Are 24-Hour Open Visitation Policies a Bad Idea? (Yes)

[TheCommuter]

Many acute care hospitals across the United States are following a trend of eliminating visiting hours altogether, and instead opting for 24-hour open visitation policies. Nowhere in most hospitals has this trend been experienced more profoundly than within the walls of the intensive care unit (ICU). Are 24-hour open visitation policies a bad idea? I think so. Although open visitation has its benefits, I believe the drawbacks certainly outnumber the good aspects.

What is the case for open visitation?

First of all, a multitude of hospital administrators, nurse managers, and some critical care nurses feel that 24-hour visitation promotes a less restrictive, more welcoming environment for stressed family members. Secondly, since many ICU patients are sedated, intubated or otherwise cannot communicate effectively, family members who continually remain at the bedside might be able to answer important questions and fill crucial holes in a medical history that may very well be nebulous. Third, some would say that open visitation policies facilitate transparent communication between families and the healthcare team. Finally, open visitation allows family members to see for themselves that everything humanly possible is being done to care for the acutely ill patient.

What is the case against open visitation?

The ICU is supposed to provide a particular milieu that certain families often disrupt. For instance, the patient afflicted with a fresh brain injury on a vent needs plenty of peace and quiet to promote recovery, yet due to open visitation policies, his family members are allowed to constantly irritate him at 2 o'clock in the morning. And since there are no longer any limits on the number of visitors who can remain in the room at one time, multiple family members are camped out in the room, including several small children. Since the family is over-stimulating this critically ill patient, his blood pressure is spiking, so now the nurse must administer an antihypertensive drip. They continue to make noise and irritate the patient, and now he is having a seizure. And by the way, the family is disobeying the nurse's directives to avoid touching the patient or speaking too loudly while the patient is seizing.

Open visitation frequently leads to nightmarish scenarios such as large families who camp out at odd hours without leaving. The critical care nursing staff must now expend valuable time and effort tending to dysfunctional families, dealing with truly bizarre family dynamics, and fetching chairs, blankets and sodas. To be frank, normal families do not invite 15 extended relatives, including infants and small children, to visit a sick patient at 2 o'clock in the morning. These visits are now routine occurrences on many critical care units. Did I mention that some of these visitors are obscene? They disrespect nursing staff and sometimes make blatant threats that keep hospital security busy. I know the family is in crisis, but the line must be drawn.

For the best interest of patients and the safety of nursing staff, it is beneficial to keep visiting hours in place and allow the unit nurses to have the final say on this matter.

[Cuddleswithpuddles]

I wonder if there are any studies that look at the effects of open visitation on family members. In my experience, some family members feel obligated to stay and suffer as a result. I have had some spouses only leave to eat and bathe themselves haphazardly in our public restrooms. I *feel* like some of them needed "permission" to leave. Some reported feeling better about leaving, sleeping in their own bed, showering at home etc. after I had strong words with them. This is all based on personal experience, of course, but I would love to see this effect measured and quantified.

Or maybe I am just a grouch and would love a scientific reason to have less family around.

Edit: I just saw the AACN practice alert and there was evidence supporting positive family outcomes. Question... answered!

[mamax3]

Yes he does! Now I'm not a ICU nurse. I'm a floor nurse but this is just the most recent example of crazy family behavior I've had to deal with. Our satisfaction scores are not terrific and we've recently all had to attend in services over this. So we are walking on eggshells with patients and family even in cases like this where they are just blatantly wrong.

[edimo]

mamax3 said:

I agree with whoever said these policies are fine when dealing with "normal" family members. But what do you do when you have that son of the patient that feels it's perfectly acceptable to wander the halls in his underwear when he wakes up in the morning? Management will not back us up if we say something to this person. It's quite ridiculous.

Management needs to grow a pair; that is unacceptable behavior. I wouldn't let a patient roam the halls in their underwear, let alone a visitor!

[xoemmylouox, ASN, RN]

I am biased in this. My father was in the ICU years ago after an accident. I lived in his room those first 3 days when we didn't think he was going to make it. I left at shift change and when they did procedures. I was quiet and often sat with the lights off, tv off, etc. As he slowly recovered and was in and out of the ICU - Med Surg I returned to work, but was there every day for hours. Again I always left at shift change or when they needed procedures done. You know what it was the best thing for my father and myself. He ended up succumbing to a sepsis infection after a month of fighting. We reconnected over that month which I am so greatful for (we had always had a strained relationship at best), I prevented many med and other errors (like he was NPO due to an inability to swallow and they kept bringing in trays of food and water to his bedside), andI was able to make tough desicions when no one else (including my father) could.

While I understand that I am not the norm as many families are not respectful, are very needy, and are way inappropriate, I think visitation should be handled with a case by case situation. If a family abuses the visitation staff needs to be allowed to ask them to leave. Management must support their staff and back them when the family gets upset and complains because at the end of the day it is about the patient.

[amygarside]

Thanks for sharing this post.

