demonstrated. However, restricted visiting hours in the intensive care units (ICUs) is often an adopted norm. The reasons for such restricted policies in Iran still remain unknown.

OBJECTIVES

The purpose of this study was to identify the rationales for restricted visiting hours in adult ICUs in Iran.

METHODS

A qualitative design using a thematic analysis approach was used for data gathering and analysis. Participants in this study were six nurses, three head nurses, two patients and four visitors. They were chosen through purposive sampling method. Data were gathered through semi-structured individual interviews.

FINDINGS

The data analysis resulted in three themes: 'health protection', 'safety promotion' and 'privacy preservation'.

CONCLUSION

The result showed that through restricted visiting hours, nurses try to protect vulnerable ICU patients from physical, psychological and legal risk. Although the ICU nurses' concerns seem reasonable in some cases, a review of visiting policies in order to meet the needs of patients and their families is essential.

RELEVANCE TO CLINICAL PRACTICE

Effective supervision by charge nurses and regulation of environmental activities with visiting hours can resolve many concerns. Health care professionals, especially nurses, are required to create the conditions in which patients' family members are informed about the patients' health status and patients can be visited in suitable ward conditions.

Family visitation in greek intensive care units: nurses' perspective

BACKGROUND

Policies of flexible and open visiting in intensive care units benefit both patients and patients' families. In Greek intensive care units, gaps exist between evidence and practice for family visitation, resulting in restricted visiting policies.

OBJECTIVES

To explore the beliefs of nurses in Greek intensive care units about the effects of visiting on patients, patients' families, and unit staff and nurses' attitudes toward visiting policies.

METHODS

A descriptive correlational survey was conducted in 6 public hospitals in Athens, Greece, with a sample of 143 critical care nurses. Data were collected via an anonymous questionnaire consisting of 3 validated scales to assess the nurses' beliefs about and attitudes toward visitation.

RESULTS

Generally, nurses were resistant to family visiting and open visiting, and most (94.4%) did not want an open policy in their unit. Nurses think that open visiting policies are supportive for patients and patients families, but the overall effects of visiting depend on both the nurse and the patient (91.6%). Nurses reported that open visiting created increased physical and psychological burdens for them (87.5%) and hampered nursing care (75.5%). Years of work experience, staffing level, and number of night shifts worked by nurses per 15 days were factors predictive of nurses' attitudes toward and beliefs about family visitation.

CONCLUSIONS

Nurses' beliefs about and attitudes toward visitation are important factors in the implementation of more flexible visiting policies in Greek intensive care units. Well-staffed units with experienced nurses and fewer shifts per week may affect nurses' negative attitude toward open visitation.

Toward less sedation in the intensive care unit: a prospective observational study

PURPOSE

Excessive sedation is associated with prolonged mechanical ventilation and longer intensive care unit (ICU) and hospital stays. We evaluated the feasibility of using minimal sedation in the ICU.

METHODS

Prospective observational study in a university hospital 34-bed medico-surgical department of intensive care. All adult patients who stayed in the ICU for more than 12 hours over a 2-month period were included. Intensive care unit admission diagnoses, severity scores, use of sedatives and/or opiates, duration of mechanical ventilation, length of ICU stay, and 28-day mortality were recorded for each patient.

RESULTS

Of the 335 patients (median age, 61 years) admitted during the study period, 142 (42%) received some sedation, most commonly with midazolam and propofol. Sedative agents were administered predominantly for short periods of time (only 10% of patients received sedation for >24 hours). One hundred fifty-five patients (46%) received mechanical ventilation, generating 15,240 hours of mechanical ventilation, of these, only 2993 (20%) hours were accompanied by a continuous sedative infusion. Self-extubation occurred in 6 patients, but only 1 needed reintubation.

CONCLUSIONS

In a mixed medical-surgical ICU, minimal use of continuous sedation seems feasible without apparent adverse effects.

Effect of a regular family visiting program as an affective, auditory, and tactile stimulation on the consciousness level of comatose patients with a head injury

AIM

The purpose of this study was to determine the effect of a regular family visiting program, as an auditory, affective, and tactile stimulation, on the consciousness level of comatose head injury patients.

