Visiting hours and quality of care: an unscientific study

Nurses General Nursing

Published

I work at a medium sized community hospital, on a mixed unit; meaning we have several intensive care beds on our floor, and several more stepdown/med-surg beds. We have had a change of leadership lately, and one of the changes that this new leadership has instituted has been to restrict visiting hours significantly. In the past it has always been up to the discretion of the RN who can visit, for how long, etc. There were policies in place, but they were very loosely enforced. Now it is expected that we adhere to these policies with no flexibility whatsoever (the only allowable exception being a hospice/comfort care patient).

Let me tell you how this is working out: the day nurses love this system. The get to get all of their work done, and not deal with visitors until the very end of their shift. The night nurses on the other hand hate the system. We are the ones who come in to work with family members breathing down our necks for the first hour of our shift, and then we are forced to be the ones who tell them they have to leave. When a post-operative patient in horrific pain is crying because you're telling her that her mother has to leave, you don't feel like you are providing good patient care. We as night nurses agreed to speak to said leadership today regarding how these policies are affecting us on nights, and were met basically with a stone wall. "These are the policies and you have to enforce them."

What is bothering me the most is that we are not being given any facts or evidence to back up these policies. I have been doing some research on my own, and most of what is out there seems to point to the opposite: less restrictive visiting policies seem to improve quality of care, as well as patient satisfaction. My research, as well as discussions with other RN's at other facilities in the area seems to point to a national trend in the opposite direction of that in which my institution is headed.

So, my question to all of you is what have you experienced in this respect? What visiting policies are in place where you work, and how strictly are they enforced? Are you allowed to use your nursing judgement at all in deciding who stays and who goes, or is it completely out of your hands? How have you seen these policies affect patient outcomes, and satisfaction?

P.S. It would help me if when you answer the above questions that you provide me with the type of unit that you work on, as well as the geographic location (you don't have to be specific, northeast, etc would be fine.)

You obviously have a poor understanding of how the Canadian health care system works. Although American nurses may practice in fear of getting fired with every decision they make, Canadian nurses do not. Patients will continue to flood the hospitals irregardless of how good our customer service techniques are. Without this barrier of fear, we have the ability to be more autonomous and free-willed with our decisions. Visiting hours exist for a reason: because vistors tend to get in the way more than anything impeding a nurse's ability to do her job. If you don't trust your loved one to stay overnight safely in the care of hospital staff, then you should be nursing them yourself in the confines of your own home.

I'm not comfortable having my family members stay overnight in the hospital without someone with them. Sadly, and with good reason, I'm not able to blindly trust that they will indeed remain safely in the care of hospital staff. I truly admire these nurses, they are functioning the best they can while extremely short staffed, insanely busy and high acuities. Unfortunately, I'm all too aware that often that is not enough to maintain safety. Just in my small circle of family and friends alone there have been numerous mishaps:

  • Stretcher side rails left down in ER hallway. Pt fell off resulting in concussion, seizure and fracture.
  • Following MVA, Pt was braced for suspected neck injury and placed in supine position with instructions not to move. Student radiology tech attempted to get her to stand up for x-ray.
  • Post Op pt fell out of bed in middle of the night and remained on the floor between bed and wall for hours.
  • Post Op pt on analgesia pump was receiving 10x the dose ordered.
  • Post Op pt was receiving pain med via epidural. Pt kept complaining of increasing pain and that something was wrong with the epidural. Concerns dismissed until time to take it out and lo and behold there was the tip sitting right on the skin.
  • Confused elderly patient on telemetry unit disconnected leads and walked off the unit. Family received call that he was lost - they found him wandering out back of the hospital.
  • Documented allergy to IV antibiotic that was hung.

When staying with family members I don't announce that I am a nurse, I remain out of the way, respectful, considerate and most of all appreciative of the care they are providing. I am not there to "visit" or continually talk to the patient, I work or read quietly in the background and am available when my family member needs assistance, as well as monitor meds, treatments and diagnostics and physical safety.

Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
family/friend involvement in patient care produces better patient outcomes.

wouldn't improved patient outcomes be a major indicator of "good patient care"?

i'm going to assume that you're pre-nursing, a nursing student or a brand new nurse.

there may be some studies that indicate that visitor involvement in patient care produces better outcomes. i cannot help but think that those studies were done in the midwest where it seems family craziness is at it's lowest point in the u.s. i'm basing that observation on years as a nurse rather than a scientific study. by and large, however, the families i see where i work now do not support, encourage or help care for the patient. instead, they throw fits and demand this or that -- always something difficult to provide. the hang out in the room and have a party or, worse, a fist fight over who gets grandma's necklace when she's gone -- and grandma is still alive.

there was the husband who waited patiently by his wife's bed for her to wake up under surgery. when she woke up, his words weren't of love and support. no, the first words out of his mouth were "i killed your dog." there's the mother visiting her 29 year old son who is dying by inches and in incredible pain every moment. his mother has forbidden the staff from medicating her son with narcotics during visiting hours because "then he sleeps through my whole visit." there are the families who bring decades old feuds into the hospital, where shouting often erupts. they sit and slurp their big gulps and knaw on their kfc in front of the loved one they're visiting -- they one on a fluid restriction -- with the smells in the face of the npo roommate. they demand so much attention from the nurse that the patient is overlooked.

i reiterate that visitors are the largest obstacle to good patient care. ymmv

Specializes in Critical Care.
i'm going to assume that you're pre-nursing, a nursing student or a brand new nurse.

there may be some studies that indicate that visitor involvement in patient care produces better outcomes. i cannot help but think that those studies were done in the midwest where it seems family craziness is at it's lowest point in the u.s. i'm basing that observation on years as a nurse rather than a scientific study. by and large, however, the families i see where i work now do not support, encourage or help care for the patient. instead, they throw fits and demand this or that -- always something difficult to provide. the hang out in the room and have a party or, worse, a fist fight over who gets grandma's necklace when she's gone -- and grandma is still alive.

there was the husband who waited patiently by his wife's bed for her to wake up under surgery. when she woke up, his words weren't of love and support. no, the first words out of his mouth were "i killed your dog." there's the mother visiting her 29 year old son who is dying by inches and in incredible pain every moment. his mother has forbidden the staff from medicating her son with narcotics during visiting hours because "then he sleeps through my whole visit." there are the families who bring decades old feuds into the hospital, where shouting often erupts. they sit and slurp their big gulps and knaw on their kfc in front of the loved one they're visiting -- they one on a fluid restriction -- with the smells in the face of the npo roommate. they demand so much attention from the nurse that the patient is overlooked.

i reiterate that visitors are the largest obstacle to good patient care. ymmv

i'm actually years out of nursing school, although even when i was wet behind the ears i was probably less tolerant of visitors, not more tolerant.

obstacles to good patient care would include inappropriate staffing levels, lack of resources, poor inter-provider communication, lack of evidence based knowledge, etc.

the patient's family/support system dynamics are more of a complicating factor than an obstacle. labwork, vital signs, pain, etc. are also complicating factors since our jobs would be much easier if we didn't have to deal with them, but correcting them, and even working them to the patient's advantage is an important part of what we do.

if a family is acting inappropriately or potentially negatively affecting the health of the patient, educate them, which may involve kicking them out. we can remove the family factor in the hospital if we want, but that just means there's one big issue we neglected to address that is going to negatively affect the patient's health in the long run. if a mom is insisting that her adult son not be medicated for pain, explain it's not up to her, i know it's a pain, but it's not worth throwing the baby out with the bath water.

Specializes in FNP.

We have open visiting, and while I agree it is a PITA, I don't think it effects my job performance. I do think it can negatively impact patients, but I don't have any data on it. A lot depends on whom is there. We have had visitors that were quiet, unintrusive and actually helpful to their loved one, and we have had visitors be disorderly, demanding and disruptive. I am not about to get into a power struggle w/ visitors. If they want to impede the care of their friend or family member, that is a problem they will have deal with within the family. If they impede the care of others in the unit, I simply have them thrown out.

