Traditional/Restrictive vs Patient-Centered Intensive Care Unit Visitation: Perceptions of Patients' Family Members, Physicians, and Nurses

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doi: 10.4037/ajcc2014980 2014;23:316-324Am J Crit Care Bettina H. Riley, Joseph White, Shannon Graham and Anne AlexandrovPerceptions of Patients' Family Members, Physicians, and NursesTraditional/Restrictive vs Patient-Centered Intensive Care Unit Visitation:

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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) areadvocated by professional organizations for critical care nursingand medicine. The patient-centered ICU paradigm recognizesthe patient-family unit as inseparable and supports visitationdesigned to meet the needs of patients and patients’ families. Objectives To understand perceptions about patient-centeredICUs among patients’ family members, physicians, and nursesfrom 5 ICUs that had restrictive visitation and to guide devel-opment of a patient-centered, open visitation paradigm. Methods Patients’ family members, nurses, and physiciansfrom 5 ICUs with a traditional/restrictive visitation policy at asoutheastern academic, tertiary care hospital were invited toparticipate in focus group meetings to understand perceptionsabout 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 servedas barriers to a patient-centered paradigm.Conclusions Patient-centered care is an expectation amongpatients, patients’ families, and health quality advocates. Theseexploratory methods increased understanding of the powerfulperceptions of family members, physicians, and nurses involvedwith patient care and provided direction to plan interven tions toimplement patient-centered, family-supportive ICU services.(American Journal of Critical Care. 2014;23:316-324)

TRADITIONAL/RESTRICTIVE

VS PATIENT-CENTERED

INTENSIVE CARE UNIT

VISITATION: PERCEPTIONS OF

PATIENTS’ FAMILY MEMBERS, PHYSICIANS, AND NURSES

©2014 American Association of Critical-Care Nursesdoi: http://dx.doi.org/10.4037/ajcc2014980

Families in Critical Care

316 AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2014, Volume 23, No. 4 www.ajcconline.org

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Open visitation is among the defining ele-ments of a patient-centered approach.12 Patient-centered care revolves around the patient, not thephysician, nurses, or the facility, and is a priorityidentified by the American Association of Critical-Care Nurses (AACN).15 In addition, to achieve aMagnet Recognition Program, exemplifying excellencein nursing practice, hospitals must adopt a concep-tual framework that includes family-centered care.16

Family-centered care and patient-centered care aresimultaneous approaches toward self-governanceof health care.11 Despite worldwide and nationalpriorities/standards incorporating families into thedecision making and care of ICU patients,10-19 as manyas 90% of ICUs in US hospitals have a restrictivevisitation policy.1

Restricted ICU visitation traditions fosterbeliefs that visitors obstruct nursing and medicalcare, exhaust patients, interfere with healing and/orcause negative physiological effects, pose an increasedinfection risk, jeopardize patients’ privacy, and createunsafe 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

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 ICUvisitation among patients’ families, nurses, andphysicians, to understand barriers and issues, andto gauge the generalizability of others’ work. Under-standing the barriers to patient-cen-tered care may support futureinterventions aimed at reshaping thecurrent ICU culture to align with apatient-centered paradigm.

MethodsThis study’s setting was an aca-

demic, tertiary care, Magnet Recogni-tion Program hospital with a level Itrauma center designation and 900 licensed adultbeds. Approval was obtained from the institutionalreview 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 5units posted similar strictly enforced visiting hours,limiting visitation to 2 people for 30-minute visits,4 times a day.

