A survey of intensive care unit visiting policies in the United Kingdom

Authors


Dr John Hunter
Email: jdhunter@talk21.com

Summary

Admission to an intensive care unit is a highly stressful event for both patients and their relatives. Feelings of anxiety, pain, fear and a sense of isolation are often reported by survivors of a critical illness, whilst the majority of relatives report symptoms of anxiety or depression while their relative was in the intensive care unit. Traditionally, infection control concerns and a belief that liberal visiting by patients’ relatives interferes with the provision of patient care have led many units to impose restricted visiting policies. However, recent studies suggest that an open visiting policy with unrestricted visiting hours improve visitors’ satisfaction and reduces anxiety. In order to determine current visiting practice and provision for relatives within intensive care units, a questionnaire was sent to the principal nurse in all units within the United Kingdom. A total of 206 hospitals out of 271 completed the survey (76%). We found that 165 (80.1%) of responding units still impose restricted visiting policies, with wide variations in the facilities available to patients’ relatives.

The intensive care unit (ICU) is a highly stressful environment for patients and their families. Survivors commonly report high levels of depression, anxiety, irritability and social isolation after hospital discharge [1]. A large French multicentre study revealed that the prevalence of symptoms of anxiety and depression in family members was 69.1% and 35.4%, respectively, and that symptoms of anxiety or depression were present in 72.7% of family members and 84% of spouses [2].

An unrestricted or open visiting policy is defined as a policy that imposes no restrictions on the time or duration of the visit. It is increasingly recognised that unrestricted visiting by relatives of critically ill patients may be beneficial [3–9]. The presence of family and friends may reassure patients, during their stay in a highly unfamiliar and stressful environment [10]. Studies suggest that the quality of life of survivors’ relatives is positively influenced by a good relationship between them and the ICU team [11]. It has been reported that this relationship is enhanced by unrestricted visiting [12]. Improvements in rates of anxiety, depression and satisfaction among family members have been demonstrated when visiting is unrestricted [12, 13]. Unrestricted visiting has also been reported to reduce cardiovascular complications in the critically ill [4]. A randomised trial comparing the haemodynamic consequences of unrestricted and restricted visiting policies found that patients who had unrestricted visiting hours experienced a decreased risk of cardiocirculatory complications and a reduction in anxiety scores [4].

A fear that unrestricted visiting may force worried relatives to be constantly present has not been objectively demonstrated [12]. The effect of unrestricted visiting on ICU staff is inconsistent, with some reporting increased satisfaction and improved trust with relatives [12], while others perceive disruption in nursing care, or increased anxiety when examining patients [3, 14], and are resistant to open visitation [15, 16].

Surveys of policy and attitudes conducted in Europe and North America within the past 10 years have highlighted the current restrictive practices and barriers to open visitation [13, 14, 16, 17]. Wide variation in policy exists, especially with regards to visitation by children and amenities for relatives.

No recent examination of visiting policy and provision of facilities for relatives has been conducted in the UK; the aim of our study was to determine current practices and provisions within the UK.

Methods

We identified all hospitals in the UK from the Directory of Operating Theatres and Departments of Surgery with intensive care services [18]. Hospitals concerned solely with paediatric, obstetric, ophthalmic or dental services were excluded. A postal questionnaire addressed to the ‘Lead Nurse, Intensive Care Unit’ was sent, along with a covering letter explaining the purpose of the study, to all the identified hospitals (n = 271). A second questionnaire was sent if no reply had been received within six weeks.

Results

A total of 206 hospitals out of 271 completed the survey (76%). Characteristics of the responding ICUs are shown in Table 1. The majority of responding ICUs had a formal visiting policy (n = 177; 86%). This policy was included in the relatives’ information booklet of nearly three quarters of these ICUs (n = 132; 74.6%). Surprisingly, only 39 (22.0%) units considered visiting hours in their operational policy. Of the responding ICUs only 41 (19.9%) had unrestricted visiting hours. In those with restricted visiting, the permissible duration of the visit is detailed in Fig. 1. The vast majority of ICUs restricted the number of visitors at any one time to two (n = 192; 93.2%). Of the remaining ICUs, three (1.5%) had no restrictions on visitor numbers, whilst the others decided upon visitor numbers depending upon individual circumstances.

Table 1.   Characteristics of the 206 responding UK intensive care units (ICUs). Values are number (proportion).
  1. HDU, high dependency unit; CCU, coronary care unit.

