Visitation in the Intensive Care Unit
The intensive care unit can be a place of extreme disquietude and trauma to the patient. Far from relaxing the patient and assisting in his or her recovery, many patients find the ward to be moderately to extremely bothersome with pain, fear, anxiety, tension, loneliness, lack of sleep, inability to communicate, and vulnerability being just some of the factors that disturb the patient (Wikehult et al., 2008). Advocates of relaxed admission of social and family support on the wards point to these factors as worsening the person’s disease and making him more vulnerable in an already very vulnerable situation. Social support, they insist, will not only help him fight his disease, accordingly, indirectly helping doctors in their job, but will also prevent depression from occurring and prevent her condition from worsening.
Opponents of liberal visitation, however, point to the fact that caregivers need to focus on their job. Given the stressful nature of the ICU, with a possible influx of emergency victims, whom doctors and nurses have to focus their full concentration on, and given the fact that caregivers have to be constantly in control of their situation, howsoever stressful and overwhelming that situation may be, the last thing doctors need is an influx of visitors who will only likely make the ward more chaotic. There is no private space on the ICU. In some emergency wards, individuals are crammed one next to the other, and there may be occasions when doctors need all the space the room can afford. More so, some individuals may become excited by the appearance of countless others on the ward. Both patients and caregivers need the calm and quiet of the environment sustained as far as possible. Visitors, proponents of this view maintain, are for the general ward. In the ICU, let the doctor do his healing.
Advantages for Visitation
The biomedical model sees a person as reducible to disease and therefore healed by medicine, but the holistic approach has long ago recognized that there are many factors that have resulted in the disease: physical, mental, spiritual, economic, political, social, environmental, and so forth. As empathized by WHO, health is as much influenced by the individual’s environmental and living conditions as it is by lifestyle changes (Brannon & Feist, 2007). Solutions to health problems must, accordingly, be pursued at both the structural / social level of living as well as at a personal / physical / medical reductionist approach. With the patient in the ICU, it is not just his physical body that lies — or stands there – on the ward, but his entire persona: the whole of the person has been impacted; other variables frequently cause the physical manifestations and, therefore, for healing to occur, psychological conditions must be addressed too.
Of the psychological interventions that can be used to affect healing, one of the most important is social support. Clinicians have long recognized that support from family and friends can positively effect the patient’s healing (Fumagalli et al., 2006). Kaufman and colleagues (quoted by Rutter, Moffit, & Caspi, 2006), for instance, show that social support can ameliorate the negative effects of hereditary and patient’s living factors. This is particularly so since social support can be one of the repressors of depression. And depression is rampant amongst ill people; most so when they are in the isolated situation of the ICU (Wikehult et al., 2008). Illness can be a stressor. That support is most needed during that time can be indicated by Brown, et al.’s (1986) study (cited by Maulik et al., 2010) showed the importance of social support to both causing and relieving depression, when he and his colleagues sampled 400 largely working class women who had gone through a major stressor (such as a disease) and had either received or failed to receive support from family or friends during the duration of that stressor. Effects of self-esteem were traced to discover whether support during the stressor positively affected the individual’s self-esteem, self-efficacy to heal the self, and resilience. The researchers found that not only did support encourage the patient to contribute to her own healing (or attempts to overcome challenge), but it also strengthened her to deal with the challenge in a more resilient manner (thereby alleviating depression). Core support was defined as coming from husband, lover, or someone very close and immediate to the individual during the occurrence of the stressor event. That this was so was substantiated in that lack of support from core ties during the time of the crisis was significantly associated with particularly high risk and tendency towards depression, as was evidenced with those who felt let down in the year following the stressor (Maulik et al., 2010). Illness is a stressor; particularly the type of illness that leads one to the ICU. For optimum healing to be assured, therefore, depression must be prevented and the person encouraged to fight and involve himself in beating and curing his own disease. Research has shown that he can do this most effectively with family and friends around him. If the individual does not receive this, some studies suggest that potentially stressful factors of the ICU can culminate in impaired communication with healthcare staff and result in what is known as the “ICU factor” and delirium (Richter, Waydhus, & Pajonk, 2006).
