Table 1.
Summary of included articles.
| Article (citation) | Study design/quality/ sample population | Aim | Conclusion | Family engagement domains | Other concepts | |
|---|---|---|---|---|---|---|
| 1 | El Aziz et al. (20) | Retrospective comparative study to compare patient outcomes and length of stay before and after restrictive visiting policy Level 1c (insufficient sample size) United States 439 Patients from one hospital |
Evaluate the impact of visitation policy (VP) on short-term surgical outcomes | Restrictive VP for colorectal surgery patients was not associated with in-creased postoperative complications and readmission rates. Length of stay (LOS) was similar between the two groups. More research needed to confirm findings. | Presence: suggestion to use novel techniques might optimize communication between patient and family (no mention of family-provider communication) | Low satisfaction scores a focus of the restrictive visiting policy Isolation |
| 2 | Ahmed et al. (21) | Descriptive, phenomenological qualitative study using interviews Level 3b UAE 37 ICU Nurse Managers from 13 non-government hospitals |
Explore how nursing services were managed and provided in intensive care units during the COVID-19 pandemic Clarify the management lessons learned to inform future challenges to the visiting policy |
Promising strategies for intensive care units in planning for responses to future crises include maximizing organization resources, boosting family-centered care, providing in-service training for nurses, and policy reform. | Communication: lack of family meetings had a negative influence on quality of care Use available technology to facilitate patient-family communication Shared decision-making/participation: lack of family involvement in decision-making process. Encourage patient virtual presence in rounds |
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| 3 | Akbari et al. (22) | Parallel randomized clinical trial Level 1b Iran 60 patients and 57 Nurses from 4 ICUs in 2 hospitals |
Investigate relationship between increasing visitation time and patients’ physiological parameters in ICU Examine nurses’ beliefs and attitudes toward visiting |
Increasing visitation times can lead to a positive effect on the patient’s physiological parameters. No significant change in nurse beliefs |
Presence: nurses believed that family presence would cause physiological stress. It had a positive effect on patients’ physiological parameter | Visiting policy linked to outcomes and satisfaction |
| 4 | Azad (23) | Narrative of a neurocritical resident Level 5b United States 1 Physician from 1 hospital |
Illustrate the disproportionate effect of restrictive visiting policies on traumatic brain-injured patients and their families. Catalyze discussions regarding the need for careful evaluation of restrictive family visitation policies and exceptions that may be required for patients with brain injuries |
COVID-19-era family visiting policies negatively affect the healthcare team’s ability to partner with families in navigating complex decisions after brain injury. | Presence: families of neurocritical brain-injured patients are not permitted bedside after an initial 2-h visit allowance for one person. Communication/information sharing: difficult and complex conversation even more difficult without being bedside. It is difficult to convey heaviness of the situation on video Shared decision-making/participation: difficult for families to limit care when they do not get a complete sense of the injury Regular, in-person family meetings facilitate trust and information sharing and often cannot be digitally replicated |
Exceptions to policy, Race and socioeconomic factors affect trust in healthcare system. Choice architecture: families felt the only way they would be allowed to visit is if they agreed to comfort measures only |
| 5 | Azad et al. (24) | Regression discontinuity and time-to-event analysis Level 2b United States 940 Patient (decedents) from 2 large academic hospitals |
Determine if a restrictive visitor policy lengthened the decision-making process for dying inpatients | Policies restricting family presence may lead to longer ICU stays and delay decisions to limit treatment prior to death | Presence: visiting policy that restricts family presence has unintended consequences. Shared decision-making/participation: policy restricting family presence led to longer ICU stays and delayed decisions to limit treatment before death. |
Exceptions to policy, visiting had a positive impact on shared decision making |
| 6 | Brauchle et al. (25) | Online survey of clinicians with a mixed methods approach Level 3b 5 German-speaking countries 385 multi-disciplinary Leading Clinicians (172 nurses, 213 physicians) from all 1,943 ICUs in Austria, Germany, Luxemburg, and parts of Switzerland |
Provide insights into visiting policies and family-centered care practices with a focus on children as visitors in ICUs | Family-centered care policies had been implemented in their units, including open visiting policies, allowing children as visitors without age restriction, and other family-centered care activities. | Presence: only 1/3 of respondents reported that ICUs were open 24h, seven days a week. 65% of respondents report family is not present during invasive procedures Communication/information sharing: 50% report not adopting family participation in rounds, and 47% somewhat adopt structured family conferences. Shared decision-making/participation: 47% of respondents report only somewhat adopting goals of care meetings in the ICU Respect/family needs met: 41% of respondents report fully adopting open visiting hours that are flexible and culturally appropriate Contribution to care/participation: 40% of respondents reported somewhat adopting disseminating information and helping families in ways to assist the patient Collaboration: 70% report not adopting a family advisory group |