DesignFocus Groups

Criteria for participation were as follows: thefamily member’s patient must be 18 years or olderwith a minimum ICU stay of 72 hours, and thefamily member participant must be 18 years orolder, speak English, and must have visited the ICUpatient at least twice. Three family focus groupmeetings were held on different days and preceded2 focus groups for nurses and 1 focus group forphysicians that met on the same day. Participants

Traditional, non-patient-centered environments prevent patients’ families fromvisiting their loved ones except during predesignated, time-limited periods inter-spersed throughout a long hospital day.1,2 Dissatisfaction with this traditionalvisitation paradigm has pushed families to become more involved in their lovedone’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 anyvisiting restrictions as a relic, unnecessary, and potentially harmful to the patient’s safety.13,14

About the AuthorsBettina H. Riley is an assistant professor at Universityof 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 isMagnet 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 nursingpractice and NET SMART, UAB School of Nursing andUAB Comprehensive Stroke Research Center, Birming-ham, Alabama.

Corresponding author: Bettina H. Riley, RN, PhD, Universityof South Alabama, College of Nursing, Baldwin CountyCampus, 161 North Section Street, Suite C, Fairhope,Alabama 36532 (e-mail: [email protected]).

Open visitation isamong the defin-ing elements of apatient-centeredapproach.

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and emotional support to their loved one (Table 1).Through vigilant watchfulness, interpretations ofbody movements or noises (eg, tracheotomy sounds,facial expressions), and recognition of the patient’sneeds (eg, repositioning), the family member per-formed, assisted, or initiated an intervention. Assurrogates, patients’ family members believed thatthey “should always be involved” and should havethe opportunity to ask as many questions as neces-sary to satisfy their decision-making needs. In addi-tion, the physicians and nurses needed to explainto them what was occurring with their family mem-ber’s medical care (Table 1).

Physicians agreed that patients’ families had arole in the ICU; they did not agree that this rolecoincided with a stationary physical presence in theICU. Physicians were not in support of open familyvisitation but viewed the role of patients’ familiesas prominent once the patients are discharged fromthe ICU (Table 1). Physicians saw themselves asopposing 24-hour visitation to safeguard thepatients’ 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 openvisitation would detract from patient care (Table 1),

included attending physicians practicing in the ICUsand nurses chosen from all shifts in the 5 ICUs.

Data Collection and AnalysesAll focus group sessions were voice recorded

and facilitated by 1 group leader and 1 assistant.Written informed consent was provided by all focusgroup 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

ResultsThe focus groups consisted of 8 different female

family members representing 4 of the 5 ICUs; 2 malephysicians and 1 female physician represented rota-tions in all but the surgical ICU; and 1 male nurseand 6 female nurses represented all 5 ICUs. Feelingsand beliefs about families’ ICU visitation experiencesvaried among the patients’ families, physicians, andnurses.

Role of FamiliesPatients’ family members thought that they

knew their ICU family member better than anyoneand were in the best position to provide a voice for


Table 1Roles in the intensive care unit (ICU)

Patient’sfamily

Physician

Nurse

Provide a calming effect:“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 paralyticstate 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’sgoing 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.”

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.”

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.”

Role Function and examples



to the belief that patients belong to their familieswho care about them and that patients’ familiesshould not be denied visitation opportunities. Nurses’beliefs also included that the best examinations ofpatients occurred when patients’ families werepresent and that taking care of the patients’ familymight be the only gift that a nurse can give to adying patient (Table 1).

Communication Patients’ families, physicians, and nurses believed

that sharing information about a patient’s healthstatus was important and necessary. Families felt“panic” if their loved one’s health status was notreported in a timely manner and felt scared makingcaregiver decisions that were based on infrequentmedical updates (Table 2). Families felt comfortedwhen greeted with personal inquiries and given aprogress report on their loved one’s condition. Inaddition, patients’ families wanted health statusinformation delivered from the physician, referenc-ing “adequate” delivery from nurses but that physi-cians were the only ones who could provide certaininformation (eg, prognosis).

Communication content was also important.One family member anticipated her husband’s dis-charge when told that her husband was “stable,” butthe physician stated, “No, stable means ‘criticallystable’ in the ICU”; the family member labeled

“critically stable” as a “new word” but paradoxical.Another family member stated that health careworkers needed to “learn how to talk to patients’family members” and to demonstrate empathy(Table 2). One family member mentioned that thelonger the ICU stay, the more thecommunication process was takenfor granted (Table 2).

