Farell, et. al. also based their visiting policy on the response of the patient. Many reported that when the unit was quiet visitors were usually allowed to stay as long as they liked, and if a patient were dying all rules and regulations were suspended. All nurses agreed that they took the time to introduce visitors to the ICU environment, which is often frightening and overwhelming. It was helpful to notice that each nurse endorsed the fact that they treated patients as they would like to be treated themselves. Ultimately, this study identified that visiting the ICU is an experience that leaves many family members exhausted and overwhelmed and the nurses felt that access should be based upon the balance between the needs of the family and the need of the patient to have rest, quiet and more intensive care from the nurse. The study also identified that it was difficult for the nurses to do this, especially as patients become more seriously ill and require more intervention, and yet needed the time to be with the family. The study did not make and definite recommendations, instead simply noted that this was a complex situation. A study by Mendonca and Warren in 1998 reviewed the needs of the family members of critical care patients. As we have identified, this can be an overwhelming experience for the family member.

The study identifies several feelings that the family members experience and attempted to assess needs particular to the family members using a needs inventory and then reassessed the patient to see if the needs were met. Using a convenience sample of 52 family members, families were provided with three questionnaires; the first with demographic data, the second listed needs the patient's family may have, and the third questionnaire consisted of the same questions in the second questionnaire, except this time queried as to whether the identified needs had been met after three days in the ICU. The sample size was small at 52 participants, but the mean age appeared appropriate. The population was also evaluated for level of education and coping mechanisms, and existing family support. Also, it was a single center study so it is difficult to know if generalization is possible. Ethnicity was identified as a distinct variable in this study, with special attention being needed to ensure that culturally sensitive and competent care is provided. There appeared to be a negative correlation between perception of support and the level of education of the family members, and lays the foundation for further study.

A study on visitation policies in critical care was done as a performance improvement initiative (Roland, et.al. 2001). In this study, family members had expressed a significant degree of dissatisfaction with the restrictive policies that were implemented at the ICU of a combined coronary and medical intensive care unit. The administrative staff at the hospital found that review of literature on the subject generally supported the liberalization of visiting policies but there were not many actual studies done on the effect of such liberal policies on patient care. The setting for this study was a 15 bed unit in a large Veterans Administration Hospital. The Roland, et. al. hospital was unique in the studies we reviewed since this study took place at a regional referral center and in many cases, patients were required to travel long distances in order to see family members. Other VA hospitals were queried as to their ICU visitation policies and experiences, although this data set was limited in that not all VA hospitals offer intensive care services. The study received 20 responses, in which 12 of the units had restrictive visitation policies and the remainder had variations on the open policy, some of whom allowed children to visit in special circumstances. Local hospitals gave similar reports. Patients' families and staffs were included in surveying regarding level of satisfaction based on current visitation hours and needs. The patients were also surveyed as to how access to their families affected their health and recovery. The surveys for the families and patients were provided after the patient had already moved off the ICU. No residents were queried since their association with the unit was relatively transitory and therefore not statistically significant. The respondent pool was small. Twenty patients responded to the initial survey and identified that they were satisfied with the current, more restrictive visiting...

Family members expressed significant dissatisfaction with the restrictive policy; in fact 35% desired that no restrictions be placed at all. Nursing generally felt that the current policy was fine, and most felt that children should be allowed with certain restrictions. Eventually the visiting hours were changed with the caveat that the nurse on staff had the ability to override visiting hours based on patient needs. The liberalization of policy resulted in higher patient satisfaction scores after patients were re-surveyed after the new policy was in effect. One limitation of this study which should be noted is that the veterans at the hospital were a relatively captive population. The changes made in the hours were more liberal (visitation was allowed from 1000 to 1300 and 1700 to 2000) but this is still not as liberal as many commercially supported hospitals are considering. The VA patients are not able to "vote with their healthcare dollars" since they may only use their VA benefits at a different hospital. This may make them less likely to complain.
One must consider the findings of all these reviews in light of actual clinical practice. As reported in Boykoff (1986), patients find the presence of their families in all stages of their recovery important and Boykoff even noted an improvement in cardiac recovery time related to the presence of supportive family and friends. This has to be balanced with the fact that many of the patients in the intensive care unit require one-on-one nursing care, and the burden of the nurse who has to be a policeman for visitors, keeping them quiet and respectful of other patients can caused increased stress to staff and other patients. Perhaps the one overwhelming constant in all the literature has been the education of the visitors and the patients regarding visiting hours, and restrictions upon the same. It appears that if the patients and families understood what hours were, the rational behind any restriction that may be present, and the policies regarding any unexpected change to the policy, then there was a greater degree of satisfaction on the part of patients, family members and staff. It would appear that a too flexible policy to visitation, based upon the judgment of individual nurses on individual shifts caused the greatest degree of dissatisfaction for everyone involved, and also would seem to be impossible to adequately implement. The anxiety and stress on the family can be an adverse effect on the patient as well, (Chartier, 1989) and a few minutes spent in orienting the family member to the patient's surrounding, the meaning of alarms which may sound, and other daunting aspects of the high tech environment which is the ICU can reduce stress all around.

Ultimately, the idea of open visiting in ICU is here to stay. As our population becomes for medically savvy and willing to vote with healthcare dollars, healthcare will have to change to meet the needs of the patient/consumer and their families. More studies need to be done using random controlled trials to assess the effect of the open ICU staff on issues such as recovery time or staff satisfaction.