Family Values

Hospital intensive care units (ICUs) around the world tend to have different policies on family visits. Individual hospitals have different resources and training policies, both of which have a bearing on their visiting policy.

There is an important debate among healthcare professionals about allowing families unrestricted access to their relatives while in an ICU. It can be argued that unrestricted visits by family members can help boost the patient’s recovery, while easing family anxiety. However, it can be argued that visiting family and friends may obstruct nurses trying to carry out necessary, and at times, unpleasant and intrusive procedures.

From the visiting family’s point of view, restricted visiting may seem obstructive and present the hospital and ICU in entirely the wrong light. It is natural for the families of ICU patients to be worried about the patient and look to hospital staff for help and reassurance.

The International Review of Patient Care recently discussed this issue with Martha Curley, a nurse scientist at Children’s Hospital Boston who is also a member the Nursing Faculty of the University of Pennsylvania, and Anne Alexandrov, professor and assistant director of The Center for Advancement of Evidence- Based Practice, at Arizona State University. Both these nursing professionals are employed in the US healthcare system, and have many years of experience in critical care nursing.

IRPC: What are your individual approaches to establishing visiting hours?

Curley: I favour open visiting hours, but I believe that the actual visiting hours should be decided jointly with the family to work out what is best for the patient – it is essential for healthcare professionals to establish a good working relationship with the family. The whole concept of visiting someone who is sick is very culturally mediated. What may work for one family might not work for others, and deciding what is going to be good for the patient needs to be jointly determined.

Alexandrov: This is true. Obviously every case is different, and it is important for the nurse and other healthcare professionals to spend some time getting to know the family and involving them in decisions about the patient’s care. I think this begins with establishing visiting, as the nurses and family can then develop a good relationship and focus on the important central goal of healing the patient and returning them to good health.

Curley: Because we do not have the luxury of one nurse dealing with one patient, it can be very difficult to manage the situation. Different people have different expectations.

Alexandrov: No situation is going to be ideal when dealing with different personalities, but both nurses and family have to remember that the patient is the important person, and their well-being is the only issue. One of the good ideas put forward recently is to employ older nurses as a family liaison to help the family understand about the patient’s condition and treatment, and what they can do to help the treatment process.

Curley: This is a good idea. One of the most important functions of the nurse or auxiliary is helping the family interact with the critically ill patient. Many people will not have had a lot of experience with ICUs and will require guidance on what they can and cannot do, and also how they can help. It is also a good idea to establish a family spokesperson for communication between the healthcare professionals and family members when decisions have to be made. This can avoid confusion and make the process more friendly and efficient.

IRPC: What do families expect from the healthcare professional?

Curley: The family should work with the nurse, and together they can decide the ground rules: when the family should visit, when they should leave and how they can help the nurse take care of the patient. Traditionally, families are at a loose end when they first come into the ICU. They don’t know what to do or how to interact and they tend to feel awkward.

Sometimes you have a revolving door of different family members and a situation where, in the worst cases, the nurse has to stop taking care of the patient to explain to different family members what is required of them and what is going on. With good communication from the start, this can be avoided – it’s a question of forward planning. On the other hand, the nurse should use the family as a resource to aid the patient’s recovery.

Alexandrov: Families who have been asked about their experiences of the ICU say that what they really need is open, honest communication, and they want it provided regularly or when they feel they need it. They also want to be able to feel that they can ask a question when they want to, and they would like the patient to be seen as an individual. People tend to respond to a good approach and a healthcare professional willing to take the time to keep them informed. Both the patient and the family deserve respect and understanding. Good communication is a big step towards this.

Most people have little or no experience of hospitals and the whole place is shrouded in mystery. Sometimes it terrifies them. In such cases, it is up to the nurse to put them at their ease and give them good information, understanding and reassurance, as even small things the family can do to help the patient are very valuable.

Curley: This is very true, particularly when we are talking about adult treatment. In paediatric ICUs things tend to be a little easier, as parents are more informed and open to good communication. In general the nurse needs to set up some sort of structure, so that family members know how to work together in a team to aid the patient’s recovery.

IRPC: Do patients recover more quickly if they have unlimited visits from their families?

Curley: Studies have shown that patients recover more quickly when they are allowed unrestricted visits from their families, and the whole process is much less stressful for their families as well.

Alexandrov: But quantitative studies have also shown that not all families want to be deeply involved in the process. I think there would be a spectrum of opinion in any family. Some want to be involved as much as possible; some feel awkward, don’t know what to do and would prefer just to observe or even stay outside and just be kept informed.

IRPC: How do staffing levels and security affect visiting?

Curley: The ratio of nurses to patients is going down, increasing the workload for nurses and making it much more difficult to develop the required relationship with the family. As far as security goes, visiting must always be controlled using some sort of ID system. Hospitals must be secure – you can’t just have people walking through hospitals – but you must also give families access.

Alexandrov: Obviously, staffing levels have dropped, but it is still a very good idea to retain a nursing liaison with the family to develop a relationship and a better understanding of the patient and family situation. When there is good communication, care improves and the patient recovers more quickly.

Curley: In some larger hospitals, there are volunteers who meet the families and orientate them. They also help nurses develop a better relationship with them. This sort of structure helps inform families.

IRPC: How do you feel about pets visiting patients?

Curley: It can be difficult. However, sometimes a pet might be the only family a patient has. So a pet being brought into hospital to comfort a patient can be extremely beneficial.

Alexandrov: It’s a wonderful idea, and makes a huge difference to the patient. ICU policies on visiting vary, depending on a hospital’s culture and resources, while some hospitals may just be stricter than others. In general, visiting policies should be geared towards the development of a good relationship between healthcare professionals and patients’ families. Dialogue and communication are vital. The family must be involved as part of the team, to help them understand what is happening and help the patient recover.