1. Miracle, Vickie A. EdD, RN, CCRN, CCNS, CCRC, Editor, DCCN

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Have you ever had one of those problems that you believe is solved only to have it rear its ugly head again? This is exactly how I feel about critical care visitation. I have been a critical care nurse for almost 30 years. During that time, I have seen (in this order) very restricted visitation, flexible visitation, open visitation, less restrictive visitation, open visitation at the nurses' discretion, and not back to restricted visitation. What happened? Those of you who know me realize I am a huge supporter of open visitation at the discretion of the nurse and family-focused care. I thought that after over 30 years of research done by some of the most experienced nurse researchers, these issues of visitation and family-focused care had been resolved once and for all.1-7 I was wrong.


Recently a very good friend of mine was hospitalized with a life-threatening illness in an intensive care unit. He has been estranged from his immediate family for several years and relies on his friends as his support system. I was relieved to hear which hospital he was in because I knew they had very flexible visitation based on the patient's condition. Or so I thought.


Imagine my dismay when I arrived at the intensive care unit and was told that visitation was limited to two immediate family members for 10-15 minutes at a time 4 times a day. I had arrived between those sessions and was denied entrance for 2 reasons: (1) it was not visiting time, and (2) I was not a member of his immediate family. I attempted to explain to the nurse that he had no immediate family who would visit, only close friends. When that did not work, I tried to explain the research about visitation. All of this was to no avail. She closed the door in my face. So I waited until visiting time but was still denied entrance because of the immediate family rule. Luckily after several close calls, he was transferred to another unit and I was able to visit with him. He had no idea I had tried to visit earlier.


I was totally shocked and dismayed about the situation. What had occurred in this facility in a period of just a few months that made them cease flexible visitation and return to more restrictive visiting policies. I really believed this battle was over but, clearly, I was wrong.


Research has shown that visitation and family-focused care is good for the patient (majority of the time). There are always exceptions. In my early years as a critical care nurse, restricted visitation was the rule, and, as a new nurse, I followed the policy. After some experience, I realized that families (and friends) can play an important part in the patient's recovery. Because of reasons particular to the unit in which I worked, I was unable to accommodate flexible visitation as much as I wanted. To me, however, the family was critical to the patient's recovery. The final straw came one evening when I allowed the family of a patient with a do-not-resuscitate order to remain at his side while he died. It was a peaceful experience and the family was very grateful. It was a defining moment for me. I still hear from the patient's family from time to time. However, the next morning, the nurse manager reprimanded me because I had allowed the family to stay with the patient. While the other nurses in the unit supported by decision, the patient's physician complained. He was only there to pronounce death. The family was never in his way. Shortly after this situation, I resigned from that facility to work in one that was more family-friendly. Then I started to read research about the importance of families and eventually did research of my own on this subject.



One study examined how patients perceived visitation. The sample size was 62 patients. The patients' perceived visitation offered reassurance and comfort and had a calming influence. Even so, these patients preferred shorter visiting times, but not specifically at the same time each day. In other words, they wanted flexible visitation to meet their needs and the needs of their family.1


Molter's seminal study in 1979 first examined the needs of families of critically ill patients. This was the first study to look at the needs of families of critically ill patients and is cited most often by authors writing on this topic. She said that families needed to have hope and desired to be close to their critically ill loved one.2 I believe this started the movement to examine less restricted visitation in critical care units. She identified the need. Now it is time for critical care nurses to plan interventions to meet these needs, which could include family conferences, involvement with patient care, and less restrictive visitation.


Another study discussed the concept of family-focused care on the baasis of the needs of patients and families. These authors also allowed for the possibility of an extended family and the need for visitation as well, and not just what is traditionally considered the immediate family. Once again, these authors reiterated the need for proximity to the patient and increased interaction between the patient, family, and nurse. Benefits of this include, but are not limited to, improved communication, reduced anxiety, and improved rest for both the patient and family. They believe that this increased interaction was actually one of the most rewarding acts for the nursing staff.3


There is a growing movement in support of family presence during resuscitation. While this is an important issue, I will not go into great detail about it in this editorial. There is much research in this area and most agree that it should be the decision of the family as to whether or not they would like to be present. These families need significant information from the nurse about the resuscitation process.4


Another report stressed the importance of involving the family in the patient's care but stressed the need to assess each situation individually. Flexibility is critical. What works for one patient and family may not work with another. However, no matter what the situation entails, increased communication with the family and being flexible is crucial. Having a family member at the bedside 24 hours a day may not be in the best interests of the patient, family, or nurse. Explain to the family that patients need rest and what is in the best interests of the patient. Be flexible, but also be consistent.5


Henneman and Cardin wrote an excellent article on family-centered care and how to incorporate this concept into daily nursing care.6 They also stressed the need for flexible visitation policies in an effort to provide comfort to the patient and information to the family.


Another study attempted to identify variables present in a critical care nurse that may affect his or her beliefs about flexible visitation. The authors looked at age, sex, length of experience as a critical care nurse, experience either as a patient in critical care or having a loved one as a patient in critical care, and education. While most of the nurses supported some type of flexible visitation (51.4%), it was still viewed skeptically by many of the respondents. Some nurses felt that families just got in the way and asked too many questions. The study found that nurses with higher education levels favored flexible visitation. However, the less experienced nurses favored flexible visitation more than those nurses who had more experience in the area. The authors recommended further education of the nurses, trial periods of less restrictive visitation, and the promotion of an environment that was family-friendly.7


In summary, there is no way I can present all of the research and articles written about this subject in this column. Flexible visitation and family-centered care is here to stay. What is most important is that most nurses realize the importance of these issues in the patient's care. We must recognize that the idea of a family is more than the traditional view of the family and that families are critical to a patient's recovery.



So now you know my feelings about visitation and family-centered care. I truly believe that in most cases, flexible visitation at the discretion of the nurse is good for the patient and family. Of course, this is based on the individual needs of the patient, family, and nursing staff. While sometimes visitation may be inconvenient for the nurse, our goal is to provide the best possible care for the patient. If this means allowing more visitation at different times, so be it. Remember, you cannot go wrong doing what is in the best interests of your patient. The rewards are well worth it. If your unit does not offer flexible visitation and you believe it should, work with your colleagues to achieve this goal. If you need help, call me.




1. Gonzalez CE, Carroll DL, Elliott JS, Fitzgerald PA, Vallent HJ. Visiting preferences of patients in the intensive care unit and in a complex care medical unit. Am J Crit Care. 2004;139(3):194-197. [Context Link]


2. Molter NA. Needs of relatives of critically ill patients: a descriptive study. Heart Lung. 1979;8:332-339. [Context Link]


3. Cullen L, Titler M, Drahozal R. Family and pet visitation in the critical care unit. Crit Care Nurse. 2003;23(5):62-66. [Context Link]


4. Mason DJ. Family presence: evidence versus tradition. Am J Crit Care. 2003; 12(3):190-192. [Context Link]


5. Puz D, Tracy MF. Getting to best practice on visiting time-yes, but[horizontal ellipsis]. AACN News. 2002;19(5):7. [Context Link]


6. Henneman EA, Cardin S. Family-centered critical care: a practical approach to making it happen. Crit Care Nurse. 2002;22(6):12-19. [Context Link]


7. Stiles A, Miracle V, Basham K, Wigginton M. Variables which affect a critical care nurse's attitude toward visitation. Ky Nurse. 1996;44(3):25. [Context Link]