Families in Critical Care

T RADITIONAL/RESTRICTIVE
VS PATIENT-CENTERED
INTENSIVE CARE UNIT
VISITATION: PERCEPTIONS OF
PATIENTS’ FAMILY MEMBERS,
PHYSICIANS, AND NURSES
By Bettina H. Riley, RN, PhD, Joseph White, RN, DNP, NE-BC, Shannon Graham,
RN, DNP, and Anne Alexandrov, RN, PhD, CCRN, NVRN-BC, ANVP-BC

Background Patient-centered intensive care units (ICUs) are

This article is followed by an AJCC Patient Care Page
on page 325.
©2014 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ajcc2014980
advocated by professional organizations for critical care nursing
and medicine. The patient-centered ICU paradigm recognizes
the patient-family unit as inseparable and supports visitation
designed to meet the needs of patients and patients’ families.
Objectives To understand perceptions about patient-centered
ICUs among patients’ family members, physicians, and nurses
from 5 ICUs that had restrictive visitation and to guide devel-
opment of a patient-centered, open visitation paradigm.
Methods Patients’ family members, nurses, and physicians
from 5 ICUs with a traditional/restrictive visitation policy at a
southeastern academic, tertiary care hospital were invited to
participate in focus group meetings to understand perceptions
about patient-centered care. All qualitative work was taped,
transcribed, reviewed, and corrected after each session. Cor-
rected transcripts and observer notes were integrated and coded.
Results Patients’ families identified facilitators of patient-
centeredness as nurses’ and physicians’ communication,
concern, compassion, closeness, and flexibility. However,
competing roles of control over the patient’s health care served
as barriers to a patient-centered paradigm.
Conclusions Patient-centered care is an expectation among
patients, patients’ families, and health quality advocates. These
exploratory methods increased understanding of the powerful
perceptions of family members, physicians, and nurses involved
with patient care and provided direction to plan interventions to
implement patient-centered, family-supportive ICU services.
(American Journal of Critical Care. 2014;23:316-324)

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T
raditional, non-patient-centered environments prevent patients’ families from
visiting their loved ones except during predesignated, time-limited periods inter-
spersed throughout a long hospital day.1,2 Dissatisfaction with this traditional
visitation paradigm has pushed families to become more involved in their loved
one’s care with a greater focus on the transparency of health-care quality.3-11 This
focus is evidenced by calls to action for hospitals to examine their current intensive care unit
(ICU) visitation practices12-19 and to try entirely open, nonrestrictive ICU visiting, labeling any
visiting restrictions as a relic, unnecessary, and potentially harmful to the patient’s safety.13,14

