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.

[Ruby Vee, BSN]

canoehead said:

I remember the mayor of a small town spending a week in the ICU, and every businessman and friend felt the need to come in and say hello. We had open visitation, so we couldn't say no, and he didn't feel he could alienate his work contacts. He was busy networking for 10-12 hours of every day. No one had the sense God gave a goose, if he got sicker, they wanted to stay and support him, but what he needed was rest (and visitors that could take a damn hint to leave).

The trouble with restricting, and making exceptions, is the people that look around and demand more based on what they see other people getting. We can't explain the reasons to their satisfaction because of confidentiality. They keep pushing, and letting them stay becomes less disruptive than getting them out. Our security won't physically force people to do anything, unless punches are thrown. I had a visitor that was going to sleep in her mom's ICU room (not allowed) and insisted on pulling her recliner right up next to the bed, blocking access on that side. Nothing we could do, she wasn't violent, just unsafe. Locked doors are my answer, security holding the line, the bathroom and food being outside the unit. Everyone will need to leave eventually, and if they don't respect nursing instructions when they are in the unit, they have a time out where they can't return for an hour, or a day, or longer.

We're a few years into our brand new building with its brand new ICUs. The ICUs were designed years before construction began, at about the time when the tide started turning from strictly enforced visiting hours to open visitation. The design incorporated all private rooms, each with a sofa (seating three), two visitor's chairs, a recliner for the patient's use and a rolling chair for the nurses to use while charting at the bedside computer handily attached to the wall with flexible "arms". We had a large waiting room for families (bigger than my first few apartments) with sofas for sleeping, tables and chairs for eating and a plethora of "laptop tables' scattered around the room. There was a refrigerator for storing lunches and drinks and a microwave for heating them, a sink for washing dishes and a few ground rules. "No food or drink in the patient rooms was one of the few ground rules." "No cell phone use in patient rooms" and "only two visitors in the room at a time." We also allowed as how "one visitor can stay the night to provide support to the patient."

Even those few rules were widely disregarded, both my families and by the (usually young, new) nurses who wanted to be seen as "the good guy" or to "just get through MY shift" who didn't mind throwing their colleagues to the wolves. (Because when you're the first nurse to insist that a rule be followed, you're the BAD nurse.)

The design featured visitor's restrooms that were not only off the unit, they were a bit of a walk down the hall and positioned next to the elevators (where they could easily be located) and the big waiting room shared by the two ICUs on that floor. For the first year, my manager bemoaned her "mistake" in allowing the visitor's restrooms to be off the unit, forcing visitors to walk down that long haul to use the toilet and requiring that they be buzzed back into the unit after 9pm. But repeated exposure to what families attempted to get away with and actually DID get away with changed her mind.

There was the family that set up the brazier (open flame) in the waiting room to cook traditional ethnic meals . . . That went on for a whole weekend until other families complained. There was the family who took over an open conference room, locked it from the inside and only opened the door for their family members who knew the "special knock". When we needed to use to conference room, we had to get security to open it using the master lock and found several toddlers running around unattended, an adult passed out on the couch with a mostly empty bottle of vodka and several other open liquor bottles. One of the toddlers had to have her stomach pumped because of the alcohol she was consuming. The family was incensed that we "Violated their right to privacy."

There was the 50 year old CABG patient who was so scared he had to have his 80-something year old mother spend the night with him. She couldn't sleep in the recliner or on the sofa bed, required help with toileting (which aforementioned nurses who weren't rule followers provided on their shifts) and needed meals fetched for her. She had to be walked to the visitor's lounge to eat those meals because she couldn't remember where it was. One memorable night when I was in charge, she wandered into another patient's room to use that patient's toilet (without pulling the privacy curtain because, given that that patient couldn't get out of bed to USE the toilet, we'd removed the curtain for cleaning) and gave that patient quite a visual. The CNAs escorted her to the employee bathroom, toileted her, cleaned her up, and took her back to her son's room. But she needed to go to the bathroom again, and became confused about where she needed to go. My first inkling of the problem was at 2am, doing emergency equipment checks, when I rounded a corner in the hallway and found a naked octogenarian squatting and pooping in the hallway.

Now we have to SPECIFY in the list of rules that adults who spend the night are responsible for self care. I never would have believed that such a thing would be necessary. It's crazy!

[Ruby Vee, BSN]

zappae63 said:

Imagine you are at home I bed because you have a terrible cold or headache, you wake up and family members are in your room as you try to rest. Do you get visitors at your house when you are sick? Why is it when a patient just had a CABG everyone decides to visit? The patient is not only exhausted,but also in a great deal of pain.

1. Visitation should be a right not a privilege. Visitors who disorderly, rude and who reek of body odor and or too much perfume need to be escorted to the nearest exit.