Disadvantages to Visitation
The disadvantages are obvious. People are there for intense, concentrated care. With family and friends arbitrarily visiting, the nurses may be disrupted from their duty, anarchy may disturb other patients and quality of care may be impeded. The ICU is there as a stopgap measure. This is the place for emergency, intensive and focused care. With transition from ICU to the general ward will come the opportunity for the patient to receive unrestricted attention from family and friends. In the meantime, the ICU is there to provide him with the optimum, fastest, most effective way of healing, and — so the argument goes – those who care for patient should allow the doctors and nurses — the caregivers — to proceed with their job uninterrupted.
Other arguments in favor of disallowing liberal visitation pertains to the risk of infection that may freely enter the ward. Most ICU staffs insist on controlled visiting policies on the grounds that liberal visiting hours may increase the patient’s stress and risk of septic complications (Berti, Ferdinando, & Moons, 2007). Although this fear has been disproved (Fumagalli et al., 2006), besides which Fumagalli and colleagues suggest that septic complications can be best prevented by scrupulous hand washing of staff members in their visit from patient to patient, other factors remain a concern and remain unaddressed: ultimately caregivers need to remain undistracted and patents need their solitude and quiet.
Foss and Tenholder (1993) (in Brannon & Feist, 2007) used a 40-questions family needs survey with a degree of importance scale to compare the effect of the intensive care unit (ICU) with the general ward. Of the needs that were considered most important, family members considered it important that the patient receive support from his family, that there should be a private place reserved for family, and that flexibility should be granted in the time allowed fro visitors.
However, despite acknowledged advantages, family members were willing to accept decreased visitation time if physician and nurses could make up for this with effective and skilled care in the ICU. The ICU is the place for intensive medical care. Doctors need to concentrate; patients need to rest. Visitors can be content with their restricted hours or wait until the patient returns home and/or is removed to the general ward.
Admission to an ICU can be a stressful event where factors such as sleep deprivation, pain, noise, and loneliness can aggravate the disease and situation. Interventions studies, reviews and surveys have found that patients and individuals prefer open visiting policies since these not only reduce their stress but also satisfy their visitors (therefore enabling them to be more accomplished ‘visitors’ when they actually do visit). The experience of Fumagalli et al.(2006) was similar: when open and flexible visiting hours were permitted, patients and visitors seemed more content (Fumagalli et al., 2006).
ICU staff, on the other hand, insist on maintaining restrictive visiting policies on the grounds that liberal visiting hours may distract caregivers, whilst increasing the patient’s stress and risk of septic complications.
The issue remains an agonizing and constantly debated point of contention amongst physicians, nurses, visitors, and patients. Some practitioners insist that the decision to restrict visiting hours is neither caring nor compassionate (Fumagalli et al.,2006). On the other hand, as they themselves say their trial was small and larger randomized trials need to occur before conclusions are drawn. In the meantime, open and flexible visitation hours are constantly demanded, and permission, as constantly, withheld.
Berti, P., Ferdinando, D. & Moons, P. (2007). Beliefs and attitudes of intensive care nurses toward visits and open visiting policy Intensive Care Medicine, 33, 1060-1065,
Brannon, L. & Fesist, J. (207). Health Psychology. Thomson / Wadsworth, USA.
Fumagalli, S. Boncinelli, L., Lo Nostro, P. et al. (2006) Reduced Cardiocirculatory Complications With Unrestrictive Visiting Policy in an Intensive Care Unit
Circulation, 113, 946-952
Maulik, P.K., Eaton, W., & Bradshaw, C.K. (2010) The effect of social networks and social support on common mental disorders following specific life events Acta Psychiatrica Scandinavica. 1600-0447.
Richter, J.C., Waydhus, C., & Pajonk, F. (2006). Incidence of Posttraumatic Stress Disorder After Prolonged Surgical Intensive Care Unit Treatment, Psychosomatics 47, 223-230,
Rutter, M., Moffit, T., & Caspi, A. (2006). Gene-environment interplay and psychopathology: multiple varieties but real effects, Journal of Child Psychology and Psychiatry 47, 226 — 261
Wikehult, B. Hedlund, D., Marsenic, M., Nymen, S., & Millebrand, M. (2008). Evaluation of negative emotional care experiences in burn care Journal of Clinical Nursing, 17, 1923-1929.
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