Open visitation is among the defining ele-
ments of a patient-centered approach.12 Patient-
centered care revolves around the patient, not the
physician, nurses, or the facility, and is a priority
identified by the American Association of Critical-
Care Nurses (AACN).15 In addition, to achieve a
Magnet Recognition Program, exemplifying excellence
in nursing practice, hospitals must adopt a concep-
tual framework that includes family-centered care.16
Family-centered care and patient-centered care are
simultaneous approaches toward self-governance
of health care.11 Despite worldwide and national
priorities/standards incorporating families into the
decision making and care of ICU patients,10-19 as many
as 90% of ICUs in US hospitals have a restrictive
visitation policy.1
Restricted ICU visitation traditions foster
beliefs that visitors obstruct nursing and medical
care, exhaust patients, interfere with healing and/or
cause negative physiological effects, pose an increased
infection risk, jeopardize patients’ privacy, and create
unsafe environments.13,17,20-22 Other studies12,13,20,21,23-28
have shown contrary findings; family visitation con-
tributed to improved physiological measures and
About the Authors
Bettina H. Riley is an assistant professor at University
of South Alabama, College of Nursing, Mobile, Alabama.
Joseph White is a nurse manager in the heart lung trans-
plant unit at University of Alabama at Birmingham (UAB)
Hospital in Birmingham, Alabama. Shannon Graham is
Magnet program director and advanced nursing coordi-
nator, Center for Nursing Excellence, UAB Hospital.
Anne Alexandrov is assistant dean for program evalua-
tion, professor, and program director, doctor of nursing
practice and NET SMART, UAB School of Nursing and
UAB Comprehensive Stroke Research Center, Birming-
ham, Alabama.
Corresponding author: Bettina H. Riley, RN, PhD, University
of South Alabama, College of Nursing, Baldwin County
Campus, 161 North Section Street, Suite C, Fairhope,
Alabama 36532 (e-mail: briley@southalabama.edu).
lower stress for patients and increased job satisfac-
tion for nurses.
As this study was the first phase of a patient-
centered care project, the aims were to examine per-
ceptions related to traditional/restricted ICU
visitation among patients’ families, nurses, and
physicians, to understand barriers and issues, and
to gauge the generalizability of others’ work. Under-
standing the barriers to patient-cen-
tered care may support future
interventions aimed at reshaping the Open visitation is
current ICU culture to align with a among the defin-
patient-centered paradigm.
ing elements of a
Methods patient-centered
This study’s setting was an aca-
demic, tertiary care, Magnet Recogni- approach.
tion Program hospital with a level I
trauma center designation and 900 licensed adult
beds. Approval was obtained from the institutional
review board for human subjects research.
Five of 8 ICUs adhering to a traditional restric-
tive visitation policy were the focus of this project
(trauma, surgical, medical, neurosurgical, cardio-
thoracic surgery), each with 20 to 28 beds. All 5
units posted similar strictly enforced visiting hours,
limiting visitation to 2 people for 30-minute visits,
4 times a day.
Design
Focus Groups
Criteria for participation were as follows: the
family member’s patient must be 18 years or older
with a minimum ICU stay of 72 hours, and the
family member participant must be 18 years or
older, speak English, and must have visited the ICU
patient at least twice. Three family focus group
meetings were held on different days and preceded
2 focus groups for nurses and 1 focus group for
physicians that met on the same day. Participants

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 Table 1
Roles in the intensive care unit (ICU)

Role Function and examples

Patient’s Provide a calming effect:

family “I’ve asked them that when he starts to wake up, could I be in there because I know that when I’m with him I can have a
calming effect on him.”
Role as surrogate:
“I feel real safe and secure that they’re in there treating him, but I need to know sometimes, my husband’s in a paralytic
state so he can’t speak for himself, so I’m the one they need to be telling things [to] and keep me informed of what’s
going on with him.”
Provide motivation:
“I want him to hear my voice. I want to talk soothingly to him; I want to tell him, to motivate him to keep fighting.”
Provide reassurance:
“…having that loving family care, just to let them know that we’re here, that we didn’t just leave you here and let these
people take care of you. We’re still out here, and we still love you.”
Physician Not in support of open family visitation:
“Twenty-four hour visitation is not preferred. It is not possible.”
Role of the family prominent when [patient] discharged from the ICU:
“…it is an integral part of what we’ve done for that patient, have their family visit. It’s important for the family, because
the family is who’s going to take care of this patient when they make it out of the ICU.”
Opposition to open visitation seen as safeguarding the [patient’s] family and patient:
“I think it would be too stressful for many family members to see the scalpel being used to place a tube inside some-
body’s chest.”
Nurse Open visitation negatively affects patient care:
“…if I’m gonna spend an hour talking to [the patient’s] family, that is an hour of patient care that I’m not giving.”
Patient’s family should not be denied visitation:
“…the fact is, these patients, belong to family who care about them and who should not be denied the opportunity to,
have interaction, that, that’s my opinion.”

