Managing 24/7 Visitors

24 hour visitation seems to be the wave of the future, and whether or not we critical care nurses think it's a good idea, it's here to stay for many of us. So given that we cannot opt out -- unless the visitor actually hurts someone -- how do we deal with the visitors? Nurses Announcements Archive Article

Managing 24/7 Visitors

A brand new ICU patient, whether they are crashing with cardiogenic shock, fresh from the ER in septic shock or just back from the OR, is a busy patient. There are assessments to be done, labs to be drawn and body cavities to be accessed . . . IV, NG, Foley? Intraaortic balloon pump? Chest tubes? But often times family haven't seen the patient since they kissed them goodbye in the pre-op holding area or at the front door this morning. If possible, it's good to have the family back briefly to see the patient and to get a quick update of all that's being done to help them. If the bedside nurse is too busy, overwhelmed or crazed to deal with family right now, perhaps the charge nurse or a neighboring nurse who isn't caught up in the admit could show the family back, answer brief questions and then give them a time frame for when they can come back and stay for a spell.

When we tell families that they can stay however long they want, even overnight, we're creating an expectation. They believe that the loving thing to do, then, is to stay overnight. If they don't stay overnight they don't love the patient enough. When families expect themselves to stay at the bedside, they often overlook taking care of themselves, skipping meals, delaying bathroom breaks and forgoing sleep. So one of the first things I tell family is that it's OK to go home. When the oxygen masks drop in the aircraft, you put your own mask on first, THEN help others. Family members of critically ill patients need to be encouraged to take care of themselves. It doesn't hurt for the patient's nurse to check in with them . . . did they get enough sleep? Have they eaten? The cafeteria is on the first floor and they serve awfully good salads. (Or ice cream or whatever.) It's OK not to be here every minute because I'll be at the bedside -- they can call me anytime.

Family members who are told that while visiting hours are 24/7, it would be a good idea for them to go home for the night are more likely to actually GO home than family members who are simply told they can stay. I usually tell the families of my fresh post-op patients that "There's nothing you can do for him tonight -- but tomorrow he's going to have to get out of bed to sit in the chair or go for a walk, he's going to need help with his meals and reminders when it's time to cough and deep breathe. That's when you can really help him. So go home and get some rest now, so you'll be fresh in the morning when he needs you." I follow up with a card with the phone number for the unit and the message that they can call any time they feel the need and the nurse will give them an update.

It is helpful if there is someone besides the bedside nurse who can screen visitors -- and usually that falls to the first person they see when entering the unit. If that's a secretary, keep the secretary updated when visiting is going to be a problem. Let them know that "we're putting a line in Mr. Smith, and it will be at least 20 minutes before the family can come back," or "Mr. Jones' family can come back, but I need to talk to them about the isolation procedures first, so call me." If the unit is so poorly designed that the first person they see is likely to be some random staff person running between rooms (and my old ICU was exactly that way), it's far more difficult. If you're that random person they see first, direct them to the front desk, to the patient's nurse or even to the charge nurse or a Clin Tech who can help them -- don't just rush on by unless your patient has just arrested.

Family are more likely to pay attention to a closed door, a drawn curtain or a sign advising them to please come back later if someone has given them a heads up earlier. I try to give the family some expectations for the shift the first time I see them. "We plan to put in a central line sometime today. If you come back to visit and the door is closed or the curtain is drawn, please give us 20 minutes or so, and then come back again." Be sure to give yourself a generous time frame. If you tell the family they can come back in 20 minutes and it takes an hour to finish, they'll be understandably worried.

Most critical care units have some sort of rules for visitors -- ours are posted in the waiting room and spelled out in a brochure visitors are handed the first time they visit. Please follow the rules. If you don't adhere to the rules for visiting, the nurse who follows you and tries to enforce the rules is then the bad guy. It's a poor nurse who sets up her colleagues to be the bad guy, but we see it all the time. Someone just wants to get through their shift with a minimum of discomfort, and so lets the visitors do whatever they want without speaking to them about it. The next nurse is then treated to a struggle and potentially a nastygram from the family to the boss. Don't do it! Just stick to the rules. They can always be relaxed if it's a special case (Grandma is about to die or grandson just got off the plane from his deployment to the middle east), but if you DO relax the rules, make sure you TELL the family that you're relaxing the rules just for right now because it's a special case. Don't create the expectation that it's always going to be a party in the room at 3 AM.

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Ruby Vee

About Ruby Vee, BSN

Ruby Vee has been a critical care nurse since the dawn of time -- almost -- and has been the family member of a critically ill patient) on too many occaisions. She has been exposed to 24/7 visiting hours on both sides of the issue and knows how difficult it can be for everyone.

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Specializes in Peds, Med-Surg, Disaster Nsg, Parish Nsg.

Family members play an important role in the patient's recovery.

Thanks for all of the great tips and reminders on how to help manage family and visitors in a sensitive manner

thanks for sharing your thoughts. This will be of great help.