METHOD

A randomized controlled trial design was used. Fifty comatose head injury patients were randomly allocated into a control group or an intervention group. The consciousness level of the patients in both groups was evaluated and recorded by the Glasgow Coma Scale, before and 30 min after the visiting program.

RESULTS

The independent t-test results demonstrated that the means of the consciousness level at the first day before intervention had no significant difference in both groups. The repeated measured ANOVA results demonstrated that the consciousness level alterations were significant between the two groups over the 6 days of intervention.

CONCLUSION

The results of the present study provided evidence to support that a regular family visiting program could induce the stimulation of comatose patients. Therefore, it can be considered as a potential nursing intervention.

Evidence-based practice in a military intensive care unit family visitation

BACKGROUND

The dissatisfaction of family members with a restrictive visiting policy in a combined intensive care and step-down unit provides an opportunity for staff to develop better ways to meet the needs of patients and their families. A review of the evidence-based practice (EBP) literature as the measure of significance indicated that less restrictive visitation policies enhance patient and family satisfaction and offer many physiologic and psychological benefits to the patient.

OBJECTIVE

The purpose of this study was to determine whether a less restrictive visitation policy could be implemented in the adult critical care department of a naval medical center.

METHODS

Staff was educated on the use of EBP, specifically the Iowa-based model, and a less restrictive visitation policy was developed and implemented.

RESULTS

Evaluation of the postintervention survey findings revealed higher patient and family satisfaction.

CONCLUSIONS

The findings from this EBP project suggest that a more open visitation policy is feasible in adult critical care units, with an increase in overall satisfaction of patients and their families with regard to their stay in the intensive care unit.

The Impact of Hospital Visiting Hour Policies on Pediatric and Adult Patients and their Visitors

BACKGROUND

Policies concerning restricted or open visiting hours are being challenged in health care institutions internationally, with no apparent consensus on the appropriateness of the visiting hour policies for pediatric and adult patients. The rules that govern practice are often based on the institutional precedent and assumptions of staff, and may have little or no evidence to support them. Policy and practice related to visiting hours is of pressing concern in Canada, and in Ontario specifically, following the reaction to the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003 and subsequent changes in visiting policies in most health care settings. A systematic investigation of the impact of hospital visiting hours on visitors (including patients, families, and significant others) would inform decision-makers who are responsible for hospital policies about the best available evidence.

OBJECTIVES

The objective of this review was to appraise and synthesize the best available evidence on the impact of hospital visiting hours on patients and their visitors.

INCLUSION CRITERIA

Types of participants This review considered studies that included both pediatric and adult hospital patients and their visitors. Participants were either patients, visitors, or health care providers in the following hospital settings: medical/surgical units, critical care (ICU, CCU, NICU), pediatrics, maternity, or general hospital wards.Articles were excluded if participants came from the following settings: post-operative and post-anaesthesia care units (PACU), dementia wards, long-term care settings or retirement homes, or delivery rooms. PACUs were excluded because there are aspects of the presence of visitors to these units that are very specific, and differ from the general visits to patients who are not in the immediate post-operative stage. Dementia wards, long-term care settings and retirement homes were excluded because these were considered to be their "home", so visiting would be quite different from that on acute care hospital wards. Finally, delivery rooms were excluded because this review does not evaluate the impact of the outcomes of presence during "delivery" (or other "procedures").Types of interventions Studies were considered for inclusion in this review if they evaluated the effect or impact of visiting policies. This included interventions targeted at limiting or expanding patient visiting. We anticipated a paucity of experimental studies regarding this review question, thus included observational studies where the impact of visiting policy on patients and/or visitors was a focus, but testing intervention(s) may not have been the primary aim. We did not consider observational studies that focused only on the presence of visitors during specific procedures, resuscitation, or childbirth. The reason is that this limited aspect of the presence of a significant other was not considered "visiting" per se, and would be best examined in another systematic review.Types of outcome measures For this review, outcome measures related to both patients and visitors as a result of visiting hour policies were considered, including but not limited to: patient and/or visitor satisfaction; attitudes; beliefs; perceptions; mood; or patient physiological outcomes. These also included health care provider beliefs, perceptions, and attitudes about the impact of visiting policies on patients and/or visitors. Studies were excluded if they examined the trend of current visiting hour policies (with no evaluation of their impact), or if they focused on visitor presence only during emergency procedures, resuscitation, or childbirth.Types of studies Randomized controlled trials (RCTs) or quasi-experimental studies were included. However, given the expected scarcity of these designs relevant to our review question, other quantitative research designs were considered, such as non-randomized controlled trials, before-and-after studies, and descriptive/observational studies.

