Position statement on visitingin adult critical care units in the UKVanessa Gibson, Catherine Plowright, Tim Collins, Deborah Dawson, Sara Evans, Peter Gibb,Fiona Lynch, Kay Mitchell, Pam Page and Gordon Sturmey
ABSTRACTTo provide nurses with an evidence-based Position Statement on the standards patients and visitors should expect when visiting an adult criticalcare unit in the 21st century in the UK. The British Association of Critical Care Nurses (BACCN) is a leading organization for critical care nursingin the UK and regularly receives enquiries about best practice regarding visiting policies. Therefore, in keeping with the BACCN’s commitmentto provide evidence-based guidance for nurses, a Position Statement on visiting practices in adult critical care units was commissioned. Thisbrought together experts from the field of critical care nursing and representatives from patient and relatives’ groups to review visiting practicesand the literature and produce a Position Statement. An extensive search of the literature was undertaken using the following databases:Blackwell Synergy, CINAHL, Medline, Swetswise, Cochrane Data Base of Systematic Reviews, National Electronic Library for Health, Institute forHealthcare Improvement and Google Scholar. After obtaining selected articles, the references from these articles were then evaluated for theirrelevance to this Position Statement and were retrieved. The evidence suggests a disparity between what nurses believe is best practice andwhat patients and visitors actually want. Historically, visitors have been perceived as being responsible for increasing noise, taking up space,taking up nursing time, hindering nursing care and spreading infection. The evidence reviewed for this Position Statement suggests there aremany benefits to patients and nurses from visitors. There was no evidence to suggest that visitors pose a direct infection risk to patients. Clearvisiting policies based on evidence will negate arbitrary decisions by nurses regarding who can visit and will lessen confusion and dispel mythswhich can only bring benefits to patients, staff and organizations. To make nurses aware of the physical and psychological benefits of visitingto patients. Visitors bring a positive energy to patients and can act as advocates. They can supply nurses with vital information about patientswhich will enable the nurse to provide more individualized care. Being cognizant of the evidence will help nurses develop policies on visitingwhich are up to date for the 21st century.
Key words: Adult intensive care • Needs • Psychological care of visitors • Psychological support for patients/carers • Relatives • Relative/spouse • Role of family in ICU
BACKGROUNDIntensive care units (ICU) have been established inthe UK since 1962 (Crocker, 2007). The Department
Authors: V Gibson, Teaching Fellow, Principal Lecturer, BACCN NationalBoard Professional Advisor, Department of Nursing, NorthumbriaUniversity, Newcastle, UK; C Plowright, Consultant Nurse Critical CareMedway NHS Foundation Trust, Lead Nurse Critical Care Kent andMedway Critical Care Network, BACCN National Board ProfessionalAdvisor, Anaesthetic Department, Gillingham, Kent, UK; T Collins, ICUClinical Educator, Maidstone Hospital, Maidstone, UK; D Dawson,Consultant Nurse Critical Care, St George’s Hospital NHS Trust, London,UK; S Evans, Senior Staff Nurse, ITU, Royal Berkshire Hospital, Reading,UK; P Gibb, Chief Executive, ICUsteps, Milton Keynes, UK; F Lynch, NurseConsultant, PICU, Evelina Children’s Hospital, Guy’s and St Thomas’ NHSTrust, London, UK; K Mitchell, Acting Managing Director, Centre for Nurseand Midwife-led Research, University College London and UniversityCollege London Hospitals, London, UK; P Page, Senior Lecturer,Department of Nursing, Anglia Ruskin University, Chemlsford, UK; GSturmey, Representative from The Patients and Relatives Committee of theIntensive Care Society, London, UKAddress for correspondence: C Plowright, Anaesthetic Department,Medway NHS Foundation Trust, Gillingham, Kent, UKE-mail: [email protected]
of Health (2000) modernized services and encouragedthe combination of Intensive Care and High Depen-dency Units into Critical Care Units and therefore thisis the term which will be utilized in this Position State-ment together with the abbreviation ICU. Critical CareUnits have long been recognized as highly stressfulenvironments. There is usually a ratio of one nurse toeither one or two patients (Bray et al., 2010) and inputfrom numerous medical teams and other professionals.Space is often limited and patients may be seriouslyill or may be dying. This set of circumstances on thecritical care unit has led to a long running debate aboutvisiting policy, with some believing in unrestrictedvisiting for relatives, whilst others strongly advocaterestricted visiting in terms of the number of individu-als allowed in at any one time and the times at whichvisiting can take place. Opinions of patients supportthat there are concerns with privacy and dignity andbeing overheard by other patient’s visitors (Whiteheadand Wheeler 2008).
