Introduction

Intensive care units are described by the families of the patients hospitalized in them as a cold and distant place, with restricted and exclusive access, where the severity and complexity of the ill person is paramount, which is why the family and friends are excluded, with the idea of providing better clinical care to the critically ill person ^(1-3). Some authors indicate that intensive care units are distinguished from other hospital areas by a high staff-to-patient ratio and access to advanced technological equipment that is not routinely available elsewhere in the hospital ⁽⁴⁾. Therefore, the complexity of these units could generate objections regarding free access for families; however, extending visiting hours in intensive care units and the participation of the family in planning the care of the critically ill person have been recommended by international societies and health organizations. As stated by the Italian National Bioethics Committee (INCB), which highlighted the fact that a liberalization of visiting policies is a concrete expression of the principle of respect for the person, and is consistent with the principles of autonomy, beneficence and nonmaleficence ⁽⁵⁾. According to the INCB and based on scientific knowledge, the presence of loved ones at the bedside in no way constitutes a threat to the patient; on the contrary, it has a beneficial impact on both the patient and the family. In particular, the INCB states that "from an ethical point of view it is unjustifiable not to perform a positive action that can provide benefits for the patient, except in absolutely exceptional cases". Only ethical and clinical reasons of serious health risks can justify the restriction of visits ⁽⁵⁾.

Despite these recommendations and scientific evidence, visiting hours are still restricted in most intensive care units in many countries ⁽⁶⁾. There are studies that reveal the importance of involving families in the rehabilitation settings in order to optimize outcomes. The probable benefits include redirecting family psychological distress to a participatory-active role, humanizing the patient's illness and recovery experience, supporting the healthcare system and staff beyond the constraints of therapy time ⁽⁷⁾.

Given the complexity of intensive care units and the latent need to improve the health of critically ill people, the aim is to identify and demonstrate the impact that the family has on the recovery of patients in these units. By supporting the positivism of such activity, future guidelines and sustainable theoretical evidence can be proposed and established as a strategic tool to provide holistic care. The objective of this work was to identify in the literature the impact that the family has on the rehabilitation and recovery of adults hospitalized in intensive care units.

Methodology

A review of the literature was carried out to answer the question: What impact does the family have on the rehabilitation of adults hospitalized in the intensive care unit? The PICOT strategy was used to structure the question ⁽⁸⁾. The CINAHL Complete, Scopus, PubMed and Scielo databases were used for the review, with 4 descriptors consulted in Spanish and English in the Health Sciences Descriptors (DeCS) and Medical Subject Headings (MeSH). First, the descriptors listed in Table 1 were selected. It should be noted that for a broader search "Rehabilitation" was used as a synonym for "Recovery".

The aforementioned databases were used with the Boolean AND, including the 4 keywords in the following order: rehabilitation AND patient AND family AND critical care, in order to perform a general search. The search was limited by the following items: published between 2014 and 2019, original research, adult and nursing category, excluding the pediatric category. The stages of this manuscript were: formulation of the question, search for information in the literature using search engines and electronic databases, analysis of the literature and reporting of the results. For data collection we used an instrument developed by us that included the following items: identification of the authors, title of the article, objectives of the manuscript, and results or conclusions relevant to the review and conclusions.

Thus, a total of 46 articles were obtained in CINAHL Complete, 353 articles in Scopus, 632 articles in PubMed and 13 articles in Scielo. Based on this, we narrowed down the searches through the selection criteria (inclusion and exclusion) and changed the order of the keywords. Four articles were selected from CINAHL Complete, 7 from PubMed, 5 from SCOPUS and 2 from Scielo. The 18 selected articles were thoroughly reviewed in order to obtain information regarding the objective of the review, in which a critical analysis and confirmation of the inclusion and exclusion criteria were carried out, so that 9 articles were selected for this review.

Results

Regarding the distribution by years of the selected articles, it is highlighted that 33.3% of them were published in 2016 and 22.2% in 2019. Regarding the geographical distribution, 44.4% of the selected manuscripts were produced in Europe, while 33.3% of the articles were produced in Australia and only 11.1% were produced in Latin America. The Table 2 lists in chronological order of publication each article selected for this review, which allowed a comparative reading between them, comparing the objectives and conclusions obtained by each author.

Discussion

This literature review has the objective of identifying the impact that the family has on the rehabilitation and recovery of adults hospitalized in intensive care units. Physical, psychological and emotional aspects and experiences of both the family of the critically ill person and the healthcare team are involved in the recovery; in the interactions, advantages, disadvantages and limitations are evidenced, as well as the interaction with the patient's rehabilitation during hospitalization and discharge from the intensive care unit.