Physicians shared beliefs thatpatients’ families, as the primarycaregivers outside the ICU, shouldreceive detailed information aboutpatients. Yet, physicians alsobelieved their primary obligationwas to patient care. Physicians statedthat making rounds included acuteinterventions and there was no timeto spare for communicating withpatients’ families (Table 2), and as teachers, theyattributed 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 ofthe health-care team (eg, resident physicians, nurses).

Nurses believed that they were advocating forpatients when they sought information from physi-cians, from patients’ medical reports, and shared itwith patients’ families, but felt that depending onthe hospital unit, in addition to workload, emergent

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Table 2Communication

Patient’sfamily

Physician

Nurse

Felt scared:“…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 justall 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.” Whendescribing nurses caring for other patients as well as their loved one, this family member went on to say, “…they’llcome in later cause they’d have to answer their main patient first. They seem not to, to want to share as much, I guessyou 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.”

No time to spare for family communication:“My duty and my obligation is to that patient first, and not the [patient’s] family.”

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.”


Nurses believedthat the bestexaminations ofpatients occurredwhen patients’families werepresent.



to open visitation (Table 3). However, physicianswere not opposed to some flexibility in visitation,recognizing that when patients’ family membersfirst 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 openvisitation. Some endorsed open visitation, believingthat patients’ families are naïve of patients’ needsand health status when allowed only “snapshots intime” (Table 3). Furthermore, if exposed to a med-ical procedure, families might understand better thecomplexities and demands of ICU care; if at thebedside longer, they could assist with activities ofdaily living. However, other nurses thought that ifpatients’ families were there longer, nurses’ work-load would increase, while others believed that openvisitation did not necessarily equate to constantbedtime presence because patients’ families wouldvisit only intermittently. Many nurses had a flexiblevisitation approach, allowing substituted visits formissed visits, an extra visit before a procedure, orprolonged visits.

Confidence, Trust, and RelationshipsPatients’ families qualified their perceptions

about ICU visitation on the basis of the individualsinvolved. Ideals or “favorites” were identified bypatients’ family members as those nurses who werecompassionate, caring, professional, knowledgeable,flexible, informative, accessible, approachable,

situations were a barrier to timely communicationwith patients’ families (Table 2). Nurses also believedthat the longer a patient’s ICU stay or when thepatient’s condition had deteriorated, the moredemands from patients’ families (Table 2).

Convenience and Flexibility of Visiting TimesPatients’ families, physicians, and nurses were

far from similar in their beliefs about visitation. AnICU family described the wait to visit as a period ofbeing helpless (Table 3). Patients’ families preferredto have access to visitation on a continual basis butexpressed an understanding that nurses and physi-cians needed time to perform procedures or medicalroutines (Table 3).

Patients’ families wanted options to delay orpostpone visitation when the patient was unavail-able (eg, asleep, undergoing a procedure); patients’families feared that the patient might not surviveprocedures (Table 3). Furthermore, patients’ familymembers did not prefer visitation times at or laterthan 8:30 PM or before 10:00 AM, believing that thelate evening times placed them in an unsafe innercity environment and the late morning time wastoo late in the day (Table 3).

Physicians believed that 24-hour visitation was“not preferred; not an option.” In addition, physiciansstated that providing procedural oversight/instructionto 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


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

Patient’sfamily

Physician

Nurse

The wait to visit perceived as a helpless period:“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’twant to wake him up,” or if they became overwhelmed, “… he’s never been in ICU before…and I couldn’t stay, somedaysI 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 seesomebody ‘til 10:30 AM, sometimes that’s a little late for me.”

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.”