SEARCH STRATEGY

Using a defined search and retrieval method the following databases from 1995-2007 were accessed: Medline, CINAHL, Embase, PsycINFO, HealthSTAR, Cochrane Database of Systematic Reviews, AMED, and ERIC.

METHODOLOGICAL QUALITY

Each paper was assessed by two independent reviewers for methodological quality prior to inclusion in the review using standardized critical appraisal instruments for evidence of effectiveness, from the Joanna Briggs Institute. Disagreements were dealt with by consultations with a third reviewer.

DATA COLLECTION

Information was extracted from each paper independently by two reviewers using the standardized data extraction tool developed by the Joanna Briggs Institute. Disagreements were dealt with by consultations with a third reviewer.

DATA SYNTHESIS

Due to type of designs and quality of available studies, it was not possible to pool quantitative research study results in a statistical meta-analysis. Since statistical pooling was not possible, the findings are presented in a descriptive narrative form.

RESULTS

Fifteen studies met the inclusion criteria for this review. The study designs were varied, and included one pilot randomized trial, two quasi-experimental studies, eight descriptive studies/cross-sectional surveys, and four pre-post intervention questionnaires. Findings were inconsistent across studies. Nurses inconsistently enforced visiting policies. In ICU settings, liberalized visiting hours did not increase septic complications. One study reinforced the need for increased patient control over visiting (individual visit contracts, devices). Flexible (open) visitation policies increased patient and visitor satisfaction, and sibling visitation was beneficial to the patient and family. In maternity settings, a 'combination policy' was useful (open visiting for partner, more restricted visiting for others).

CONCLUSION

Key recommendations are provided that refer to clinical practice in critical care, maternity, and general ward settings, as well as recommendations for future research. In critical care settings, policy makers/administrators need to be aware of their staff nurses' beliefs and attitudes about visiting policies, educate them about the rationale for these policies and consider program development to assist nurses to work with families. Open visitation, and ways to increase patient control of visiting should be considered. No connection was found between liberal visiting hours and increased infection rates. When facilitating sibling visitation in the NICU, a pre-visit education process is recommended. Maternity settings may wish to consider a 'combination' policy, where the women's partners and/or significant other would have open visiting (all day), with restricted visiting for others. In other general hospital ward settings, open visiting with a 'quiet hour' is suggested.

Establishing an action research group to explore family-focused nursing in the intensive care unit

This paper presents the first phase of a four-phase collaborative action research study which aimed to facilitate family-focused nursing in the intensive care environment. The purpose of phase one was to determine intensive care nurses' perceptions of family-focused critical care nursing and the appropriateness of family-focused nursing in the intensive care unit. A collaborative action research group was established with six registered nurses working in the intensive care unit of a metropolitan tertiary referral hospital. Data were collected through group discussions and analysed using open coding. Findings revealed two categories related to perceptions of family-focused intensive care nursing: partnership in care and maintaining a balance. The group unanimously agreed that family-focused nursing was appropriate in the intensive care environment. The three subsequent action research phases of this study are reported elsewhere.

Patient Falls and Open Visiting Hours

This study investigated the linkages between patient falls and open visiting hours in an acute care setting in Taiwan. The activities of the accompanying family members/aides when patients fell were analyzed. More than 35% of the family members/aides who were watching patients were ineffective in preventing the falls.