included attending physicians practicing in the ICUs
and nurses chosen from all shifts in the 5 ICUs.
Data Collection and Analyses
All focus group sessions were voice recorded
and facilitated by 1 group leader and 1 assistant.
Written informed consent was provided by all focus
group participants. Transcriptions from the voice-
recorded tapes were analyzed by following proce-
dures and guidelines developed by Lee et al,22
Dawson et al,29 and Miles and Huberman.30
Results
The focus groups consisted of 8 different female
family members representing 4 of the 5 ICUs; 2 male
physicians and 1 female physician represented rota-
tions in all but the surgical ICU; and 1 male nurse
and 6 female nurses represented all 5 ICUs. Feelings
and beliefs about families’ ICU visitation experiences
varied among the patients’ families, physicians, and
nurses.
Role of Families
Patients’ family members thought that they
knew their ICU family member better than anyone
and were in the best position to provide a voice for
and emotional support to their loved one (Table 1).
Through vigilant watchfulness, interpretations of
body movements or noises (eg, tracheotomy sounds,
facial expressions), and recognition of the patient’s
needs (eg, repositioning), the family member per-
formed, assisted, or initiated an intervention. As
surrogates, patients’ family members believed that
they “should always be involved” and should have
the opportunity to ask as many questions as neces-
sary to satisfy their decision-making needs. In addi-
tion, the physicians and nurses needed to explain
to them what was occurring with their family mem-
ber’s medical care (Table 1).
Physicians agreed that patients’ families had a
role in the ICU; they did not agree that this role
coincided with a stationary physical presence in the
ICU. Physicians were not in support of open family
visitation but viewed the role of patients’ families
as prominent once the patients are discharged from
the ICU (Table 1). Physicians saw themselves as
opposing 24-hour visitation to safeguard the
patients’ families and patients (Table 1).
Nurses were divided about the roles of patients’
families in the ICU, with beliefs ranging from oppos-
ing open visitation in the ICU, to stating that open
visitation would detract from patient care (Table 1),

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 Table 2
Communication

Role Function and examples

Patient’s Felt scared:

family “…it would be nice to have them every 2 or 3 days, or even…once a week would be nice, instead of waiting until it’s some-
thing major, and then they all crowd around you, you know like they’re fixing to take him to surgery…and they’re just
all there, like instantly come out from everywhere and you’re forced to make these decisions all at once. It’s kinda scary.”
Want health-care workers to demonstrate empathy, suggesting that they need:
“…some way to let them help touch the experience without actually ever having it.”
Communication process taken for granted:
“I’ve been here 7 weeks now. They would come in, when we would come in, ask us, if we had any questions or introduce
[themselves], if they were the nurse....now we’ve been here this long, sometimes they do, sometimes they don’t.” When
describing nurses caring for other patients as well as their loved one, this family member went on to say, “…they’ll
come in later cause they’d have to answer their main patient first. They seem not to, to want to share as much, I guess
you could say.”
Wanted more face time with their physician:
“…if they could make a time, or some, some way that the doctor could speak with you. I know they can’t speak with us
every day, but at least every 2 days.”
Physician No time to spare for family communication:
“My duty and my obligation is to that patient first, and not the [patient’s] family.”
Nurse Families became demanding:
“I think the longer the patient is there, the pickier the [patient’s] family gets, and it gets harder. It’s like daddy’s not getting
any better, so it must be your fault, … he’s not getting any better, cause you’re not taking care of him.”
“…that family member doesn’t understand that you cannot be over there to answer the questions.…you might say, ‘Hi,’
real quick, cause you have to be in this room…you know they’re dying.”

to the belief that patients belong to their families
who care about them and that patients’ families
should not be denied visitation opportunities. Nurses’
beliefs also included that the best examinations of
patients occurred when patients’ families were
present and that taking care of the patients’ family
might be the only gift that a nurse can give to a
dying patient (Table 1).
Communication
Patients’ families, physicians, and nurses believed
that sharing information about a patient’s health
status was important and necessary. Families felt
“panic” if their loved one’s health status was not
reported in a timely manner and felt scared making
caregiver decisions that were based on infrequent
medical updates (Table 2). Families felt comforted
when greeted with personal inquiries and given a
progress report on their loved one’s condition. In
addition, patients’ families wanted health status
information delivered from the physician, referenc-
ing “adequate” delivery from nurses but that physi-
cians were the only ones who could provide certain
information (eg, prognosis).
Communication content was also important.
One family member anticipated her husband’s dis-
charge when told that her husband was “stable,” but
the physician stated, “No, stable means ‘critically
stable’ in the ICU”; the family member labeled
“critically stable” as a “new word” but paradoxical.
Another family member stated that health care
workers needed to “learn how to talk to patients’
family members” and to demonstrate empathy
(Table 2). One family member mentioned that the
longer the ICU stay, the more the
communication process was taken
for granted (Table 2).
Nurses believed
Physicians shared beliefs that that the best
patients’ families, as the primary
caregivers outside the ICU, should
examinations of
receive detailed information about patients occurred
patients. Yet, physicians also
believed their primary obligation when patients’
was to patient care. Physicians stated families were
that making rounds included acute
interventions and there was no time present.
to spare for communicating with
patients’ families (Table 2), and as teachers, they
attributed their time constraints to new, stricter,
rounding schedules for their resident physicians.
Physicians stated that communication with patients’
families could be delegated to other members of
the health-care team (eg, resident physicians, nurses).
Nurses believed that they were advocating for
patients when they sought information from physi-
cians, from patients’ medical reports, and shared it
with patients’ families, but felt that depending on
the hospital unit, in addition to workload, emergent