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.”




available, funny, and trustworthy (Table 4). In con-trast, patients’ families identified unprofessionalbehaviors of providing no explanation when barredfrom visiting or when a nurse new to the familymember provided unsolicited, disturbing “advice”about removing her husband from life support afterhe had started treatment with dialysis only 4 hoursearlier (Table 4). Furthermore, patients’ familymembers stated that nursing care was better whenthe patient to nurse ratio was 1 to 1.

Patients’ families wanted a better relationshipwith more face time with their physician, recogniz-ing that there could be numerous physicians involvedin the care of their loved one (Table 4). One familymember was frustrated with not seeing the doctorat least during visitation and another wanted, asidefrom emergency communications, weekly updates.

The physicians wanted the patients’ families toknow that the physicians were accessible, but thephysicians believed that they did not have the timeto spend with patients’ families and still accomplishtheir priority: direct patient care (Table 4). Existingrelationships were often not face to face, andalthough physicians expressed a preference to meetin person initially, doing so was not a priority andphone contact after rounding was seen as a practicalway of responding to the concerns of patients’ fami-lies. Physicians agreed with patients’ families thatthe volume of physicians seeing a patient in an aca-demic facility was a barrier to an ideal relationshipbetween physicians and patients’ families (Table 4).

ICU nurses described their relationship withvisiting patients’ family members on the basis of theindividual, with each having “completely different”


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

Patient’sfamily

Physician

Nurse

Ideals or “favorites” were identified by family members; better outcomes:“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 offof life support.” Continuing, this family member stated, “And it still upsets me, because when we started this ordeal, hisprimary 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.”

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 helpthe 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.”

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 ifyou would let them sleep.’ …I’ve done that so many times as a bedside nurse, and I think they appreciate that as long asyou 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 informationand then expect you to understand every time you come in…every time you call…it seems like we expect people tounderstand way too fast.”




partnership model of care, which has reduced com-munication deficits and improved role confusion inother settings.32 By providing a welcoming environ-ment, involving patients’ family members in ICUoperations 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 anethics consultation, this model conserved time forphysicians contributing hours back to direct patientcare, and improved evaluations of communicationbetween patients’ families and nurses and job satis-faction scores among nurse managers.

Ratings by patients’ families (not physicians ornurses) of satisfaction with ICU team communica-tion were increased by addition of a family supportperson,36 indicating the need to determine furtherwhat barriers to communication exist for physiciansand nurses. Furthermore, the intervention of acommunication facilitator (nurse or social worker)revealed that the breakdowns in communicationwere more common and serious after ICU dis-charge, the opposite of what physicians here thoughtwas most important,37 suggesting that a communi-cation process initiated before a patient’s’ dischargeshould be examined to prevent a total disconnectwith the patient.

Burnout in nurses could be the answer to thedecline in health-care workers’ communication thatpatients’ families experienced with longer stays inthe ICU and the increased caregiver burden experi-enced by patients’ families who had members withextended ICU stays. Among the reasons for burnoutin nurses and physicians are relationships betweencoworkers and supervisors, conflicts with patients,and caring for dying patients.38 Placement of a clini-cal nurse specialist who provides education aboutworking with patients in difficult situations andburnout assists in reducing burnout and increasingjob satisfaction among nurses.39

These findings also supported quality-of-lifediscussions in the ICU that were not regularly rec-ognized, managed, or appropriately discussed.40

Consideration should be given to training staff incommunications related to end of life by usingtechniques40 such as forming a support team or useof bereavement carts stocked with information andresources, hand casts, and books on grieving.32

Convenience and Flexibility of Visiting TimesViewing visitation as a privilege, not a right,

was not uncommon in the ICUs, where the nurseswere clearly in charge of visitation and where, depend-ing on the nurse’s attitude, some families clearly

expectations such as undivided and complete avail-ability of the nurse. Unfulfilled expectations ofpatients’ families might result in complaints to thenurse’s manager. In 1 case, a patient’s family did

not believe a diagnosis and a repre-sentative was chosen to look at thepatient’s records to “make sure thatwe’re doing our job like we’re sup-posed to,” leading to feelings ofbeing “policed” (Table 4). Further-more, nurses felt “frightened by thesituations that patients bring withthem to the hospital,” such as fightsbetween family members and visitors“threatening to finish the job” andassumed 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 feelingunsafe at work.