Table 1 Standards on visiting in adult critical care units in the UK
Patients should expect:• To have their privacy, dignity and cultural beliefs recognized• Confidentiality• The choice of whether or not to have visitors• The choice to decide who they want to visit including children and other
loved ones• The choice of care assisted by their relatives• A critical care team who recognize 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 relevant information regarding critical illness, the critical care
environment and aftercare and support. This should be reinforced withwritten materials
• A separate area for private discussions with healthcare professionals• Involvement in patient care as the patient would wish• Written information regarding the unit procedures e.g. hand washing, times
of ward rounds• Information concerning patient progress on at least a daily basis• Information when there are any significant changes to the patient’s condition• Not have to wait for long periods of time in the waiting room without
regular updates• Access to interpretation facilities if needed
The British Association of Critical Care Nurses(BACCN) is a leading organization for critical carenursing in the UK and regularly receives enquiriesabout best practice regarding visiting policies. There-fore, in keeping with the BACCN’s commitment toprovide evidence-based guidance for nurses a PositionStatement on visiting practices in adult ICUs was com-missioned. This brought together experts from the fieldof critical care nursing and representatives from patientand relatives’ groups to review visiting practices andthe literature and produce a Position Statement. Thepurpose of this article is to summarize the main find-ings of the Position Statement on Visiting in AdultCritical Care Units in the UK. A full version of thedocument can be found on the BACCN website atwww.baccn.org.uk. Table 1 summarizes the Standardon visiting in adult critical care units in the UK.
METHODOLOGYIn developing this Position Statement, a comprehen-sive literature review was undertaken and the expertopinions and experiences of the group members werealso taken into consideration. The BACCN ProfessionalAdvisors asked for expressions of interest from theBACCN membership to be involved in writing thisPosition Statement. It was also vital to have input
from patients and relatives regarding their views onvisiting and this was facilitated through ICUsteps (acharity founded in 2005 to support patients and rel-atives affected by critical illness) and The Patientsand Relatives Committee of the Intensive Care Society(the Committee was established in 2004 to representpatients’ and relatives’ interests to the Intensive CareSociety). The expert group consisted of nurses whoworked in adult and paediatric critical care, whoworked in universities and people who had eitherbeen a patient or a relative in a critical care unit.
The literature review was undertaken by themembers of the expert group. The following searchdatabases were accessed: Blackwell Synergy, CINAHL,Medline, Swetswise, Cochrane Data Base of SystematicReviews, National Electronic Library for Health,Institute for Healthcare Improvement and GoogleScholar. The following search terms were used: openvisiting, closed visiting, restricted visiting, unrestrictedvisiting, relatives visiting, family visiting, care of familyand care of relatives.
In addition to these search terms the descriptor ofICU, ITU and critical care were also used to makethe search more specific to the literature review. Afterobtaining selected articles, the references from thesearticles were then evaluated for their relevance tothis Position Statement and were retrieved. Becauseof the complexities of translating papers, only liter-ature written in English was reviewed. The searchfound a number of articles that originated from a num-ber of different countries and professional journals.Although material from other countries has been uti-lized in the production of this Position Statement thePosition Statement is aimed at a UK audience. Ref-erences were reviewed between 1990 and 2011 in anattempt to ensure that the work was relatively cur-rent; older references were included if the expert panelconsidered them to be seminal pieces of work.
A search of the evidence revealed limited Level 1evidence on randomized controlled trials concerningvisiting (NICE, 2005). Indeed the study of visitingpolicies and practices perhaps does not lend itselfto positivist research methodologies alone but moretowards surveys and qualitative research methodolo-gies. Therefore, in order to raise the profile of visitingand produce some guidance for nurses a broad rangeof evidence has been reviewed in this Position State-ment. Expert opinion and formal consensus were alsoutilized as sources of evidence in its development. Inreviewing the evidence and producing this PositionStatement the expert panel have been cognizant of theAGREE (2009) tool for the appraisal of guidelines andapplied them when developing this Position Statement.