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 Table 3
Convenience and flexibility of visiting times in the intensive care unit (ICU)

Role Function and examples

Patient’s The wait to visit perceived as a helpless period:

family “You’ve had to care for someone as deeply as we do, and then wonder what’s going on, on the other side of that door…
feel so helpless.”
Nurses and physicians needed time to perform procedures or medical routines:
“…I’m okay with that, but you know I’d stay in there all the time, stand in the corner somewhere.”
Delay visitation:
“… he was naturally asleep and…I know that when a sick person is asleep their body is healing better then, so I don’t
want to wake him up,” or if they became overwhelmed, “… he’s never been in ICU before…and I couldn’t stay, somedays
I didn’t even stay in their 5 minutes, because of his condition, and I could not cope with it.”
Special visits:
“…he may not make it…time is very precious right now.”
Visitation times:
“…very tiring being here from early in the morning to that late at night, and the first morning visit was too late in the day;
…I know that in the mornings they’re probably doing the baths and getting everything ready, but when you can’t see
somebody ‘til 10:30 AM, sometimes that’s a little late for me.”
Physician Patients’ rights as a barrier to open visitation:
“Our ICUs are not set up logistically to allow throughput of people at any time of the day and protect patients’ rights.”
Nurse Family naïve of actual needs and health status of patient:
“We make ‘em look good, we clean ‘em up, we prop their hands up on pillows, they look perfect…and they think they’re fine.”

situations were a barrier to timely communication
with patients’ families (Table 2). Nurses also believed
that the longer a patient’s ICU stay or when the
patient’s condition had deteriorated, the more
demands from patients’ families (Table 2).
Convenience and Flexibility of Visiting Times
Patients’ families, physicians, and nurses were
far from similar in their beliefs about visitation. An
ICU family described the wait to visit as a period of
being helpless (Table 3). Patients’ families preferred
to have access to visitation on a continual basis but
expressed an understanding that nurses and physi-
cians needed time to perform procedures or medical
routines (Table 3).
Patients’ families wanted options to delay or
postpone visitation when the patient was unavail-
able (eg, asleep, undergoing a procedure); patients’
families feared that the patient might not survive
procedures (Table 3). Furthermore, patients’ family
members did not prefer visitation times at or later
than 8:30 PM or before 10:00 AM, believing that the
late evening times placed them in an unsafe inner
city environment and the late morning time was
too late in the day (Table 3).
Physicians believed that 24-hour visitation was
“not preferred; not an option.” In addition, physicians
stated that providing procedural oversight/instruction
to residents or medical students might reduce the fam-
ily’s confidence in the delivery of medical treatment.
Physicians also identified patients’ rights as a barrier
to open visitation (Table 3). However, physicians
were not opposed to some flexibility in visitation,
recognizing that when patients’ family members
first arrive from out of town, or any time after a sur-
gery or procedure, they may need additional visita-
tion time “to see . . . that their loved one’s okay.”
Nurses were varied in their feelings about open
visitation. Some endorsed open visitation, believing
that patients’ families are naïve of patients’ needs
and health status when allowed only “snapshots in
time” (Table 3). Furthermore, if exposed to a med-
ical procedure, families might understand better the
complexities and demands of ICU care; if at the
bedside longer, they could assist with activities of
daily living. However, other nurses thought that if
patients’ families were there longer, nurses’ work-
load would increase, while others believed that open
visitation did not necessarily equate to constant
bedtime presence because patients’ families would
visit only intermittently. Many nurses had a flexible
visitation approach, allowing substituted visits for
missed visits, an extra visit before a procedure, or
prolonged visits.
Confidence, Trust, and Relationships
Patients’ families qualified their perceptions
about ICU visitation on the basis of the individuals
involved. Ideals or “favorites” were identified by
patients’ family members as those nurses who were
compassionate, caring, professional, knowledgeable,
flexible, informative, accessible, approachable,