Beliefs and attitudes of intensive care nurses toward visits and open visiting policy

OBJECTIVE

To describe the beliefs and attitudes of intensive care unit (ICU) nurses toward visiting, visiting hours, and open visiting policies in critical care settings.

DESIGN

A descriptive, cross-sectional, multicenter survey.

SETTING

Seventeen hospitals in Flanders (Dutch-speaking Belgium), including 30 ICUs. Sixteen mixed adult medical/surgical ICUs, three medical ICUs, five surgical ICUs, three coronary care units, two post-cardiac surgery ICUs, and one burn unit.

PARTICIPANTS

A total of 531 intensive care nurses.

MEASUREMENTS AND RESULTS

We devised a questionnaire comprising 20 items assessing beliefs and 14 items assessing attitudes. Nurses indicated their level of agreement for each statement on a five-point rating scale. Nurses believed that open visiting hampers planning of adequate nursing care (75.2%), interferes with direct nursing care (73.8%), and causes nurses to spend more time in providing information to the patients' families (82.3%). The presumed effects of visits on the patients and families were contradictory. Most nurses (75.3%) did not want to liberalize the visiting policy of their unit.

CONCLUSIONS

ICU nurses have rather skeptical beliefs and attitudes toward visiting and open visiting policy. This suggests that the culture at Flemish ICUs is not ready for a drastic liberalization of the visiting policy.

Visiting hours policies in New England intensive care units: strategies for improvement

OBJECTIVE

Dying patients often feel isolated and alone, and restricted visiting hours in the intensive care unit (ICU) has been shown to increase anxiety and dissatisfaction in both critically ill patients and their families. Unrestricted visiting has been identified as a top-ten need by families of patients in the ICU. Because emotional distress experienced by patients and families may persist well beyond the ICU stay, an open visiting policy, by meeting the needs of patients and families, may improve the quality of end-of-life care in the ICU. This two-part study included a survey to determine the visiting hours policies of New England-area hospital ICUs, and nursing focus groups to describe challenges and barriers that nursing staff working in an open ICU have experienced and to provide solutions that will facilitate implementation of an open visiting hours policy.

DESIGN

Two-part study: survey and focus groups.

SETTING

ICUs in New England and one medical ICU in a tertiary care hospital.

SUBJECTS

Registered nurses employed in medical ICUs.

INTERVENTIONS

Adult ICUs in the six New England states were located using a library listing of all regional hospitals. A telephone questionnaire interview was used to ascertain visiting hours policies in each ICU. Six focus-group sessions were conducted with nursing staff who work in an urban, northeastern ICU with 8 yrs of experience with an unrestricted visiting hours policy.

MEASUREMENTS AND MAIN RESULTS

A total of 171 hospitals completed the questionnaire (96%). From all ICUs surveyed, 62 (32%) had unrestricted, open visiting hours. Out of these, 57 (92%) were medical ICUs or mixed medical/surgical ICUs. Nursing staff identified three major areas of concern with an open visiting hours policy: space, conflict, and burden. Strategies for resolution that are either employed or advocated by nursing staff are described.

CONCLUSIONS

The majority of ICUs in New England have restricted visiting hours. Only one third of ICUs have open visiting policies. Nursing concerns with an unrestricted ICU were identified and solutions were offered that may provide guidance for other ICUs considering adopting an open visiting hours policy.

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.

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.

[Organization of visits in Spanish ICU]

It is a fact that visits in the intensive care units (ICU) have always been very restrictive due to diverse criteria. Nowadays, some of them have been progressively liberalized, giving to the relatives more satisfaction and a better cover to their necessities. In our country there are no surveys about the organization of these visits at the present time, apart from some exceptional cases which commentate the situation in a particular center.

OBJECTIVE

Know how are visits organized in the intensive cares units in Spain.

MATERIAL AND METHOD

DESIGN

cross-sectional study; scope: 98 ICU of different Spanish hospitals; studied variables: the number of visits, their duration, the number of relatives in each visit, the number of relatives visiting the patients at the same time, the amount of information each day, the professional that informs, the use of written information and information by telephone, preventive measures taken before the entry in the unit, how relatives take part in the cares, location of the waiting room and use or not of a protocol of attention to relatives.