As the first aspect, the importance of strengthening research on the subject is emphasized, in order to better understand the families ^(4,7,15); this way, they can modify their behavior and contribute to the improvement of the critically ill user. It is important to know how intensive care unit nurses can promote a family-centered environment by including the family in rehabilitation activities where appropriate. The studies reviewed indicate that empowering families in the rehabilitation setting requires an openness and willingness to learn from and with patients and their families, and to understand that all of these actions have the potential to lead to improved outcomes ^(9,14). Further research is recommended to explore this area in more depth ^(7,10). The authors postulate that it would be interesting and very necessary to develop other studies with different approaches, i.e. quantitative, qualitative and mixed, that would allow responding to the knowledge gaps regarding the impact caused by the family in the recovery of patients with critical health conditions, in order to answer questions such as: Are there macro- hemodynamic benefits in patients with family support during hospitalization? How long does it take to implement family support in the ICU? How many resources are needed to establish solid strategies regarding the incorporation of the family in the recovery of the critically ill? Should the healthcare team develop new visiting protocols for critical care units in Chile? Will the development of further studies help to break down the barriers visualized in this study and experienced in healthcare?

As a second relevant aspect, studies show that there are some key factors or aspects to strengthen the recovery of the critically ill patients. Authors describe key elements for the recovery of persons with critical health alterations, which include the following: a) medical knowledge and expectations, including the justification for rehabilitation, the perceived benefits and the actual impact of the benefits; b) evidence and application of rehabilitation, including when to intervene; c) patient factors such as prognosis, sedation, delirium, cooperation, motivation, goals and the presence of family; d) safety considerations, such as the physiological stability of the patient and the presence of devices; e) environmental influences, such as available personnel, resources, equipment, time and competing priorities; f) culture and teamwork, multidisciplinary team participation, professional roles, and communication; the culture of the unit was considered as the most relevant point ⁽¹¹⁾. Other studies recognize the family as a central and vital part of the critically ill person. However, the problem arises in clinical practice (in the everyday life of the ICU), since intensive care units are highly complex areas, which are characterized by being stressful and generating an emotionally labile atmosphere, for professionals as well as for patients and their families ^(1-3,12-13).

Finally, the literature reviewed indicates that a great deal of self-management by healthcare teams and families is required, so that entry and access is not arbitrary ⁽¹²⁾; some new methodologies have been applied in developed countries, but have not yet been implemented in developing countries or countries with lower economic income, or have not been reported to evaluate their effectiveness. On the other hand, it is recognized that empowering families in the framework of recovery and rehabilitation requires a cohesive health team that is available and prepared to learn from patients and their families, as the latter also have the potential to lead to improved outcomes ^(11,16), considering the possible constraints that may arise and the time needed to implement the measures. In order to enhance these work strategies, changes must be made with respect to the design, infrastructure and internal organization of intensive care units to improve the well-being and privacy of patients and their families, bearing in mind the personal and emotional demands of each of the patients and their families ⁽¹⁾.

Conclusions

The review conducted allows us to conclude that the units for critically ill patients continue to be a restricted and highly complex place, making it difficult for families to be admitted to these units. Although studies reveal the importance of incorporating the family in the recovery of the critically ill patient, since they are recognized as an important element in this health-illness process, there are still other aspects and areas to be researched, such as the consequences on clinical and hemodynamic factors, to mention a few, in order to demonstrate conclusively that the family resource should not be underestimated for the improvement of people with critical health conditions.

From the results obtained in this review, the positive impact of the family on the recovery of the person in critical condition is indirectly highlighted; however, there is still a void of expected clinical evidence for the application in intensive care units, due to the high demand for applicable and demonstrable evidence that these units require due to their high complexity.

The selected studies reflect on the need for educational interventions for the healthcare team as a strategy to understand the importance of recovery and rehabilitation from the moment the patient is admitted to the intensive care unit, in order to transmit the knowledge acquired by the team to the family, with the aim of providing greater confidence and security to enhance care. We cannot fail to mention that there are different mechanisms for implementing the improvement measures, regardless of what they are; all are evidence that there is a significant impact on outcomes, on family members' experiences and on patients independently. Finally, it is necessary to develop additional research from the discipline of critical care nursing, in order to explore the importance of incorporating families in the recovery of the person in critical condition, which not only have an influence on the emotional level, but also on the clinical level.

Conflict of interest

The authors stated there are no conflicts of interest.

Funding

This literature review received no funding.