FINDINGSVisiting Policies and PracticesVisiting policies create a great deal of debate regard-ing whether visiting should be open (unrestricted) orclosed (restricted). Plowright (1996) found that manyICUs only allow two visitors at a time to each patient.Visitors are perceived to increase noise levels, take-upspace, take-up nursing time and hinder direct nurs-ing care (Plowright, 1998; Berti et al., 2007; Farrell et al.,2005; Quinio et al., 2002). Berti et al. (2007) reported thatnurses feel that a significant amount of time is takenup providing information to the family and that thiscan hinder direct nursing care and therefore nurses donot view open visiting in a positive way. Gurses andCarayon (2007) suggest that visitors are not a focusof care and they used a questionnaire to determinewhat ICU nurses saw as impediments to care andfound that time spent educating visitors, answeringtheir questions and taking telephone calls rated highly.Quinio et al. (2002) also found that visitors are seen asa drain on staff resources and time. Nurses seem to feelinteracting with visitors makes their job more difficult(Levy, 2007).
Not only are restrictions placed on the number ofvisitors and the times of visiting but also what visi-tors may wear. In Hunter et al.’s (2010) survey of ICUvisiting, infection control issues were mentioned – allunits required some form of hand cleaning, and in10 (of 206 that answered), visitors are expected towear gowns. Giannini et al. (2008) report there is noevidence for asking visitors routinely to wear gownsand notes that this reinforces the idea of visitors ‘notbelonging.’
Are there Benefits to Patients forRecommending Unrestricted Visiting?Patients felt a positive energy from their visitors andthat their rights were protected through visitors actingas advocates (Bergbom and Askwall 2000; McAdamet al., 2008). Nurses can gain a lot of useful informationfrom visitors thus providing more individualized carefor patients (McAdam et al., 2008; Williams, 2005;Marco et al., 2006; Gonzalez et al., 2004). As well aspsychological well-being visitors may have a positivephysiological effect in aiding the weaning process(Happ et al., 2007). However, some patients foundvisitors disruptive to rest and that they intensifiedpain (Carroll and Gonzalez 2009). There is no evidenceto suggest that visitors pose a direct infection riskto patients (Adams et al., 2011; Fumigalli et al., 2006;Tang et al., 2009). The expert group who developedthis Position Statement consider that it is importantto respect the rights of patients and allow patients todecide whether or not they want visitors.
What Visiting do Visitors Want?The literature clearly demonstrates that the physicaland psychological well-being of visitors is an importantissue. Visitors need to feel welcome, and the level ofICU provision for visitors suggests how importantvisitors are perceived to be by the ICU staff they arevisiting (Rashid, 2006). Visitors find waiting isolating,distressing and frustrating (Bournes and Mitchell2002). They spend a great deal of time in waitingrooms and therefore the comfort of the waiting roomis important. Access to overnight accommodation inthe vicinity of the ICU, refreshments, a bathroom,a telephone and a private discussion room forconsultation with ICU staff were also reported asimportant. (Kutash and Northrop 2007; Deitrick et al.,2005; Fridh et al., 2009; Lederer et al., 2005).
Information Staff Should have about Relativesof PatientsCritical Care staff require accurate information aboutvisitors including who is the next of kin, who will actas a point of contact and phone numbers. Visitors canprovide information about the patient which may helpdirect treatment. Staff need to be cognizant of legis-lation and other information concerning, vulnerableadults, child protection and cultural diversity.
Should Children be Allowed to Visit an AdultCritical Care Unit?Dealing with child visitors to the adult critical careenvironment is a particular source of stress and uncer-tainty for staff working in critical care areas. A visit bya child can offer a diversion and help patients feel safe(Hupcey, 2000). Patients found visits by children main-tained the patient’s social identity (Gjengedal, 1994).Children cope with visiting an adult patient in ICU(Knutsson et al., 2008) as long as they are supportedby their parent or guardian and staff. However, criticalcare staff do need support and education to help themfacilitate child visitors to the adult ICU (Clarke andHarrison 2001).
Should Pets be Allowed to Visit the CriticalCare Unit?Pets visiting the ICU is another controversial area.However, in the current era where ‘family’ is hard todefine a patient may have no next of kin and may livewith a much beloved pet. Pets bring physical, social,psychological and general health benefits to people(Halm, 2008). Animal-Assisted Therapy and Pet Ther-apy Schemes are fairly well established but visitationby a patient’s own pet is less so (Connor and Miller2000; Giuliano et al., 1999; Hooker et al., 2002). Connor
and Miller (2000) suggest that many nurses met thisneed by sneaking animals into the hospital or bringingthem to a window. There is evidence to support the factthat animals may spread infections (Brydon, 2008) yetBrodie et al. (2002) following their review concludedthat sharing our lives with animals, either at home orin hospital, far outweighs the risks. Infection controlmay be an issue but critical care units should considerletting pets in to visit as long as it is appropriate, sensi-ble infection control precautions are taken and the visitis limited to the pet’s owner only.