Suffering when family, including children, cannot be there |
| 7 | Brown et al. (26) | Retrospective cross-sectional study Level 2b United States 2931 Patients from 4 hospitals |
To explore if the restrictive visitation impacts use of benzodiazepines and antipsychotics in older adults in the hospital setting | Benzodiazepine use was lower in older patients on days when visitors were allowed | Presence: the absence of caregiver support may lead to increased delirium, agitation, or anxiety, leading to increased benzodiazepine use. Presence of a caregiver improves quality of medication prescribing Contribution to care/participation: caregivers improve orientation and reduce agitation |
Isolation |
| 8 | Chan et al. (27) | Mixed methods study using online survey and open-ended questions describing how the services were affected Level 3b Hong Kong 142 multi-disciplinary Clinicians (Physician 24, Nurse 56) from public hospitals |
Examine the mental health of palliative care professionals during COVID | 82% felt stressed when communicating with patients and family members under the no-visiting policy during the pandemic Professionals identified tightening visiting policies as 1 of 3 themes that affect the provision of palliative care |
Presence: the absence of family and caregivers led to increased loneliness and distress, which in turn affects the provider Respect/needs of the family met: difficult for provider to assess and provide support because of reduced interaction with family Contribution to care/participation: caregivers experience guilt because they are unable to fulfill caregiver duties |
Isolation Loneliness Burnout (professional) |
| 9 | Chary et al. (28) | Commentary Level 5b United States 1 Physician from 1 hospital |
To describe inconsistent visitor restriction policies | Inconsistent visitor policies contribute to health inequities among minority older adults with limited English proficiency | Presence: allowing exceptions for caregivers of patients with cognitive impairment. Health disparity for patients with limited English proficiency who did not know they could accompany the patient. Communication/information sharing: caregiver is seen as difficult when trying to advocate for patient when it may be related to mistrust. Caregivers offer important information for initial work-up. The process of conference calls with LEP family is time-consuming, inconvenient, and cumbersome Collaboration: visiting policies posted online in only English, even with the population most affected by Covid being Latinx. |
Exceptions to policy are unfairly given and not in a systematic way; health equity cultural capital (social skills and connections that allow for advancement within institution), which includes health literacy, fluency in dominant language, confidence, and comfort in advocating for oneself; street level bureaucracy-front line staff as the gatekeeper |
| 10 | Chua et al. (29) | Multisite study identifying key elements of website manner that are helpful when conducting serious illness conversations by virtual visit Level 3c United States Unknown number of Clinicians in unknown number of hospitals |
Explore the effectiveness of virtual palliative care | Like bedside manner, nuanced verbal and nonverbal web side manner skills are essential to conducting serious illness conversations during virtual visits. | Presence: virtual communication requires nuanced verbal and non-verbal skills like bedside manner. Communication/information sharing: thoughtful use of the virtual visit can pose a benefit for patients, families, and clinicians to facilitate serious illness conversations during social distancing and visitor restrictions Shared decision-making/participation: serious illness conversations require eye contact, lighting, a private setting, and intentionality to help establish rapport |
Social, economic, technological, and demographic barriers |
| 11 | Creutzfeldt et al. (30) | Semi-structured interviews Level 3b United States 19 Family members from 1 hospital |
Explore the experiences of family members of patients with severe acute brain injury focusing on the impact of family presence in the hospital. | Family presence at patient’s bedside fulfills important needs. Visitation restrictions require hospitals to be creative and inclusive to help maintain these connections. | Presence: being bedside helps the family Communication/information sharing: observing and listening to providers on rounds helps families cope, builds trust in the team, and shares clinical information. Regular standardized video communication can also accomplish this. Respect/family needs met: being bedside helps the family cope, advocate, and support patient. The family also receives support from other families and ICU staff. |
Understanding the diversity of needs is an important step toward meeting those needs Distress |
| 12 | Danielis et al. (31) | Retrospective cohort study was conducted according to the “Strengthening the Reporting of Observational Studies” in Epidemiology statements Level 3b Italy 80 Patients from 1 postoperative surgical unit in 1 large academic center |
