Perceptions of an open visitation policy by intensive care unit workers

An intensive care unit (ICU) admission is a stressful event for the patient and the patient’s family. Several studies demonstrated symptoms of anxiety, depression, and posttraumatic stress disorder in family members of patients admitted to ICU [1–3]. In 1979, Molter published the Critical Care Family Needs Inventory [4]. Since then, other studies have focused on attendance to those needs [4–6]. An open visiting policy (OVP) in an ICU meets at least one of these needs: to be with the patient frequently. In the past several years, the search for improvement in patient care in a holistic way became evident. Patient-centered and family-centered care has been increasingly encouraged to improve the quality of care and the satisfaction of patients and their families. One of these proposals is to ensure an OVP to relatives of patients admitted to ICU [7, 8].

In general, the time period of an ICU visit is described as restrictive or open/liberal. A restrictive policy allows family to visit during certain periods of the day and restricts the number of visitors per period. An OVP allows access to family at all times (24 hours), with or without restriction on the number of family members during any given period. An OVP is very common in the pediatric ICU setting but is still uncommon in an adult ICU [7, 9–12].

Several studies developed in Europe and North America have demonstrated that most ICUs have a restrictive visiting policy [11–17]. Some studies recognize that the OVP is related to a reduction in symptoms of anxiety and depression for the patient and an improvement in family satisfaction [18]. Fumagalli et al. reported a reduction in cardiovascular complications with an OVP [19]. However, some issues have been presented as barriers for the adoption of that strategy [9, 10, 20–22]. An OVP could cause an increase in the workload for ICU workers and also create some delay in the performance of duties [10, 22]. Nurses tend to be more skeptical about an OVP, despite recognition of the possible benefits to the patient [22].

In Brazil, there is no formal recommendation about the visiting policy in an ICU, and each institution is allowed to decide its own individual visitation strategy. Our institution adopted a 24-hour visitation policy 5 years ago (November 2008).

The objective of this study was to evaluate the perception of physicians, nurses, and respiratory therapists (RTs) regarding an OVP in one private ICU with 5 years of experience. Another objective of this study was to evaluate the length of stay of visitors in a patient’s room and the usual type of visitor.

There is an increasing agreement in adoption of the philosophy that an open ICU policy is very important to both critically ill patients and family members.

This study has interesting findings. First, this is the first study that we know of which evaluated physicians’, nurses’, and RTs’ perceptions of an OVP in Brazil and Latin America. Second, the overall duration of visits was much longer than in previous reports of OVP. In our study, median visiting time was 11.5 hours per day. Fumagalli et al. reported a mean visiting time of 2.6 hours per day during an unrestricted visiting policy in a cardiology ICU [19]. Garrouste-Orgeas et al. analyzed visiting times from day 1 to day 5 after ICU admission, and the maximum median visit length was 120 minutes [18].

Our results suggest that there are major differences in the duration of ICU visits in different world regions. Not surprisingly, our families spend more time in an ICU, due to the fact that in Brazil families become very united in the face of serious disease and view as their responsibility to protect the patient from distress. Families play a major role in the decision-making process during the patient hospitalization.

Third, although the majority of ICU workers answered that an OVP policy impairs the organization of the care given to the patient and interferes with their work, they think that an open visitation policy helps the patient’s recovery by decreasing anxiety and stress. Regarding family members, the ICU staff did not report great benefit. For example, according to them the OVP does not always help to increase the family’s satisfaction or to decrease anxiety and stress. This partially could be explained by our model of work. Information may be given to a family representative at any time, but the patients’ doctors, who have full knowledge of the case, provide the most important information. With this model, the physicians on duty do not have a regular time for family conferences.

According to studies in other countries, the restricted visiting policies were preferred by the staff, especially by the nurses, because according to them, opening an ICU to visitors could interfere with their care process [22]. In our study, we found that the staff may feel uncomfortable when examining the patient with the family present and had complaints about the presence of the family for 24 hours per day. Some of the respondents appointed that OVP changed their work attitude in the ICU. Recent studies have demonstrated the effect of unrestricted visitation policies in ICUs and identified that 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 / medical care [10, 22]. Although our staff expressed positive statements about OVP, our results can help to identify the burdens and conflicts, which may assist other ICUs in determining solutions.

Despite the fact that there was a positive statement indicating that an OVP increases the family’s trust in the ICU team, they do not think that a longer family presence increases the satisfaction with the patient’s care. One reason for this feeling may be 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 would create a burden of stress for the ICU team. This may sometimes lead to minor conflicts between ICU workers and families.

Fourth, we did not find substantial differences between physicians’, nurses’, and RTs’ perceptions about an OVP. In contrast with other studies, we did not find that nurses have a more skeptical opinion about the benefits of an OVP in ICU [10, 22]. We also did not find that physicians have a more positive perception about it. One possible reason for those findings could be that the median time of work in HSL ICU is relatively low, 4 years (IQR 2–6), making an adaptation of this model of ICU visiting easier. As far as we know, this is the first study to describe and compare opinions of RTs. The RT group believed more frequently than the nurses and physicians that visitation hinders the patient’s rest and led to a delay in examining and performing procedures on patients. We did not find any other significant differences when comparing physicians and nurses. One possible reason for those differences is that RTs spend more time directly with the patient compared with nurses and physicians, as an RT session takes approximately 20–30 minutes per patient.

Another interesting finding is that, despite an existing OVP, in cases of end-of-life and serious conflicts, ICU workers were favorable of an adaptation in the visiting policy. Moreover, for all participants in this study there is a clear preference for self-hospitalization in an OVP.

The relationship between patient, ICU team, and family is extremely complex. This study demonstrates that our ICU team has a perception that an OVP is of benefit for the patient; however, this beneficial perception is not so clear with regards to the family. The perception of an increase in workload caused by the longer presence of the family in the ICU does not cause a negative perception of that visitation strategy.

Our study found that 79.2% of ICU staff members have gaps in communication training with families and 84% indicate a desire to have good family communication skills. The effectiveness of communication during daily rounds in the ICU can help staff organize their workload and improve their daily goals [23]. Lee et al. identified some strategies for implementation of improvement in the dynamics between staff and visitors [17]. According to this study, communication is one of three major themes that were identified and they encouraged formal communication skills training to facilitate implementation of an open visiting policy. We intend to introduce communication training for our team.

The present study has some limitations. First, the questionnaire was not formally validated, but it was built based on previous models. However, this does not invalidate our study, because the authors tested the questions, and during data collection there were no doubts reported about any questions. Furthermore, we did not make a qualitative interview with the ICU team. This approach could have helped to better understand the negative results. Second, this is a single-center study of a private Brazilian ICU and this model of OVP ICU with private rooms and organization is not representative of all Brazilian ICUs, although many ICUs are now changing to facilitate different visiting hours. In Brazil, the majority of ICUs are in public health facilities and are closed ICUs. Therefore, we cannot compare the perceptions of our ICU staff with others institutions that have very different characteristics. A third point is that a high level of severe burnout syndrome has been reported in ICU healthcare workers, and this was not explored by our study [24].

Finally, our research did not focus on the family and the patient’s perceptions. Future research efforts should be directed towards evaluating the impact that an OVP has on patient outcomes and family members.

According to physicians, nurses, and respiratory therapists, the greatest impact of OVP is the benefit to the patient rather than to the family or the staff. Furthermore, the ICU staff feels that they need communication training to better interact with family members who are present in the ICU 24 hours per day.