Should family members be considerate of the medical needs of their family member in the ICU, and the ICU environment? Yes, absolutely. Should family members make their own decisions as to whether to stay with their sick family member in the ICU 24/7? Yes, absolutely, as long as their conduct is reasonable. Should the family member feel they may go home to rest if they wish? Yes, absolutely. These decisions are individual decisions, made by family members, and while we as nurses may believe we have a greater perspective on the whole situation than the family members, when it comes to the decisions they make about their loved ones, we actually don't. It is up to the family members to decide how and to what degree they wish to support their sick family member. They have a relationship and a bond with that person that we as nurses don't. So we should tell family members they can stay overnight, if that is permitted by policy, as some close family members (who may be involved in the patient's care) will decide for themselves that this is the best way they can support their loved one, who they know far better than we ever will.

Studies in regard to extended visiting show only beneficial effects for patients and family members. If family members are willing to undergo the personal hardships associated with 24 hour visiting, then that is their decision to make. As I discussed with you on another thread, I have stayed with my family member round the clock on one occasion for 7 days, and on another occasion 8 days. I would absolutely do it again, as my family member felt very supported and motivated to recover, and in fact made very good progress and on the second hospitalization was discharged early. Having trained as a nurse, I was able to contribute to the care my family member received, which was also very helpful. Family members have to make their own decisions about what is right for the patient and for themselves. I do not believe that we, as nurses, should try to influence family to not stay 24/7, but should give the family members room to make their own decisions.

I'd be worried that if I told someone to go home and then the patient died, they'd blame me for them not being there when their loved one passed.

Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
Should family members be considerate of the medical needs of their family member in the ICU, and the ICU environment? Yes, absolutely. Should family members make their own decisions as to whether to stay with their sick family member in the ICU 24/7? Yes, absolutely, as long as their conduct is reasonable. Should the family member feel they may go home to rest if they wish? Yes, absolutely. These decisions are individual decisions, made by family members, and while we as nurses may believe we have a greater perspective on the whole situation than the family members, when it comes to the decisions they make about their loved ones, we actually don't. It is up to the family members to decide how and to what degree they wish to support their sick family member. They have a relationship and a bond with that person that we as nurses don't. So we should tell family members they can stay overnight, if that is permitted by policy, as some close family members (who may be involved in the patient's care) will decide for themselves that this is the best way they can support their loved one, who they know far better than we ever will.

Studies in regard to extended visiting show only beneficial effects for patients and family members. If family members are willing to undergo the personal hardships associated with 24 hour visiting, then that is their decision to make. As I discussed with you on another thread, I have stayed with my family member round the clock on one occasion for 7 days, and on another occasion 8 days. I would absolutely do it again, as my family member felt very supported and motivated to recover, and in fact made very good progress and on the second hospitalization was discharged early. Having trained as a nurse, I was able to contribute to the care my family member received, which was also very helpful. Family members have to make their own decisions about what is right for the patient and for themselves. I do not believe that we, as nurses, should try to influence family to not stay 24/7, but should give the family members room to make their own decisions.

As I probably told you on a previous thread, I, too have been the patient and the patient's daughter. 24/7 visiting is not for everyone, yet many family members take it as "If I don't stay at the bedside at all times, I don't love the patient enough."

I spent 12 grueling days at my father's bedside -- 10 of them in ICU -- because the nurse presenting the "option" to us as a mandate. My mother and my sister both heard "you WILL stay at the bedside as long as he is here" when the nurse told them they "MAY." Mother wouldn't leave the bedside, and my sister fully supported her . . . although someone (that would be me) had to stay with Mother because she had early dementia and strange situations and sleep deprivation exacerbated her dementia. At the end of that time, mother's dementia had finally become obvious to even casual observers and I think I was probably psychotic as well. How kind it would have been for some nurse to take pity on us and insist that Mother leave to get some sleep . . . so that I could as well! I discussed the situation with both Dad's nurses and Dad's doctors, but everyone was terrified of getting a bad survey if they told us we had to leave. So they left it up to Mother (the one with the obvious dementia) to decide.

I'm not saying that every family has a family member with dementia or that my situation was universal. What seems to be becoming universal, however, is the mindset that we as nurses are creating: if you DON'T stay all night, you're a bad family member. This is nuts.

Great post Ruby !!!! Great advice on how to manage visitors especially in the ICU.

I think all Ruby is saying is as nurses we should give families that option. When I worked in ICU I presented studies on the benefits of having overnight visitors with ICU patients. Studies do show that it can improve a patients' well being in some circumstances. However, not all family members can handle spending a lengthy time at the bedside with their sick loved one. It is okay for the nurse to recommend to go home, get rest, eat, and etc.

Specializes in critical care, neuro.

I love this. I always get so engrossed in the patient that I forget about this frequently. Yet get exhausted by the hovering family member. I need to remember to tell them to get some rest at home - especially because when they're in the ICU the family needs to get rest so that when the patient goes to the floor and goes home, they're at the top of their game.