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 Table 4
Confidence, trust, and the relationship with nurses and physicians

Role Function and examples

Patient’s Ideals or “favorites” were identified by family members; better outcomes:

family “I don’t go home unless she’s going to be on duty those 2 days. That’s how confident I am in her, I really am.”
“Well, I can tell you that my patient has had some favorites, and you can tell the ones that are so good because his num-
bers (physiological measures on the bedside monitor) look better...”
Offering advice – inappropriate role:
“A nurse who I had never spoken to before…told me that I needed to consider just how long we were going to keep him
on life support, that…I need to have a talk with him and we needed to decide just when we were going to take him off
of life support.” Continuing, this family member stated, “And it still upsets me, because when we started this ordeal, his
primary care doctor told me, ‘sometimes in a case like this we reach a point where there’s nothing else that we can do.’
And he said, ‘if that time comes, I will be the one to come and discuss it with you.’”
Frustrated with lack of relationship with the physician:
“…they know when the visiting hours are. And they don’t have a problem doing a procedure when it’s visiting hours…they
could take the time to come and spend it with the family.”
Physician Not enough time:
“If I were rounding and taking care of patients and the family member stopped me for every single question they wanted
to know, I wouldn’t be able to deliver adequate care to the next person…it’s just not physically possible…I want to help
the family…but that is my secondary concern.”
Too many physicians seeing a patient in an academic facility:
“…the patient is not necessarily being seen by the same doctor every day, the same resident, so there’s a lack of continu-
ity…that inhibits their ability to feel truly connected and configured into the plan.”
Nurse Instruct family about the family member’s conduct during the visit:
“I think as nurses we have to…say, ‘let’s have a quiet visit…I know that you want to visit with her, but this may be an
appropriate time to just hold their hands, and just accept the fact that they’re gonna sleep, and I would appreciate it if
you would let them sleep.’ …I’ve done that so many times as a bedside nurse, and I think they appreciate that as long as
you give them a reason why.”
Family aggression and conflict were common:
“…in a trauma setting…we have family members that come up that are fighting mad.” “And there have been nights
where if there was not a door between us and them, they would come after us.”
Feelings of being “policed”:
“…it doesn’t matter if they come from whatever kind of nursing background, or social work background…they’re policing us.
That’s their job, and they’ll stand at the bedside to police us, to make sure we’re doing what we’re supposed to do.”
Provide too much education and at inopportune times:
“…sometimes I feel that our education comes at inopportune moments…we inundate them with all of this information
and then expect you to understand every time you come in…every time you call…it seems like we expect people to
understand way too fast.”

available, funny, and trustworthy (Table 4). In con-
trast, patients’ families identified unprofessional
behaviors of providing no explanation when barred
from visiting or when a nurse new to the family
member provided unsolicited, disturbing “advice”
about removing her husband from life support after
he had started treatment with dialysis only 4 hours
earlier (Table 4). Furthermore, patients’ family
members stated that nursing care was better when
the patient to nurse ratio was 1 to 1.
Patients’ families wanted a better relationship
with more face time with their physician, recogniz-
ing that there could be numerous physicians involved
in the care of their loved one (Table 4). One family
member was frustrated with not seeing the doctor
at least during visitation and another wanted, aside
from emergency communications, weekly updates.
The physicians wanted the patients’ families to
know that the physicians were accessible, but the
physicians believed that they did not have the time
to spend with patients’ families and still accomplish
their priority: direct patient care (Table 4). Existing
relationships were often not face to face, and
although physicians expressed a preference to meet
in person initially, doing so was not a priority and
phone contact after rounding was seen as a practical
way of responding to the concerns of patients’ fami-
lies. Physicians agreed with patients’ families that
the volume of physicians seeing a patient in an aca-
demic facility was a barrier to an ideal relationship
between physicians and patients’ families (Table 4).
ICU nurses described their relationship with
visiting patients’ family members on the basis of the
individual, with each having “completely different”