Type of hospital
 University teaching hospital64 (31.1%)
 District general hospital142 (68.9%)
Number of beds
 6 or less39 (18.9%)
 7–1078 (37.9%)
 > 1089 (43.2%)
Number of level-3 admissions in 2007
 < 20025 (12.1%)
 201–30052 (25.2%)
 301–50074 (35.9%)
 > 50055 (26.7%)
Type of ICU
 ICU only40 (19.4%)
 Combined ICU/HDU162 (78.6%)
 ICU/CCU4 (1.9%)
Figure 1.

 The permitted duration for relatives’ visits in 165 intensive care units (ICUs) with a restricted visiting policy.

Unsurprisingly, nearly all units (n = 198; 96.1%) allowed increased visiting in the case of a dying patient. Children were not permitted to visit in only eight (3.9%) of the responding ICUs. More than half of ICUs implemented a quiet period (n = 119; 57.8%). The majority of those units with a quiet period restricted visiting during this time (n = 96; 89.7%).

Facilities available to visitors are detailed in Table 2. Every responding ICU provided a sink for visitors to wash their hands, with most (n = 199; 96.6%) also supplying hand gel. Hand washing or disinfection with alcoholic hand gel was compulsory in all surveyed ICUs. Thirty-seven (18.0%) units also insisted that visitors wore aprons. The wearing of gowns (n = 10; 4.9%), gloves (n = 10; 4.9%) and surgical masks (n = 1; 0.5%) was rarely required.

Table 2.   Facilities available for visitors in the 206 responding UK intensive care units (ICUs). Values are number (proportion).
Dedicated visitor’s room204 (99.0%)
Facilities available in the visitor’s room
 Fridge85 (1.3%)
 Freezer8 (3.9%)
 Microwave41 (19.9%)
 Constant hot water72 (35.0%)
 Tea, coffee and milk125 (60.7%)
 Television125 (60.7%)
 DVD/video16 (7.8%)
 Magazines152 (73.8%)
 Books1 (0.5%)
 Easy chair136 (66.0%)
 Recliner30 (14.6%)
 Sofa105 (51.0%)
 Lockers9 (4.4%)
 Drinks machine74 (35.9%)
 Snack machine15 (7.3%)
 Visitors’ comments book72 (35.0%)
Facilities available for visitors in the vicinity of the ICU
 Bathroom119 (57.8%)
 Use of kitchen39 (18.9%)
 Access to sleeping accommodation128 (62.1%)
 Vending machines88 (42.7%)

The vast majority of ICUs (n = 194; 94.2%) provided relatives with written information about the unit. This was mostly in the form of a booklet (n = 154; 79.4%). Other methods included a size A4 information sheet (n = 7; 3.6%), a business card with contact information (n = 30; 15.5%), a leaflet (n = 42; 21.6%) or website with specific information for family members (n = 10; 5.1%).

Approximately half of the responding ICUs (n = 98; 47.6%) scheduled a meeting for medical staff and relatives on admission. Daily meetings were formally arranged with medical staff in 36 (17.5%) ICUs whilst 139 (67.5%) only arranged meetings on an ad hoc basis. Only three (1.5%) units arranged a formal meeting on discharge.

Information was conveyed over the phone often or always in 20 (9.7%) units, sometimes in 135 (65.5%) and never in 46 (22.3%). Mostly, relatives were free to phone at any time (n = 193; 93.7%).

A dedicated private room for breaking bad news was provided in 144 (69.9%) units. One hundred and twenty-four (60.2%) units were able to offer a bereavement service if required.

A satisfaction questionnaire was available to relatives in 92 (44.7%) ICUs.

Discussion

This is the first survey of the visiting policies of ICUs in the UK. The relatively high response rate and the characteristics of the responding units shown in Table 1 suggest that this study accurately reflects practice within the UK.

One of the 10 most frequently identified needs of relatives caring for a loved one in the ICU is to be able to visit the patient frequently [19]. Increased visitation decreases stress and anxiety, improves sensory deprivation and facilitates communication with the relatives. Unrestricted ICU visiting hours are advocated by a number of studies and reviews [3, 4, 6, 7, 13, 14, 20] and are also recommended by the American College of Critical Care Medicine Task Force clinical practice guidelines for support of the family in the patient-centred ICU [21].

