Visiting policy in Spain is very restricted, with a closed ICU culture despite the fact that many studies recommend an open-door approach with incorporation of the family to patient care.12–19 Families demand more time and flexibility in visiting. There is no reason for being restrictive in this regard, and it has been demonstrated that visits improve patient wellbeing, lessen family anxiety and increased perceived quality of care–thereby improving the image and humane dimension of the organization. A freer, expanded and more flexible visiting regimen allows families to adapt patient care to their working obligations and the care of other family members, such as children or the elderly. Closeness to the patient in critical situations or when death is imminent is even more necessary, and is of help in the mourning process. In cases of particularly vulnerable patients such as those with Down syndrome, mental disorders, very young patients or subjects with intense stress, permanent accompaniment by the family should be allowed.

Considering the risk of infections and potential psychological trauma, the visiting policy referred to children has been even more restrictive. However, in the pediatric and neonatology ICUs, where visiting is allowed, no increase in infections has been reported.20 Some studies have found that patients see visits by their small children as a potent stimulus for recovery, and it has been demonstrated that children who have been able to visit their ill relative have been able to better understand the situation and the disease.20–22 If the patient/family so wishes, visiting by children should be allowed, adopting an individualized approach. This requires organizing the visit, providing information in simple language, offering all professional support for the child, and following a scheme or protocol established according to different age groups.

Different international recommendations consider that family visits should have no restrictions, although logically visiting must be adjusted to the patient desires and clinical conditions.15,23 Our patients have the right to receive the affection and care of their relatives, and so an open-door policy should be a priority issue in the organization of the ICU.

We know that families wish to participate in patient care. If feasible from the perspective of the patient clinical condition, families could collaborate in some aspects of care, such as personal hygiene, the administration of meals, or the stimulation of physiotherapeutic exercises–in all cases under due nursing supervision. Offering the family the opportunity to contribute to recovery of the patient may have a positive effect for both the patient and the caregiver, reinforcing closeness and communication with the healthcare professionals. Some nursing societies have drafted recommendations on how to integrate family participation in patient care, based on the philosophy of centering care also on the family10.

People increasingly demand more information and more active participation in relation to health decisions. Studies in different cultural and geographical settings indicate that one of the most important aspects referred to patient and family satisfaction is communication with the healthcare professionals.24,25 Working in an ICU requires communication skills, since incorrect information can adversely affect the relationship with the medical team. In general, training in communication has been lacking, and conveying information is a difficult art that is learned through practice, mistakes and common sense. If we want to do things correctly, we must learn and use the specific methodology referred to communication in situations of crisis. We must be able to transmit very technical and complex information in simple and easily understandable terms; explain the diagnosis and prognosis; modulate the high emotional content of the message; and control the stress it produces. We also must remember that physicians are exposed to their own worries and concerns, and that the task of having to give bad news produces anxiety in the healthcare professional. Bad news must be explained clearly and with empathy, adapting ourselves to the rhythm of comprehension which the patient/family needs, and detecting situations of emotional block and denial of reality. The family suffers anxiety and depression, which complicate the understanding of information and the decision making process. The professional must understand, cope with and redirect inadequate emotional reactions with assertiveness, and at the same time must show understanding and empathy. The family typically has greater confidence with the nursing personnel, and lets them know their doubts and concerns. In this context it is necessary to divide the information given: the nursing professionals must talk to the family about general patient care and the use of apparatuses (respirators, monitors, alarm systems), and the physicians must address matters related to diagnosis, prognosis and treatment. It is important for the professionals working in the ICU to improve their training in communication skills with a view to achieving greater levels of satisfaction, a better physician–patient relationship, and less personal stress.

Some studies have found that critical patients remember intubation and the incapacity to speak as one of the most bothersome and stressing experiences. Communication between the intubated patient and the healthcare personnel is generally insufficient and ineffective, and this proves frustrating for everyone. It is despairing to watch the efforts of intubated patients to express something, and to see how professionals try to explain different options without success–until they stop trying and simply say: “I don’t understand you, but don’t worry, everything is fine”.26 Communication with intubated patients requires personal effort, time, interest, and a clear understanding of how important it is for the patient to be understood. Intensive Care Units should work to design and develop new non-verbal communication systems that can allow us to communicate with intubated patients, since the classical systems (involving written words or images) are limited and insufficient.

A recent study in France has found that only 72% of the ICUs have individual rooms, 66% have natural light, 26% have telephone access, 38% have radio access, 68% have a clock within view, and only 11% inform of the date.27 The lack of natural light and a visible clock causes a loss of time reference and alterations in circadian rhythm. Too much light during the night in turn prevents melatonin secretion, which is essential for inducing sleep. One of the most frequent patient complaints is the impossibility of sleeping because of too much light and noise.27 Some studies have even found noise to exceed the maximum levels recommended by the World Health Organization.28 It has been described that poor sleep quality and delirium may be associated29–the latter in turn having important short- and long-term repercussions. In this respect, some studies have reported a decrease in the appearance of delirium when nighttime rest is facilitated by improving the environmental conditions (e.g., by turning off lights or making use of ear plugs and sleep masks).30 If we want to improve patient sleep, one of the pending issues is lowering light intensity and noise levels. Strategies should be adopted, such as good alarm management, adequate illumination systems, and increased awareness among all healthcare professionals of the importance of caring for patient quality of sleep.

In open-door ICUs, personal hygiene and clinical exploration are sometimes performed without taking patient embarrassment or the presence of other non-ICU professionals into account–this constituting a lack of respect for patient privacy. In general, patients in the ICU are naked–this being absolutely unnecessary provided they are clinically stable. Such a situation can go against patient dignity. In this regard, patient clothing should be considered, with the adoption of additional efforts to protect individual privacy. We also should ensure a more friendly environment and improve patient wellbeing (e.g., music, television), and facilitate communication and the right to maintain social ties, with access to mobile phones and electronics.

One of the most common complaints among families is the fact that waiting rooms are uncomfortable and unpleasant. These rooms should be made more comfortable both in practical terms (with nearby toilets/bathrooms and cafeterias) and as regards their appearance–avoiding the typical dull institutional image and creating a more pleasant and relaxing environment. With a view to improving the comfort of patients in the ICU, some scientific societies have developed a series of recommendations15,23,31 that can help make the ICU a much more pleasant place.