INSTRUMENTATION

The information has been obtained by a questionnaire placed in a web site of the Internet and directed to professionals of different Intensive cares units.

RESULTS

The ninety and eight evaluated units represent 37 Spanish provinces from all the autonomous communities. The most frequently noticed pattern for the organization of visits shows a restrictive character of the visits in Spain.

CONCLUSIONS

There are clear differences in the organization of visits between the studied ICU and no connection between the most common practice and what the survey, after evaluating the necessities of the relatives, recommends. These recommendations are: more visits, more flexibility of schedules, more integration of the relatives in the patients cares, broach the information from diverse disciplines, washing hands as the only necessary measure to be taken by the relatives.

Improving the ICU: part 2

ICUs are a vital but troubled component of modern health-care systems. Improving ICU performance requires that we shift from a paradigm that concentrates on individual performance, to a systems-oriented approach that emphasizes the need to assess and improve the ICU systems and processes that hinder the ability of individuals to perform their jobs well. This second part of a two-part treatise establishes a practical framework for performance improvement and examines specific strategies to improve ICU performance, including the use of information systems.

Palliative Care in the Surgical ICU

Palliative care for the critically ill has become an increasingly important component of care in the SICU. As the population ages, medical technology continues to offer new treatments that can prolong life, and more and more Americans die in the hospital in critical care settings, the appropriate management of the end-of-life must be part of the clinical expertise of surgeons and intensivists. Part of this expertise must include the components of palliative care (eg, pain and symptom management, psychosocial support, communication skills, shared decision-making) and specialized areas of withdrawal and withholding of life support. Integrating palliative care expertise into the SICU is not straightforward; understanding when and how to make the transition from curative to palliative care can be fraught with uncertainty regarding prognosis and patient preferences. Attention to the principles of good pain management, communication with patient and family, and discussion of goals of care are not just for patients who are at the end-of-life, but are appropriate care for all critically ill patients, regardless of prognosis. In this framework, "intensive care"encompasses palliative and curative care.

Families of critically ill patients and the effect of nursing interventions

Family needs of critically ill individuals and the nursing interventions to meet these needs have spanned 3 decades of research. Researchers have found that interventions appear to meet some family needs, but more can be done to provide family-centered care and improve patient outcomes.

The meaning of social support for the critically ill patient

Social support has been shown to be important for the critically ill patient. However, what constitutes adequate support for these patients has not been investigated. Thus, the purpose of this qualitative study was to investigate patients' perceptions of their need for and adequacy of the social support received while they were critically ill. Thirty adult patients who were critical during some point of their stay in the intensive care unit (ICU) stay were interviewed, once stable. Interviews were tape-recorded and began with an open-ended question regarding the ICU experience. This was followed by open-ended focused questions regarding social support, such as 'Who were your greatest sources of social support while you were critically ill?' 'What did they do that was supportive or unsupportive?' Data were analyzed according to Miles and Huberman (1994). The categories that emerged were need for social support based on patient perceptions (not number of visitors), quality of support (based on perceptions of positive and negative behaviors of supporters) and lack of support. This study found that quality of support was more important than the actual number of visitors. Patients with few visitors may have felt supported, while those with numerous visitors felt unsupported. Patients who felt unsupported also were more critical of the staff and the care they received. Nurses need to individually assess patients regarding their need for support, and assist family/friends to meet these needs.

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.

Creating a healing environment for elders

The number of elderly, both in society at large and in the critical care population, is increasing at an unprecedented rate. Critical care nurses must address how best to provide care to these elders. The authors focus on physiologic, cognitive, and psychosocial characteristics of the elderly that place them at risk for complications during their stay in critical care. The critical care environment also contributes to complications such as sleep deprivation, sensory deprivation or overload, painful procedures, and decreased social support. The critical care environment may also be a factor in facilitating delirium, common in critically ill elders. Critical care nurses can proactively help to create a healing environment for these elders by facilitating sleep, implementing strategies to reduce delirium, preventing or minimizing painful experiences, and liberalizing family visitations.