What Education is Required by Nurses toUnderstand the Role and Purpose of Visitingwithin Adult Critical CareThe opinion of the expert group is that the importanceof visiting needs to be included in both pre-registrationand post-registration education curricula. There hasbeen a general call for Higher Educational Institutionsto address more intensively the importance of visitingpolicies and to facilitate the development of higherreflexive competencies (Juchems et al., 2008). The opin-ion of the expert group is that the all staff commencingwork within critical care units should receive edu-cational input through induction programmes high-lighting the needs of family members and how thoseneeds can be met effectively. Effective role modellingby senior staff members can be particularly powerfulin educating junior members of the critical care team(Linton and Farrell 2009).
DISCUSSIONThis Position Statement was developed with the aim ofproviding evidence for critical care nurses in the UK toestablish appropriate and evidence-based visiting poli-cies following requests from members of the BACCNfor advice on visiting policy. The evidence suggests adisparity between what nurses believe is best practiceand what patients and visitors actually want.
In the past, visitors were perceived as beingresponsible for increasing noise, taking up space,taking up nursing time, hindering nursing care andspreading infection (Plowright, 1998; Berti et al., 2007;Farrell et al., 2005; Quinio et al., 2002). The evidencereviewed for this position statement suggests there aremany benefits to nursing and other staff from visitors.There was no evidence to suggest that visitors posea direct infection risk to patients (Adams et al., 2011;Fumigalli et al., 2006; Tang et al., 2009). In additionthe evidence suggested, there were many benefits topatients from visitors which included psychologicalwell-being, protection of rights, aiding in the weaning
process and reduction in cardiovascular complications(Happ et al., 2007).
Dealing with child visitors to the adult critical careenvironment remains a particular source of stress anduncertainty for staff working in critical care areas.There are often no clear hospital guidelines or policiesregarding children visiting an adult ICU. The evidencereviewed in this Position Statement suggested visitsby children can offer a diversion and help patientsfeel safe and maintain patient identity (Hupcey, 2000;Gjengedal, 1994). Critical care staff need support andeducation to help them facilitate child visitors to theadult ICU and children need to be prepared for thevisit (Clarke and Harrison 2001).
Pets visiting the ICU is another controversial areaand whilst this position statement is not advocatingturning the ICU into a menagerie the judicious facili-tation of pets visiting individual owners may providea massive psychological boost for the patients andremind them of the normality of life outside of the ICU.
The importance of visiting needs to be includedin both pre and post-graduate education curricula.All staff commencing work within critical care unitsshould receive educational input through inductionprogrammes highlighting the needs of family membersand how those needs can be met effectively.
CONCLUSIONThis Position Statements sets out the standards patientsand visitors should expect when visiting an adultcritical care unit in the 21st century in the UK anddemonstrates that visitors provide many benefits topatients and staff. Clear policies on visiting practicesbased on evidence will negate arbitrary decisionsby nurses regarding who can visit, and will lessenconfusion and dispel myths which can only bringbenefits to patients, staff and organizations. For afull version of the Position Statement please visitwww.baccn.org.uk
ACKNOWLEDGEMENTSThe authors thank Barry Williams representativefrom The Patients and Relatives Committee of theIntensive Care Society, and Margaret Douglas andPatricia Delaney for reading and feedback on draftdocument.
CONFLICT OF INTEREST STATEMENTThe production of this Position Statement was fundedby the British Association of Critical Care Nurses. Theauthors received no financial gain and have no conflictof interests.
• Visiting policies and practices create a great deal of debate and differ from area to area.• Nurses act as gate keepers and their views on visiting often differ from what patients and relatives want.• Many issues remain controversial and are administered in a haphazard fashion because nurses are unsure of the evidence.
WHAT THIS PAPER ADDS
• This paper represents an extensive literature review into visiting policies and practices and covers the published evidence of the wishes ofpatients and relatives.
• This paper offers evidence-based guidance on many aspects of visiting to nurses in Adult Critical Care Units in the UK.
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