Ruby, I have seen all those scenarios and more. There really is a great deal of weirdness out there!

Specializes in Public Health, TB.

Jeez, Ruby, I am beginning to think you are magnet for whackadoodles!

But seriously, the articles I have read about visitation describes 1-2 immediate family members at a time, which doesn't seem unreasonable (unless they are psycho). In fact, we ask a family member to stay with the confused, demented pt so that we don't have to restrain(we never have enough sitters and our hospital hates to pay for them).

I am on a cardiac floor, and we get crowds of family, neighbors, co-workers, dealers, what have you. You can ask, demand, order them to leave, but as soon as you enter another room, another group has moved in.

Instead of having to call security when there is a problem, I would love to have them at the entrances, screening people as to their intent and relationship to the patients. Make them sign for one of two visitor badges available for each patient. Both badges signed out, so sorry, perhaps you would like to wait or try later?

Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
jeez, ruby, i am beginning to think you are magnet for whackadoodles!

but seriously, the articles i have read about visitation describes 1-2 immediate family members at a time, which doesn't seem unreasonable (unless they are psycho). in fact, we ask a family member to stay with the confused, demented pt so that we don't have to restrain(we never have enough sitters and our hospital hates to pay for them).

i am on a cardiac floor, and we get crowds of family, neighbors, co-workers, dealers, what have you. you can ask, demand, order them to leave, but as soon as you enter another room, another group has moved in.

instead of having to call security when there is a problem, i would love to have them at the entrances, screening people as to their intent and relationship to the patients. make them sign for one of two visitor badges available for each patient. both badges signed out, so sorry, perhaps you would like to wait or try later?

that's me -- a whackadoodle magnet!

i love your idea about security and the visitor badges. it would take crowd control out of our purview and put it where it belongs; with people who are trained in crowd control. without having to enforce crowd control in our 6 bed ward or our triple rooms, it frees me to actually teach the family, update them, work with them. none of those things are possible if multiple family members for each patient are causing a disruption . . . and we usually get at least one of those a day.

Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
i'm actually years out of nursing school, although even when i was wet behind the ears i was probably less tolerant of visitors, not more tolerant.

obstacles to good patient care would include inappropriate staffing levels, lack of resources, poor inter-provider communication, lack of evidence based knowledge, etc.

the patient's family/support system dynamics are more of a complicating factor than an obstacle. labwork, vital signs, pain, etc. are also complicating factors since our jobs would be much easier if we didn't have to deal with them, but correcting them, and even working them to the patient's advantage is an important part of what we do.

if a family is acting inappropriately or potentially negatively affecting the health of the patient, educate them, which may involve kicking them out. we can remove the family factor in the hospital if we want, but that just means there's one big issue we neglected to address that is going to negatively affect the patient's health in the long run. if a mom is insisting that her adult son not be medicated for pain, explain it's not up to her, i know it's a pain, but it's not worth throwing the baby out with the bath water.

we don't have enough staffing to take care of the patient and multiple disruptive family members, or multiple people who seem to feel that they deserve some pampering, too. one determined family member can triple or quadruple your work-load, a few who aren't even trying to be a bother can double it. and in this current climate of "customer service," we have no power to eject visitors who are negatively impacting the health of the patient. (or if we do eject them, our manager relents and lets them back in -- even after they've threatened staff with deadly weapons.) as far as the mom insisting that the adult son not be medicated -- it was up to her, whatever i thought about that. she talked to the doctor, and the doctor wrote an order for no pain meds between the hours of xx and xx. (yes, i know the doctor was wrong, but that's the least of his issues!)

i've worked places where the family was reasonable, grateful and honestly trying to be helpful. most of the families i encounter in this hospital are not. sometimes, it is worth throwing the baby out with the bathwater. but your milage may vary.

Specializes in Assessment coordinator.