DiscussionThe aims of this study were to understand the

barriers to patient-centered care. Understanding thebarriers will aid in the design and implementationof patient-centered milieus.

Role of FamiliesEmpowerment of patients’ families is essential

in advancing family roles in a patient-centered careenvironment.31 The integration of patients’ familiesin physicians’ rounds benefits the families’ surro-gate decision-making and patient care processes.7

In spite of the physicians’ and nurses’ stance thatopen 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-bers, physicians, and nurses duringunrestricted visiting, rounds, andend-of-life situations.

CommunicationEffective communication, being

empathetic and available, avoidingpersonalization, 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 herecould be addressed by the implementation of a


A nurse-led initiative showedthat participation

of patients’ families did not

significantly slow down rounds.

Implementation ofa partnership

model of care mayreduce communi-

cation deficits.



benefited, while others experienced stress from rigidrules. Open visitation installed through a partnershipmodel of care using a major change interventionfacilitated this major culture shift.32 Use of this samemodel 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 thanclinical staff.32,36 Physicians’ concerns related to resi-dents practicing in an open visitation environmentremain an area of needed research.

Confidence, Trust, and RelationshipsPatients’ families in this study and in a similar

study41 valued trust of the health-care provider; how-ever, confidence, trust, and relationships betweenpatients’ families, physicians, and nurses varied fromintimate to nonexistent. Role confusion and poorcommunication contribute to poor outcomes inthese areas between these key stakeholders.35 Onestudy’s intervention that improved these relation-ships was focused on physician and manager round-ing with patients’ families.32 Researchers in otherstudies36 reported that establishment of a family-support position assisted patients’ families in com-munication and resulted in higher satisfaction ratingsamong patients’ families.

To assist ICU nurses working under duressfrom abusive families of patients, a communicationtool that includes suggestions for behavioral inter-ventions42 was recommended. Supervision of theclinical staff by a clinical nurse specialist helps resolvedifficult 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 fornurses’ 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 unlikethe results reported by others who have exploredsome aspects of intensive hospital visitation poli-cies,3-9 making a number of solutions applicable toaid movement toward a patient-centered model.

LimitationsPatients’ families were reluctant to express the

truth because of fear of retribution: “I don’t want toget her into trouble for fear, you know, she’d be leftthere with him.” Patients’ families, physicians, andnurses had difficulty scheduling participation becauseof their perceived need to remain near the ICU.

Generalizability of findings is limited, futureresearch should include more males in focus groupsand contrast and compare findings among patients’families, nurses, and physicians on units that doand do not embrace a patient-centered philosophy.

ConclusionsThese exploratory methods have shown merit

in understanding the issues, potential barriers, andneeds of patients’ families, nurses, and physiciansrelated to ICU visitation at a large, academic, terti-ary care, inner city, medical center. These findingsare essential for building meaningful and impactfulchange interventions as part of a project aimed toembed a patient-centered ICU culture throughoutthe hospital.

FINANCIAL SUPPORTA University of Alabama at Birmingham School of NursingDean’s Scholar Award was provided to Dr Alexandrovas support for this project.

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eLettersNow that you’ve read the article, create or contribute to anonline discussion on this topic. Visit www.ajcconline.organd click “Responses” in the second column of either thefull-text or PDF view of the article.

SEE ALSOFor more about family presence in critical care, visit theCritical Care Nurse Web site, www.ccnonline.org, andread the article by Bishop, et al, “Family Presence inthe Adult Burn Intensive Care Unit During DressingChanges” (February 2013).



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Traditional/Restrictive vs Patient-Centered Intensive Care Unit Visitation: Perceptions of Patients' Family Members, Physicians, and Nurses