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 expectations such as undivided and complete avail-
ability of the nurse. Unfulfilled expectations of
patients’ families might result in complaints to the
nurse’s manager. In 1 case, a patient’s family did
not believe a diagnosis and a repre-
sentative was chosen to look at the
A nurse-led patient’s records to “make sure that
initiative showed we’re doing our job like we’re sup-
posed to,” leading to feelings of
that participation being “policed” (Table 4). Further-
of patients’ more, nurses felt “frightened by the
situations that patients bring with
families did not them to the hospital,” such as fights
significantly slow between family members and visitors
“threatening to finish the job” and
down rounds. assumed the responsibility of “keep-
ing people safe, that’s the biggest
thing ever.” Several nurses also reported being phys-
ically injured by families of patients and feeling
unsafe at work.
Discussion
The aims of this study were to understand the
barriers to patient-centered care. Understanding the
barriers will aid in the design and implementation
of patient-centered milieus.
Role of Families
Empowerment of patients’ families is essential
in advancing family roles in a patient-centered care
environment.31 The integration of patients’ families
in physicians’ rounds benefits the families’ surro-
gate decision-making and patient care processes.7
In spite of the physicians’ and nurses’ stance that
open visitation was a barrier to patient care, a nurse-
led initiative showed that participation of patients’
families did not significantly slow down rounds,
but eliminated the need for lengthy family confer-
ences.32 However, Cypress,33 in her review of the lit-
erature, stated that sparse research in this area called
for advanced practice nurses to exam-
ine the roles of patients’ family mem-
Implementation of bers, physicians, and nurses during
a partnership unrestricted visiting, rounds, and
end-of-life situations.
model of care may
reduce communi- Communication
Effective communication, being
cation deficits. empathetic and available, avoiding
personalization, and listening thera-
peutically are integral parts of patient-centered care.34,35
Deficits in physicians and nurses’ availability, engage-
ment, and therapeutic communication found here
could be addressed by the implementation of a
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partnership model of care, which has reduced com-
munication deficits and improved role confusion in
other settings.32 By providing a welcoming environ-
ment, involving patients’ family members in ICU
operations with open visitation, bedside reporting,
manager rounding, including patients’ family mem-
bers in physician rounding, enabling patients’ fami-
lies to call for a rapid response team and request an
ethics consultation, this model conserved time for
physicians contributing hours back to direct patient
care, and improved evaluations of communication
between patients’ families and nurses and job satis-
faction scores among nurse managers.
Ratings by patients’ families (not physicians or
nurses) of satisfaction with ICU team communica-
tion were increased by addition of a family support
person,36 indicating the need to determine further
what barriers to communication exist for physicians
and nurses. Furthermore, the intervention of a
communication facilitator (nurse or social worker)
revealed that the breakdowns in communication
were more common and serious after ICU dis-
charge, the opposite of what physicians here thought
was most important,37 suggesting that a communi-
cation process initiated before a patient’s’ discharge
should be examined to prevent a total disconnect
with the patient.
Burnout in nurses could be the answer to the
decline in health-care workers’ communication that
patients’ families experienced with longer stays in
the ICU and the increased caregiver burden experi-
enced by patients’ families who had members with
extended ICU stays. Among the reasons for burnout
in nurses and physicians are relationships between
coworkers and supervisors, conflicts with patients,
and caring for dying patients.38 Placement of a clini-
cal nurse specialist who provides education about
working with patients in difficult situations and
burnout assists in reducing burnout and increasing
job satisfaction among nurses.39
These findings also supported quality-of-life
discussions in the ICU that were not regularly rec-
ognized, managed, or appropriately discussed.40
Consideration should be given to training staff in
communications related to end of life by using
