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Review

Are visitors beneficial to patients in adult ICUs?

  • Comment

Although visiting is often restricted for patients on adult critical care units, evidence suggests that the benefits outweigh the drawbacks

Abstract

Despite their benefits, visits are limited in critical or intensive care settings. The British Association of Critical Care Nurses commissioned a position statement using evidence-based literature on visiting practices in adult ICUs. This article examines the evidence, the benefits and drawbacks of visiting.

Citation: Plowright C, Gibson V ( 2013) Are visitors beneficial to patients in adult ICUs? Nursing Times; 109: 36, 13-14.

Author: Catherine Plowright is consultant nurse in critical care at Medway Foundation Trust; Vanessa Gibson is teaching fellow and learning and teaching champion at Northumbria University; both are British Association of Critical Care Nurses national board professional advisers.

Introduction

The psychological impact of admission to a critical or intensive care unit has been well reported. Maintaining links with normal life promotes psychological wellbeing and visitors play a vital role in this. However, there is still controversy over visiting in ICUs. Berti et al (2007) reported nurses felt the time taken up by providing information to visitors could hinder direct care. They appeared to feel interacting with them made their job more difficult (Levy, 2007).

The British Association of Critical Care Nurses (BACCN) commissioned an evidence-based position statement on visiting practices in adult ICUs (Gibson et al, 2012).

Aim

The aim of the position statement is to inform nurses of the standards that patients and visitors should expect when visiting adult ICUs and to demonstrate the benefits of visitors to patients and staff.

Method

ICUsteps - a charity for patients and relatives affected by critical illness - and the patients and relatives committee of the Intensive Care Society helped us to develop the statement. A literature review was undertaken and expert opinions and experiences of group members were considered.

Results

There were critical differences between what nurses believe is best practice and what patients and visitors want. After reviewing the evidence, we developed standards on visiting ICUs (Box 1).

Box 1.BACCN Visiting Standards

Patients should expect:

  • To have their privacy, dignity and cultural beliefs recognised
  • Confidentiality
  • The choice of whether to have visitors
  • The choice to decide who they want to visit, including children/other loved ones 
  • The choice of care assisted by relatives
  • A critical care team who recognise the importance and value of visiting

Relatives should have:

  • A comfortable and accessible waiting room with bathroom facilities nearby
  • Access to overnight accommodation in the vicinity of the ICU
  • Easy access to food and drink
  • A telephone nearby
  • Access to information regarding critical illness and the critical care environment, aftercare and support. This should be reinforced with written materials
  • An area for private discussions with health professionals
  • Involvement in care as the patient wishes
  • Written information on procedures, for example handwashing and times of ward rounds
  • Information concerning patient progress on a daily basis at least
  • Information when there are significant changes to the patient’s condition
  • Regular updates, so they do not need to wait for long times without these
  • Interpretation services if needed

Source: Gibson et al (2012)

Literature review

Nurses have been found to perceive visitors to: increase noise levels; take up space; take up nursing time; and hinder direct nursing care (Plowright et al, 1998). As a result, visitors are seen as a drain on resources and time (Quinio et al, 2002).

Plowright (1996) found many ICUs allowed patients two visitors at a time; anecdotally, this is thought to be the case in 2013.

A UK survey found all ICUs required hand cleaning. Ten of the 206 responding units expected visitors to wear gowns (Hunter et al, 2010); however, Giannini et al (2008) found no evidence to support this practice and said it reinforced the perception that visitors did not belong in ICU.

Visitors can be beneficial. Bergbom and Askwall (2000) and McAdam et al (2008) found patients felt a positive energy from visitors and that their rights were protected by visitors acting as their advocates. McAdam et al (2008) said information from visitors enabled nurses to offer more individualised care (McAdam et al, 2008). The presence of visitors has been found to help with weaning from ventilators (Happ et al, 2007), and no evidence suggests they pose a direct infection risk (Adams et al, 2011).

However, patients can find visitors disruptive to rest, and there is some evidence that their presence can intensify pain (Carroll and Gonzalez, 2009). Patients should decide whether they want visitors.

Children visiting adult ICUs can be a source of stress and uncertainty for nurses (Clarke, 2000). However, children can offer a diversion and help patients to feel safe (Hupcey, 2000). They can help patients to maintain their identity as, for example, a parent or grandparent (Gjengedal, 1994).

Knutsson et al (2008) found children coped well when visiting, particularly if supported by a parent or guardian and staff. Staff need training to support child visitors (Clarke and Harrison, 2001).

Some patients may want a pet to visit and this can cause controversy. However, pets can bring physical, social, psychological and general health benefits (Halm, 2008); some patients may have no next of kin and live alone with a much-loved pet.

While some local pet therapy schemes bring animals to wards, visits by a patient’s own pet are less common. Nurses are believed to have sneaked animals into hospitals or brought them to a window for a patient to see (Connor and Miller, 2000). There is no evidence that infection is an issue and ICUs should consider allowing pets to visit, provided that it is appropriate, infection control precautions are taken and the visit is limited to the pet’s owner.

What do visitors want?

Waiting area comfort is important: waiting can be isolating, distressing and frustrating (Bournes and Mitchell, 2002). Visitors may need overnight accommodation, refreshments, a bathroom, a telephone and a private area for consultation with staff (Fridh et al, 2009; Kutash and Northrop, 2007; Deitrick et al, 2005; Lederer et al, 2005).

Nurse education

Nurses need education on visiting and this should be included at pre- and post-registration levels. Induction programmes should include the needs of family members. Role modelling by senior staff can be powerful in educating junior critical care staff (Linton and Farrell, 2009).

Conclusion

When considering policy on visitors to adult ICUs, critical care nurses should ask:

  • “If I was a patient in a critical care unit, who would I want to visit me?”
  • “If my loved one was critically ill, when would I want to visit and for how long?”

We are sure the answers will be similar to the findings above. The BACCN position statement sets out the standards patients and visitors should expect. It demonstrates that visitors provide many benefits to patients and staff. Clear, evidence-based visiting policies will prevent nurses from having to make on-the-spot decisions about who can visit and when, and will reduce confusion and dispel myths.

Key points

  • Critical care nurses sometimes feel that visitors hinder their ability to provide care
  • Nurses can use visitors to find out more about patients, putting them in a better position to provide individualised care
  • Visitors do not increase direct infection risk
  • Allowing children to visit can help patients maintain their identity, and children cope well with such visits
  • Patients should decide themselves whether they want visitors
  • Comment

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