Assess the consequences of hospital visitation restrictions on the most common outcome measures for adult patients who underwent surgery. | Visiting policy restrictions should be balanced between potential benefits (e.g., preventing negative outcomes on patients) and threats (e.g., increasing the spread of the virus). | Presence: patients that experienced no visitor policies were more likely to experience disorientation, restraint, and sleeplessness. Communication/information sharing: family members communicated patients’ pain to provider; therefore, the pain was better managed Contribution to care/participation: family, in addition to providing support and comfort to patients, might play an active role in early recognition of clinical deterioration and pain |
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| 13 | Dhawan et al. (32) | Cross-sectional analysis of visitation policies abstracted from public-facing Web sites of comprehensive cancer centers (CCCs) Level 5b United States 50 National Cancer Institute designated adult comprehensive cancer centers |
Examine the availability of language translations of visitation restrictions on adult National Cancer Institute-designated CCCs websites. | Even in cities and states with larger Hispanic/Latinx populations, most CCCs did not publish resources in Spanish. This study highlights a key opportunity to mitigate communication barriers and deliver culturally competent, patient-centered care. | Presence: non-English-speaking families had to take additional steps to obtain the visiting policy. Respect/family needs being met: visiting restrictions impact communal medical decision-making for patients from allocentric cultures who value familism. Shared decision-making/participation: visiting policy is a barrier to high-quality communication needed in serious illnesses like cancer. |
Cultural competence |
| 14 | Eden and Fowler (33) | Descriptive, exploratory survey design Level 3b United States 45 Family members from one hospital |
Details a study of family members’ perceptions related to being isolated from hospitalized patients with confirmed positive COVID-19. | Most family members (89%) wanted to visit their loved one in the hospital, and the same amount called the patient or patient-care unit themselves. | Presence: emotional anguish when the family could not physically visit the patient. Communication/information sharing: family received limited information about their family member’s condition. One-quarter of family members recalled getting phone calls from staff with updates. No family member reported a “virtual visit” facilitated by the hospital staff |
Isolation |
| 15 | Eugênio et al. (34) | Cross-sectional study Level 3b Brazil 95 Family members and 95 multi-disciplinary clinicians (19 nurses, 57 nursing technicians, and 11 physicians) from one clinical-surgical ICU in one hospital |
Compares the perceptions of patients’ relatives with the perceptions of health professionals regarding a flexible visitation model in intensive care units. | Family members and staff-have different perceptions of flexible visits in the ICU. A positive view regarding the perception of decreased anxiety and stress among the family members and greater information and contributions to patient recovery predominates with a flexible visiting model. |
Presence: having a companion bedside benefits the patient’s recovery and reduces anxiety and stress in patients and families Communication/information sharing: facilitates information exchange. Providers wanted education to help them communicate with families. Contribution to care/participation: presence of family allows them to be active agents in patient care and important ally in the team. |
Burnout (professionals) |
| 16 | Fiest et al. (35) | Environmental Scan of Canadian hospital visitation policies during first wave of pandemic Level 5b Canada 257 Policy Documents of Canadian hospitals with adult ICUs |
Describe the extent, variation, and fluctuation of Canadian adult intensive care unit (ICU) visitation policies before and during the first wave of the COVID-19 pandemic. | During the first wave of the COVID-19 pandemic, most Canadian hospitals had public-facing visitor restriction policies with specific exception categories, most commonly for patients at end-of-life. | Presence: alternative ways to connect (email, virtual, phone call) Communication/information sharing: dedicated team member to schedule and facilitate virtual visit Respect/family needs met: few policies allow for culturally appropriate practices or protocols. Also, no allowances for patients with prolonged stays. |
Exceptions for end-of-life, critical illness, patients requiring assistance related to cognitive or physical disability |
| 17 | Fino et al. (36) | Cross-sectional study online survey of health- care workers probing on socio-demographic and work-related variables Level 3b Italy 209 multi-disciplinary Clinicians (146 Nurses, 63 physicians) from one region in country (“worst-hit”) |
Investigate whether facilitating virtual patient-family communications would mitigate distress levels in engaged healthcare professionals. | Nurses assisting patient-family videocalls reported significantly lower levels of distress and a better quality of wakefulness than those who did not. In contrast, physicians reported higher levels of distress during such virtual communications. | Communication/information sharing: virtual communication technologies between families and providers need to be complemented with education for the providers on how to enhance, especially in terms of communicating online and on difficult topics | Isolation Burnout (professionals) |
| 18 | Kean and Milner (37) | Quality Improvement Project Level 5b United States 1 Adult ICU in one hospital |