I remember 34 years ago asking my instructor a question that I have continuously asked everyone who restricts visiting hours on the sick:

"What, exactly, are we, or am I doing to this person that their family should not be witness to?" In 34 years, I have never been hindered by the presence of family members. If everyone wants to watch an enema, so be it, if the patient is ok with it. I have never received an answer that makes me want to limit visitors. My family has been in several institutions, and I firmly believe that there are some care situations where a loved one should never be left alone. Just try to throw me out if I am causing trouble. One doctor totally freaked out when my son's father videotaped the closed reduction of his wrist fracture. We weren't out for lawsuits, my son loves watching his morphine video as he calls it, from 16 years ago. Again, what are you doing that the family shouldn't see. If everyone had a vigilant family member there would be less med errors....etc.

Specializes in Emergency & Trauma/Adult ICU.
.Make them sign for one of two visitor badges available for each patient. Both badges signed out, so sorry, perhaps you would like to wait or try later?

LOVE this idea. So simple, so common sense.

Specializes in Emergency & Trauma/Adult ICU.
I remember 34 years ago asking my instructor a question that I have continuously asked everyone who restricts visiting hours on the sick:

"What, exactly, are we, or am I doing to this person that their family should not be witness to?" In 34 years, I have never been hindered by the presence of family members. If everyone wants to watch an enema, so be it, if the patient is ok with it. I have never received an answer that makes me want to limit visitors.

Maybe you haven't received a satisfactory answer because that is not the sole reason to restrict visitors.

You may never have been hindered by the presence of family. But has the comfort or progress of your patients? Have truly none of them ever exhibited tachycardia, tachypnea or agitation during family visititation, which resolved after the family left? You've never witnessed family shaking a sedated or neuro-injured patient while yelling, "Come on Uncle Bill - wake up!"? I see these things daily -- they are the norm, not the exception.

If everyone had a vigilant family member there would be less med errors....etc.

Really now? Nurses, in collaboration with other disciplines such as medicine and pharmacy, can't work to reduce med errors? We need the families of patients to prevent this? Do you think that med errors could be reduced by reducing the number of potential distractors which interfere with the med administration process? And do you think that the potential distractors include the number of non-patient bodies in a given room at any point in time?

Specializes in Medical Surgical.

Ruby Vee: I have done all my patient care in the Midwest. The families here are crazy too. All the hospitals in town are putting in big private rooms and encouraging the families to stay 24/7 so they will get great Press-Ganeys. There are some families who actually are trying to help and certainly if the patient is a child or dying the families should be there all they want. But we are staffed for the PATIENTS, not the number and sanity level of families. Some family members want to judge my nursing care (or at least the hospitality part of it, because that's all they understand). Well, ok, yes it is suboptimal tonight but that is because all my time has been taken up reassuring family members, listening to their concerns, answering their questions, to the point that I have no time for the patients. And we live or die by the Press-Ganeys. One dissatisfied family member can ruin a nurse's reputation. I have had to answer to high administration for late supper trays (another patient was having a very bad cardiac dysrhythmia), ignorance (I wasn't able to describe in detail the color, amount and facial expression on her father's face when he had his bowel movement on a previous shift), and negligence (true story: I wouldn't grind up a steak and put it in her husband's IV fluids to increase his protein intake). Families get in my way and detract from their loved one's care to a much higher degree than they help it. If we could only have an hour or two visitor-free. No, we have to welcome all comers at all times and we are not allowed to ask anyone to leave unless they are actually brandishing a lethal weapon and it is locked and loaded. Customer service has destroyed nursing and the nursing relationship in the U.S.

I have kicked out many a visitor as needed. I'm always polite about it and try to have a little code with my patient for when they need a break. If my patient can't get sleep and heal because visitors can't control themselves they need to go. This is about my patient not the visitor. They can visit them when the patient is home and healthy.

I'm grateful to all the visitors who help out and lend support to their loved ones. They are such a blessing to the patients and the staff.

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