An outbreak of restrictive intensive care unit visiting policies

Intensive care units (ICU) are high-stress and fast-paced environments, where a specialized multidisciplinary team cares of critically ill patients (South and Adair, 2014). The discussion about patient- and family-centred care has become particularly important in the quest to understand the needs of the individuals involved as well as to improve satisfaction with the care provided in the ICUs (Ning and Cope, 2020). Among patient and family-centred care interventions, liberal ICU visiting polices have been associated with decreased rates of patients’ anxiety symptoms and increased rates of family’s satisfaction (Nassar Junior et al., 2018, Ning and Cope, 2020, Rosa et al., 2019).

The COVID-19 pandemic, with its high case and fatality rates, forced the world into lockdowns and social isolation that extended to critical care units. Almost every ICU has instituted a “no visitation” or, at least, a very restrictive visiting policy. These restriction visiting policies aimed mainly at reducing transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among relatives, patients and healthcare providers. Secondarily, they aimed at sparing personnel protection equipment (PPE) that could have run short and decrease healthcare team workload who already had to deal with an increasing number of severely ill patients. More than a year after all these severe restrictions were imposed, we can see all three concerns might be unfounded. First, only a minority of patients with COVID-19 had a hospital-acquired infection (Rhee et al., 2020). Second, there was no substantial shortage of PPE, at least in high and upper-middle income countries and visiting policies could have been relaxed in the second wave of the pandemic. Safe visitation could have been accomplished if visitors accurately reporting their symptoms and healthcare team helped them with the compliance with PPE (Munshi et al., 2021). Third, restrictive visiting policies ultimately led healthcare providers to regret about these restrictions and to witness hasty end-of-life decisions (Azoulay et al., 2020). For patients, an additional burden of restrictive visiting policies was delirium. In a multicentre multinational study, more than 50% of ICU patients with COVID-19 had developed delirium during their ICU stay. Family visitation (in person or virtual) was the only identifiable factor associated with a lower risk of delirium (Pun et al., 2021).

In this issue of Intensive and Critical Care Nursing, Jensen et al. (2022) present a study carried out in three Scandinavian countries on the challenges imposed by ICU visiting restrictions due to COVID-19 pandemic. Despite selection bias (Scandinavian ICUs only) and response bias (low return rate of questionnaires) this study sheds light on the impact of the pandemic on ICU routine and on nurses’ care. All ICUs had visiting restrictions. In Denmark and Norway, most ICUs reported a restricted access. Swedish ICUs mainly adopted a “no visiting” policy, only allowing access for relatives of dying patients. Surveyed nurses described several adversities imposed by the pandemic to the ICU routine: higher workload, a compromise on their usual professional standards of family care, an increased level of moral and emotional strain (as “they sought to balance the restrictions and the needs of patients and relatives”), among others. We can infer from this study that there were many causes for the high prevalence of psychological distress, anxiety and depression symptoms that comprised healthcare providers during the present pandemic. ICU restrictive visitation policies was one of them. Additionally, restricted visiting policies may have been impacting on patients’ outcomes, such as ICU length of stay, delirium occurrence and wellbeing, and on relatives’ satisfaction (Eltaybani and Ahmed, 2021, McLennan and Aggar, 2020), especially on those who could not be able to say goodbye to their loved ones, since facilitating a “good death” and humanized care at the end of life impact minimizing stress and processing grief (Otani et al., 2017).

Open visitation policies have advantages and disadvantages for patients, relatives, and healthcare providers (Table 1 ). Many relatives find visiting a critically ill patient in the ICU as a stressful event, fearing they will not be recognized by the patient, as well as finding them under mechanical ventilation and unable to interact (Schneeberger et al., 2020). Liberal visitation policies previously also seemed to be associated with increased burnout rates among healthcare providers (Nassar Junior et al., 2018), but this has not been confirmed in a recent randomized controlled trial (Rosa et al., 2019). As mentioned before, Jansen et al. suggested that restrictive visitation ICU policies during the current pandemic may have increased psychological distress among nurses. Therefore, evidence from clinical studies point towards for more benefits than harms for patients and relatives. Jensen et al. study adds evidence this may be the case even for healthcare providers.

Table 1.

Potential advantages and disadvantages of an open visiting policy.

	Advantages	Disadvantages	Scandinavian Experience during COVID-19 pandemic
For patients	More patient satisfaction; Promoting patient recovery by reducing stress; Positive psychological effect; Positive effects on vital signs, decreased ICU length of stay, less delirium	Patient not getting enough rest; nurses may have less time for patients; harmful physiologic consequences	Individual considerations must be considered;
For families	Less stress; less anxiety; improved communication with the healthcare team, engagement in patients’ care	Family members become exhausted and feel obligated to stay	Restricted access to loved ones; worse grieving (impossibility to say ‘Good-bye”)
For healthcare providers	Higher job satisfaction due to family members’ positive feedback; improved communication with families, improvement in nursing care due to better knowledge of patients’ values and preferences	Burnout; less time on direct patients’ care; More conflicts	Additional workload to supply family absence, less knowledge of patients’ values, increased stress, regret.

The COVID-19 pandemic has enormously burdened healthcare providers. However, the study of Jansen et al. has also suggested that creativity, common sense, and empathy of healthcare providers in supporting family members and facilitating communication/contact were essential for the trying to maintain humanized care within ICU. The study also stresses the importance of a qualitative data analysis to identify the subtleties of the impact of visitation restrictions on those involved. The evidence emerging from studies on ICU visitation policies during the COVID-19 pandemic has been shedding light on what practices should we modify, improve, or routinely adopt to improve our ability to provide family-cenered and to preserve healthcare providers wellbeing.