techniques40 such as forming a support team or use
of bereavement carts stocked with information and
resources, hand casts, and books on grieving.32
Convenience and Flexibility of Visiting Times
Viewing visitation as a privilege, not a right,
was not uncommon in the ICUs, where the nurses
were clearly in charge of visitation and where, depend-
ing on the nurse’s attitude, some families clearly
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benefited, while others experienced stress from rigid
rules. Open visitation installed through a partnership
model of care using a major change intervention
facilitated this major culture shift.32 Use of this same
model allowed reduction in ICU interruptions stem-
ming from outside sources (eg, phone calls) by 40%,
and practical needs (food, hotels, pillows, blankets)
were addressed by support personnel rather than
clinical staff.32,36 Physicians’ concerns related to resi-
dents practicing in an open visitation environment
remain an area of needed research.
Confidence, Trust, and Relationships
Patients’ families in this study and in a similar
study41 valued trust of the health-care provider; how-
ever, confidence, trust, and relationships between
patients’ families, physicians, and nurses varied from
intimate to nonexistent. Role confusion and poor
communication contribute to poor outcomes in
these areas between these key stakeholders.35 One
study’s intervention that improved these relation-
ships was focused on physician and manager round-
ing with patients’ families.32 Researchers in other
studies36 reported that establishment of a family-
support position assisted patients’ families in com-
munication and resulted in higher satisfaction ratings
among patients’ families.
To assist ICU nurses working under duress
from abusive families of patients, a communication
tool that includes suggestions for behavioral inter-
ventions42 was recommended. Supervision of the
clinical staff by a clinical nurse specialist helps resolve
difficult situations and increase job satisfaction,
reduce burnout, and increase retention.39 In addition,
the unresolved distress and emotional intensity dis-
closed in these sentinel events signal a need for
nurses’ debriefing, possible counseling38,43 and admin-
istrative management of unsafe working conditions.
This study provided data about a gap in the lit-
erature regarding roles, communication, and rela-
tionships of the trio of families of ICU patients,
physicians, and nurses. Our findings were not unlike
the results reported by others who have explored
some aspects of intensive hospital visitation poli-
cies,3-9 making a number of solutions applicable to
aid movement toward a patient-centered model.
Limitations
Patients’ families were reluctant to express the
truth because of fear of retribution: “I don’t want to
get her into trouble for fear, you know, she’d be left
there with him.” Patients’ families, physicians, and
nurses had difficulty scheduling participation because
of their perceived need to remain near the ICU.
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Generalizability of findings is limited, future
research should include more males in focus groups
and contrast and compare findings among patients’
families, nurses, and physicians on units that do
and do not embrace a patient-centered philosophy.
Conclusions
These exploratory methods have shown merit
in understanding the issues, potential barriers, and
needs of patients’ families, nurses, and physicians
related to ICU visitation at a large, academic, terti-
ary care, inner city, medical center. These findings
are essential for building meaningful and impactful
change interventions as part of a project aimed to
embed a patient-centered ICU culture throughout
the hospital.
FINANCIAL SUPPORT
A University of Alabama at Birmingham School of Nursing
Dean’s Scholar Award was provided to Dr Alexandrov
as support for this project.
eLetters
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SEE ALSO
For more about family presence in critical care, visit the
Critical Care Nurse Web site, www.ccnonline.org, and
read the article by Bishop, et al, “Family Presence in
the Adult Burn Intensive Care Unit During Dressing
Changes” (February 2013).
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Traditional/Restrictive vs Patient-Centered Intensive Care Unit Visitation: Perceptions of
Patients' Family Members, Physicians, and Nurses
Bettina H. Riley, Joseph White, Shannon Graham and Anne Alexandrov
Am J Crit Care 2014;23 316-324 10.4037/ajcc2014980
©2014 American Association of Critical-Care Nurses
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