[Racer15, BSN, RN]

I am torn. As a nurse (ER, not ICU) I get it. As a family member...I like the newer rules. When I was about 14 years old my great aunt was in a car accident and suffered head trauma that landed her in the ICU. We drove from out of state to see her, but per hospital policy, children were not allowed in the ICU. I was upset to say the least, but those fabulous nurses "snuck" me, my 10 year old sister, and four year old brother in to see her. She was thrilled, 15 years later and she still talks about the time we visited her in the ICU. For my aunt and my family, children being allowed in the unit was a good thing. We were quiet and the nurses loved us, I still remember how they called us her three angels, lol. But I can also see how it can be too much in a critical care setting. I've been on both sides more than once and I don't know what the right answer is. It's hard to be the family member being pushed out because of policy but it's hard to be the nurse trying to do your job with freakin crazy family at your throat.

[OrganizedChaos, LVN]

Someone posted this in Facebook, the rest times for the CVICU. It makes a lot of sense. I've never worked in a hospital, but I know how hard it can be to try to do procedures & can be taxing on the patient.

[SchoolNurseIrina]

As a recent patient going through ED, ICU, MedSurgTele, and MedSurg, I like the open visitation policy. Despite the fact that I am a nurse myself, having someone with me at all times was very comforting and I was confused for a good portion of my stay. I developed insomnia after a few days so having no restricting visiting hours was helpful in making me feel like I wasn't alone- also on 2 separate occasions my catheters were bleeding- which I didn't notice but my family member did.

I do agree that whole families (more than 2 people) camping out in the patient's room at all is not okay. Maybe a time limitation for a certain number of visitors should be enforced.

My family and in-laws were given a consultation room to camp out in for more than 7 days. It had a desk with a computer and plenty of reasonable chairs. People could do their work and sleep when they needed to. Maybe giving the family a place to camp out versus restricting them would be a better alternative. Granted not every hospital has room for that, but maybe for future design purposes it would work.

[oahufish]

Our Facility has recently implemented the 24/7 open Visitation Policy as well. It was put in place by management, hospital wide without and input from staff. We were originally told that it would be at the Nurses discretion, but are now being reprimanded by management if we ask visitors to step out for report or procedures!

I just don't quite understand why they are so insistent on it having to be 24hrs a day!!! Is it asking too much to have one unobstructed hour at each shift change to get in the room do a report uninterrupted, complete a good head to toe assessment, pull the sheets down see my patient from head to toe and complete some initial charting without an onslaught of questions and comments!!!

I'm in a fast paced CVICU which often means we're hustling in the morning to deline patients, pull chest tubes, get them up and moving around and ready for possible transfer out, all while getting ready for our next postop Heart. Everything goes so much smoother when we have uninterrupted time early in shift to get all this done...then when family does come in I'm more able to focus on their questions, concerns and patient plan for day.

The other scenario where I prefer not to have visitors is during the immediate Post operative period until I'm certain the patient is somewhat stabilized. If my patient is has uncontrolled bleeding, Tamponade, unstable CO/CI, unstable rhythm, CVVHD etc...I need to be focused on the immediate care and task's at hand and don't have time to navigate around visitors and be interrupted with multiple questions. As things improve, and are more under control they are welcome to step in for short visits and I'm more than happy to explain everything I'm doing, and any progress to the immediate family. As many other folks have stated though, this is not the time for Family Reunions with distant cousins and picnics in the room! As far as our stable postop and Tele holdover patients go, I have no problem with multiple visitors day or night...except for that our around shift changes. Unfortunately though, our management is not interested in how we are able to best able to manage the patient and provide care!!!

[ThePrincessBride, MSN, RN, NP]

I'm a little conflicted. On one hand, I would never want a limitation to when and how often parents can see their sick babies or spouses with their loved ones or children with their dying parent. My mother recently flew across the country to be with my very sick grandma. My grandma has seven kids and each one would stay at her bed side 24/7 and even sleep there so she wouldn't be alone. The prognosis was grim.

If it were my children, my mom/grandparents, or siblings, I wouldn't want visitation restricted in an icu setting. However, being a healthcare worker, I do see the cons of unlimited visitation and feel that health care providers should be allowed to kick out disruptive visitors and the visitors should be respectful and step out when the nurse needs to provide care to his or her patient.

[beckster_01, BSN, RN]

mamax3 said:

Yes he does! Now I'm not a ICU nurse. I'm a floor nurse but this is just the most recent example of crazy family behavior I've had to deal with. Our satisfaction scores are not terrific and we've recently all had to attend in services over this. So we are walking on eggshells with patients and family even in cases like this where they are just blatantly wrong.

Maybe the bad scores are coming from normal visitors that don't like seeing crazy people walking around in their underwear in the hospital.

[3fins]

Bottom line is 24 hour visiting policies make it more difficult for the nurse to care for a patient.

In other words, make it more difficult for the nurse to do what they're there to do.

Moving around a cramped room, finding visitors chairs, monitoring visitor behavior, dealing with needy families, family members who talk your arm off, etc. All this takes time away from patient care and the mountain of charting that is done in the unit.

And why is it that every kid under the age of 12 decides to take off his/her shoes once they enter the patient's room, and mom and dad remain oblivious?

FYI I'm known to be one of the most accommodating nurses on the unit when it comes to families, but I firmly believe in substantial limits on visiting in any ICU - several hours in the morning and several hours in the evening. Exceptions made only for a patient who is actively dying or going hospice.