2. Visitors can easily distract nurses when programming Smart pumps, assessments and patient care. I can't think of anyone I know who would want a bunch family members in the room for a bath or linen change. I guess one's spouse or significant other.

3. We are not waitstaff to the patients families and or friends. I mention friends because some patients prefer their friends.

4. Yes, I agree as ICU nurses we need to allow families to visit, perhaps not 24/7 but through the day and night for periods of time.

5. Our unit closes at shift change at handoff. We tried to open the doors in the past and allow visitation however a visitor developed a case of "nose troubles" and listened to pieces of the handoff on another patient.

6. With the impending nursing shortage on the horizon, I hope upper management does not make an OVP in our unit because most of us find many of the visitors barriers to patient care.

I totally agree with the premise in your first paragraph. Then I digress. Visitation is a privilege, not a right. Other than that, your post is spot on.

[Ruby Vee, BSN]

Salter444 said:

I have read a few studies regarding open visitation and I keep feeling they are all skewed to deliver the politically correct answer. There are multiple factors that make open visitation good for the patient/family as well as many valid reasons where the policy can hinder care.

I am old school and still prefer more structured visiting hours in more acute areas. No visiting during change of shift, no early morning visitation (am care) and no overnight in-room visitation. Granted there are exceptions to all rules but overall limiting visitation allows for better coordination and delivery of care.

I, too have read the studies and walked away with the same unsettled feeling that the studies are skewed. Or wrong. Or failed to include enough variables.

A nice, supportive family who is honestly here to support Dad through his surgery and who respect the nurse and the process of hospital care are not only a support to the patient but a pleasure for the nurse to deal with. And there are some of those families out there -- I see more of those families in some of the places where I've worked than in others. In some locales, the norm is a noisy, disruptive family who couldn't care less about Dad, but who view visiting as entertainment. (As a CNA colleague of mine observed, "We got cable, guest internet and air conditioning. That's why they're here. They probably haven't bothered with Dad (or Mom or Granny) in years."). I suspect the studies were done in the nice, midwestern suburban hospitals where families tend to be less obviously dysfunctional than in the large, inner city teaching hospitals where knives are pulled to address family disputes in the patient's room.

[Ruby Vee, BSN]

zappae63 said:

Oops I meant to say visitation should be a privilege not a right.

Oops. I responded before reading this. So we are in agreement.

[delphine22]

Our unit keeps waffling because there's a push to involve the pt's significant other/decision maker in bedside report, especially if the pt is sedated or confused. Then there's a rule that everyone BUT one support person clears out between 6:30 and 7:30 am and pm. We are a locked unit so every visitor has to call in to gain access. Shocker, when we're all in report and have no secretary at night there's usually no one to answer the phone!

One time I tried to enforce this, answered the phone (which had been ringing for a solid minute) during shift report and said, "I'm sorry, we're in shift change right now and can't admit visitors, please follow the signs and wait in the waiting room until 7:30 and then call back." It was a patient's wife who only had a short window to visit and he wasn't oriented. I felt like crap saying no to her and let her in.

[The_ABG_Queen]

I'm an RT. They enacted open visitation in our ICU this week and it's already causing problems. Family waltzed right into the room in the middle of a bronch. They were upset at what they saw and started asking the doctor (you know, the guy performing the bronch) a bunch of questions. It was Incredibly distracting. Eventually we had to have someone escort them out. The Dr. was irate because he could have made a grave mistake being distracted that way. The door to the waiting room is now unlocked and there is no way to prevent the family from coming in once the procedure started because everyone involved in the care of that patient was already in the room. What happens when we crack a chest bedside in the CICU and the family walks in and sees their loved one's chest wide open? Or the gunshot victim who was admitted under an alias because someone tried to kill him and now the killer comes back to finish the job? No metal detectors. No locked doors. It's a BAD policy.

[Lunah, MSN, RN]

The_ABG_Queen said:

I'm an RT. They enacted open visitation in our ICU this week and it's already causing problems. Family waltzed right into the room in the middle of a bronch. They were upset at what they saw and started asking the doctor (you know, the guy performing the bronch) a bunch of questions. It was Incredibly distracting. Eventually we had to have someone escort them out. The Dr. was irate because he could have made a grave mistake being distracted that way. The door to the waiting room is now unlocked and there is no way to prevent the family from coming in once the procedure started because everyone involved in the care of that patient was already in the room. What happens when we crack a chest bedside in the CICU and the family walks in and sees their loved one's chest wide open? Or the gunshot victim who was admitted under an alias because someone tried to kill him and now the killer comes back to finish the job? No metal detectors. No locked doors. It's a BAD policy.

Oh, no no no! Open ICU does not mean WIDE open, the unit should still be locked, the number of visitors at one time should be limited, and nurses and staff need to maintain some control over the environment. That is awful and unsafe.