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]

Quiet, respectful and reasonable family members aren't the norm anymore: it's all about "my right to visit" and not about supporting the patient. I've seen families consuming a bucket of chicken IN THE ROOM when the patient, who is NPO, is dying to have some. I've seen families having knock down, drag out fights with each other and the nursing staff. One family member brought his dog (NOT a service animal) in to visit and when the nurse asked him to leave, sicced the dog on him. There are families that won't let the patient rest and families who asked to stay over night to translate who sack out on the sofa in the room and refuse to get up and translate when needed. I've interrupted overnight visitors having sex with each other while the patient watches. Families will call the nurse to come fluff a pillow or hand the patient the TV remote rather than just doing it themselves. Families expect the nurse to listen to their gall bladder surgery stories while we're trying to assess the patient's gushing blood loss. One son, a physician, I'm told, left his Alzheimer's patient of a mother at the bedside "to visit Dad" and drove himself 200 miles back home, leaving Mom at the bedside for the staff to care for. She wandered into other patient's rooms and played with their equipment, climbed into bed with a patient who was terrified of her and got lost on the way to the cafeteria. Six shifts worth of nurses let it continue -- I called our Medical Director who called the son and told him he had four hours to collect his mother or we'd notify Adult Protective Services. (HE was there in five hours, livid.)

I'm always grateful when family memebers are reasonable, pleasant and cooperative, but I've learned not to expect it.

As the daughter of patients, and as the patient herself, I'm NOT in favor of 24 hour open visitation. (As a nurse I think it's a horrible idea, as a family member I think it's worse.) When my Dad was admitted to ICU, the nurses made it clear that 24 hour visitation was in vogue, and my aged mother took that to mean she had to stay. Mom was in the early stages of dementia, and would NOT leave the bedside. That meant that either my sister or I had to be with her, because someone had to watch Mom so the staff wouldn't have to. Dad was in the ICU for ten days. I got almost no sleep. Mom didn't get any uninterrupted sleep . . . she woke up any time anyone came to see Dad. The one time I dozed off in the recliner, Mom took it upon herself to "go make coffee for the nurses" and almost started a fire in their break room. If someone had encouraged Mom to go home and sleep from the beginning, this wouldn't have been as much of an issue.

And as a patient myself -- my husband can stay as long as he likes, but I don't want to have to entertain visitors 24/7.

[LadyFree28, BSN, LPN, RN]

Ruby Vee said:

Quiet, respectful and reasonable family members aren't the norm anymore: it's all about "my right to visit" and not about supporting the patient. I've seen families consuming a bucket of chicken IN THE ROOM when the patient, who is NPO, is dying to have some. I've seen families having knock down, drag out fights with each other and the nursing staff. One family member brought his dog (NOT a service animal) in to visit and when the nurse asked him to leave, sicced the dog on him. There are families that won't let the patient rest and families who asked to stay over night to translate who sack out on the sofa in the room and refuse to get up and translate when needed. I've interrupted overnight visitors having sex with each other while the patient watches. Families will call the nurse to come fluff a pillow or hand the patient the TV remote rather than just doing it themselves. Families expect the nurse to listen to their gall bladder surgery stories while we're trying to assess the patient's gushing blood loss. One son, a physician, I'm told, left his Alzheimer's patient of a mother at the bedside "to visit Dad" and drove himself 200 miles back home, leaving Mom at the bedside for the staff to care for. She wandered into other patient's rooms and played with their equipment, climbed into bed with a patient who was terrified of her and got lost on the way to the cafeteria. Six shifts worth of nurses let it continue -- I called our Medical Director who called the son and told him he had four hours to collect his mother or we'd notify Adult Protective Services. (HE was there in five hours, livid.)

I'm always grateful when family memebers are reasonable, pleasant and cooperative, but I've learned not to expect it.