Develop and implement more family-centered visitation policies in the ICU | Evidence supports open visitation as best practice that aligns with patient/family-centered care and patients in adult ICUs. Resulting open visitation policy improved satisfaction among nurses, patients, and visitors. | Communication/information sharing: open visitation improves communication and understanding Respect/family needs met: patient has right to consent to visitor |
There was conflict between nurses who made exceptions to the restricted visitor policy and those who did not. |
| 19 | Kim et al. (33) | Retrospective observational study using medical record review before covid (restrictive visiting policy) and (no-visiting policy) after covid Level 3b South Korea 2,196 Patients from one ICU in 1 hospital |
Evaluate the effect of intensive care unit (ICU) visit on the incidence of delirium, delirium subtype, and anxiety level in ICU patients. | The no-visiting policy during pandemic did not affect the incidence of delirium. The proportion of patients with hyperactive or mixed delirium was higher during the no-visiting period. No visiting was a risk factor for the non-hypoactive delirium subtype and high anxiety levels. | Presence: there was no difference in the incidence of delirium, regardless of whether the visit was allowed. A potential explanation is that the limited daily visiting hours of restrictive ICU visits might be too short to help reduce the incidence of delirium. This finding confirmed the importance of family visits in changing delirium subtypes and alleviating anxiety in ICU patients and provided a foundation for nonpharmacological intervention in the ICU. |
Isolation |
| 20 | Maloh et al. (38) | Cross-sectional, descriptive, and comparative survey design Level 3b Jordan 234 Nurses from 5 hospitals (1 public and 4 private) |
Evaluate nurse managers’ and nurses’ perspectives on the effects of an open visitation policy at intensive care units (ICUs) on patients, families, and nurses’ care. | ICU managers and staff nurses do not favor implementing an open visitation in their units despite its known benefits, international recommendations, and relevance and compatibility with the local religious and cultural context. | Presence: managers believed that family interfered with nursing care. Communication/information sharing: the second most agreed-upon belief was that a more flexible policy would cause nurses to spend more time providing information to the family and interfere with communication between nurses. Respect/family needs met: most nurses also believed that the visiting policy did not need to be adapted to be more culturally appropriate. In the Arabic and Muslim environment, social bonds and family connection are important; family members, friends, and coworkers are expected to assist critically ill family members. |
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| 21 | Marmo and Milner (39) | Mixed-methods study Level 3b United States 96 Hospitals (Magnet and Pathway to Excellence) |
Compare visitation policies of Magnet and Pathway to Excellence hospitals with pre-pandemic open visitation in adult intensive care units. | Despite evidence supporting the benefits of visitation and the harms of restricted visitation and expert recommendations for returning safe visitation to hospitals, Magnet and Pathway to Excellence hospitals continue to enforce restricted visitation policies in intensive care units. | Presence: a common theme was that visitors were not welcome even though the nurses reflected that not having visitors does cause harm to the patient, family, and staff, which they separated from the harm of the virus. Communication/information sharing: changes in visitation policy, with subthemes of technological and nontechnological adaptations to nursing work to facilitate communication with family. Contribution to care/participation: no overnight visitation was allowed unless the visitor was essential to the patient’s care. |
Exceptions for patients at the end of their life. A culture shift from open to restricted visitation and the use of evidence-based practices to improve patient care outcomes. |
| 22 | Padua et al. (40) | Quasi-experimental study Level 2b Italy 11 Patients from one ICU in 1 hospital |
Assess whether digital communication benefits patients with disorders of consciousness (DOC), considering the sensory and emotional deprivation due to the COVID-19 emergency lockdown. | “Digital re-connection” is needed, especially for fragile population groups such as patients with DOC. | Presence: patients experienced an autonomic activation with both visual-audio interactions with family. | |
| 23 | Rosa et al. (41) | Cluster-randomized crossover trial as a secondary analysis of the ICU Visits Study Level 1b Brazil 863 Family members from ICUs in public and private nonprofit hospitals with 6 or more beds |
Investigate whether the effect of a flexible ICU visiting policy that includes flexible visitation plus visitor education on anxiety symptoms of family members is mediated by satisfaction and involvement in patient care. | Flexible ICU visiting policy reduces anxiety symptoms among family members and increases satisfaction. Increased participation in some patient care activities because of flexible visitation was associated with higher severity of anxiety symptoms. | Presence: flexible visiting policies and proximity improves anxiety symptoms by increasing satisfaction Communication/information sharing: by meeting common family needs during ICU stay, such as proximity with the patient, better communication, and reassurance. Flexible visiting policy might reduce uncertainty about patient survival, effective management, comfort, and risk of significant disability. Contribution to care/participation: higher involvement in care in ICU, associated with flexible visitation, is also associated with higher severity of anxiety symptoms in families. |