This study highlights that despite the growing recognition of the value of unrestricted visiting in the ICU, many units in the UK still have restricted visiting policies with almost 80% of the units surveyed restricting visiting. Only three of the units with an open visiting policy did not restrict the number of relatives allowed at the bedside. Surprisingly, 12% of ICUs had no formal written visiting policy, perhaps reflecting the low importance given to family-centred care. Although the reasons for restricted visiting were not explored in the present study, others suggest that some clinicians continue to view ICU visiting hours to be intrusive and time consuming [5]. Nurses’ attitudes towards visitation are also inconsistent [7], with many being hostile towards open visitation policies [15]. A recent Belgian study reported that most nurses (75.3%) did not want to liberalise the visiting policy on their unit. Reasons cited included a belief that open visiting hampered planning of adequate nursing care (75.2%), interfered with direct nursing care (73.8%) and caused nurses to spend more time in providing information to the patients’ families.

Traditionally there has been a reluctance to allow children to visit a critically ill relative. An American survey of 78 ICUs reported that only 11% had official policies that allowed children to visit [22]. The reasons usually cited for this phenomenon are the desire to protect children from additional stress and to protect the child from the risk of infection [23, 24]. However, it has been reported that children who were allowed to visit a sick relative on ICU had less negative behaviour and emotional changes than children who were barred from visiting [25]. In only eight of our responding units were children not allowed to visit a sick relative.

Sleep deprivation is commonplace amongst critically ill patients and it is recognised that optimising the environment to promote sleep requires the active removal of ambient stressors [26]. Recognising this, nearly 60% of our surveyed units implemented a quiet period during the day, when visiting is usually restricted.

One of the most difficult experiences for relatives is waiting to be allowed access to the bedside or to communicate with staff [27]; a dedicated waiting area is consistently identified by relatives as a necessity for quality care [28, 29]. Although nearly all units provided a dedicated visitors’ room, there was wide variation in the facilities available. Surprisingly, nearly 40% of units did not provide facilities for relatives to make tea or coffee.

Infection control issues are commonly cited as a reason to impose restrictions on visiting [3], with fears that microorganisms will be transferred between relatives and patients. Unsurprisingly, our study showed that hand washing or disinfection was compulsory in all of the surveyed ICUs. Unlike many European ICUs [13, 17] which require visitors to wear gowns, only 10 units required relatives to wear gowns during visits. Current evidence does not support the wearing of protective clothing by relatives as a measure of infection control [30, 31]. The compulsory wearing of protective clothing may also be perceived as symbolic of a restrictive visiting policy.

Poor communication is a major source of stress for both staff and relatives [32]. Provision of written information about the unit has been shown to improve both communication and patient satisfaction [33, 34]. A prospective randomised controlled trial in 34 French ICUs compared comprehension of diagnosis, prognosis, treatment, and overall satisfaction in relatives who did and did not receive a written information booklet. Comprehension was significantly higher in the group with access to the booklet [33]. Our survey demonstrates that most UK ICUs provide written information to the relatives, usually in the form of a booklet.

Direct verbal contact with the family is fundamental for effective communication. The duration and quality of the first meeting appears to be of vital importance, with the family’s comprehension increasing with the length of the interview [35]. Despite this, only half of our surveyed units scheduled a meeting for medical staff and relatives on admission. Nearly three-quarters of units only arranged meetings with the family on an ad hoc basis. This is likely to deny many families the opportunity to discuss matters with a critical care physician as many families fail to ask to see the doctor [35]. It’s been suggested that communication could be improved by having regular, scheduled meetings [29].

Nearly all surveyed units allowed relatives to telephone at any time, although wide variations existed on the amount of detailed information that could be conveyed, probably reflecting concerns about confidentiality. Nevertheless, a policy of unrestricted phoning creates an additional burden for nursing staff. Daily phone calls from the nurse to the relatives at a specified time, or agreeing fixed specific hours for obtaining information, can reduce the number of incoming calls from family members without compromising their satisfaction with care or with how well their information needs are met [36].

In conclusion, our study demonstrates that many UK ICUs still operate a restricted visiting policy despite evidence that patients and relatives benefit greatly from open visiting. Many of the traditional rationales for restricted visiting are not supported by the literature and indeed, most family members adapt well to the daily clinical routine and support the nurses and physicians in their work. Although most units provide adequate infrastructure to support family members and provide written information about their ICU, it is concerning that fewer than half of the surveyed units arranged a formal meeting with the relatives soon after admission.

Competing interests

No external funding and no competing interests to declare.

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