Burnout (professional) |
| 24 | Segar (42) | Narrative Level 5b United States 1 Physician from 1 hospital |
Share narrative of physician experience with visiting policy and a dying patient | A narrow view of patients’ and families’ preferences has led to unjustly applying policies to accommodate dying patients. | Presence: family bedside is beneficial to patients, families, and providers. Providers experience distress when they know it benefits the patient and family but are forced to turn the family away. Presence is therapeutic for the management and prevention of delirium in the patient. Communication (information sharing): poor quality of communication when technology is the only interaction with the family. Giving the family bad news over the phone is additionally distressing for providers. Shared decision-making/participation: restrictive visiting policy delays family conferences Respect/family needs being met provider worries about providing a culturally appropriate death and respects the wishes of the family and patient within the confines of the policy. |
Exceptions create choice architecture and are unfairly given Isolation Distress |
| 25 | Shinohara et al. (43) | Comparative study Level 2b Japan 200 Patients from 1 ICU in 1 hospital |
Investigate the association between the no-visitation policy and delirium in intensive care unit (ICU) patients | No-visitation policy was not associated with the development of delirium in ICU patients. | Presence: no relationship between the number of days until the development of delirium and the no visitation policy in this study. The patients may not recognize the visitors because of poor consciousness which may reduce the effectiveness of visits to prevent delirium. | |
| 26 | Suh et al. (44) | Cross-sectional descriptive survey Level 3b South Korea 99 Family members from 1 adult ICU from 1 academic medical center |
Compare the quality of life, depressive symptoms, and emotions in family caregivers of ICU patients before and during the COVID-19 pandemic and explore families’ perceptions and suggestions for the visitation. | Visitation restriction is necessary during the COVID-19 pandemic despite sadness and anxiety reported by caregivers. Hence, alternative visitation strategies are needed to mitigate psychological distress and provide sufficient information to ICU family caregivers. | Presence: families reported being sadder and more anxious than before the restrictive vising policies. They also felt that the separation had adverse consequences. Communication/information sharing: only half of families felt they were kept informed of their family member’s condition. Respect/family needs met: family reported not having enough information about their family member’s medical condition and treatment plan. Collaboration: the respondents suggested more frequent meetings with clinicians, offered alternative contact methods with the patients, and improved orientation of the family visitation policy. |
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| 27 | Wasilewski et al. (45) | Qualitative descriptive study Level 3b Canada 10 Patients, 5 family members, and 12 Clinicians (2 nurses) from 1 hospital network system |
Explore how infection control measures impacted stakeholders’ perceptions of care quality and interactions with others and investigate how these experiences and perceptions varied across stakeholder groups. | Infection control challenged psychosocial health and maintenance of vital human connections. All stakeholders experienced loneliness and isolation as well as COVID-related stigma. Technological innovations mitigated some of the isolation. The study underscores the need to balance safety with well-being of all stakeholders. | Presence: participants spoke of the pronounced isolation, loneliness, and need for human connection. Absence of family meant that patients did not have someone readily available for emotional support. Respect/family needs met: not all families have equitable access to the technology that helps connect families and patients. Infection control and prevention measures perpetuated the COVID-related stigma that stakeholders experienced. |
Participants in our study were English-speaking and had mid-to-high socioeconomic status (SES). Isolation Loneliness |
| 28 | Zeh et al. (46) | Pre- and post-retrospective cohort novel survey study Level 3b United States 117 Patients from 1 academic center |
Understand the impact of visitor restriction rules on the postoperative experience of patients undergoing surgery. | Implementation of restrictive visitor policies may adversely impact the post-operative experience of Covid-negative patients undergoing surgery and highlight the need for patient-centered strategies to improve the postoperative experience of patients during ongoing or future disruptions to routine hospital practices | Presence: patients indicated that they rely upon family for social support and that without them, they were lonely and felt isolated Contribution to care/participation: some patients in the No-Visitor Cohort felt that their visitors provided direct support. They were less likely to report timely access to pain, nausea, and other medications and help to get out of bed. Respect/family needs met: patients in the No-Visitor Cohort were less likely to strongly agree that their and family members’ preferences were adequately considered upon discharge. |
Decrease in hospital satisfaction at least partially related to the absence of visitors Isolation Loneliness |