As the daughter of patients, and as the patient herself, I'm NOT in favor of 24 hour open visitation. (As a nurse I think it's a horrible idea, as a family member I think it's worse.) When my Dad was admitted to ICU, the nurses made it clear that 24 hour visitation was in vogue, and my aged mother took that to mean she had to stay. Mom was in the early stages of dementia, and would NOT leave the bedside. That meant that either my sister or I had to be with her, because someone had to watch Mom so the staff wouldn't have to. Dad was in the ICU for ten days. I got almost no sleep. Mom didn't get any uninterrupted sleep . . . she woke up any time anyone came to see Dad. The one time I dozed off in the recliner, Mom took it upon herself to "go make coffee for the nurses" and almost started a fire in their break room. If someone had encouraged Mom to go home and sleep from the beginning, this wouldn't have been as much of an issue.

And as a patient myself -- my husband can stay as long as he likes, but I don't want to have to entertain visitors 24/7.

Well said; to add: I was an ICU pt; most of my stay was unstable, I was a non-accidental trauma; it was a HUGE strain on my family; I had a TON of people visit, but they were respectful and took turns and didn't disrupt the staff; they KNEW I was sick and kept it respectful, despite their fears. My brother stayed 12-14 hours a day, but stayed out of the way; when my sister with my brother-in-law or parents visited, they swapped turns to not overstimulate me as well as get a break and follow policy; they left the bedside when teams had to visit me IF the provider asked them to come in, they did; they let the most important part-the healthcare team do their JOB, as well as let me SLEEP.

Again, sometimes rules and standards have to apply in order to benefit the pt, even in the pt/family centered world; standards are OK; even if the benefit is keeping serenity when the family dynamic is vulnerable as well; I'm prioritizing as a nurse, and last time I checked, prioritizing is a huge part of what I do.

[wannabecnl]

I'm not an ICU nurse, so maybe I'm talking out of turn, but if someone is sick enough for ICU care, the circumstances are different. I've recovered patients in the ICU after hours and seen spouses asleep at the bedside, their hand in the patient's hand for hours. That is the right thing to do; the clock doesn't matter, and if they want to stay AND are a healthy presence for the patient, they should be allowed to do so. On the other hand, that's one person. Some hospitals have huge ICU rooms, but mine doesn't, and you really couldn't have more than 2 visitors and still allow the staff easy access to the patient, monitors, vent, and drips. If the patient is sick enough to be in the unit, the nurses must be able to provide that special level of care, so limiting the number of guests is also the right thing to do.

I've cringed to hear the OR staff talking WAY too loudly in the ICU at night (ICU nurses sometimes do as well, and I've been guilty when I have a chatty post-op or family member). I think it is entirely reasonable to explain to family members that they need to keep the volume down to allow the other patients to rest; if they can't do that, they're out for patient safety reasons. And asking for soda? Yikes! I like to think I would point out that if I were getting a soda for a different visitor, I wouldn't be able to provide the care that this person's loved one needed, so ix-nay on the waitressing! As my instructor used to say, it's a hospital, not the Hilton.

[jaunajem]

That's about the most pitiful comment I have ever heard. Obviously, not a ICU nurse.

[TheCommuter, BSN, RN]

jaunajem said:

That's about the most pitiful comment I have ever heard. Obviously, not a ICU nurse.

This discussion has 27 comments. To which one were you referring?

Thank you for your input, although I respectfully disagree with you because I believe no one has submitted a "pitiful comment" throughout this discussion.

[beckster_01, BSN, RN]

We have an open visiting policy, but when explaining the policy to families I ALWAYS include the caveat that the nurse reserves the right to limit visitors according to patient needs. I am open and honest with family members and have never had an issue, even with the most difficult of families. It is easy for them to see the result of overstimulation, and when I explain how stimulation --> sedation --> delerium, they are generally understanding. I always make sure the family knows we have one thing in common: the patients needs come first, always.

[tokebi]

In our hem/onc floor, many long-term stay transplant patients have a family member or a friend camp out 24/7 at the bedside. It does get cramped in the already small room, and I do get tired of the obstacle course nursing, and yes family members can be demanding and over-protective.

In spite of all that, I see the benefits everyday. My patients ambulate more when their family member is there to encourage them. They bring foods that are more palatable, and patiently help with feeding. Their mere presence is the cure for depression and boredom that are so common in lengthy hospital stay. They provide the level of care that I wish I could but cannot.

[eCCU]

Okami said:

Open visitation is a great concept, on paper.

I remember a few months ago a critically ill patient coded in the ICU and the night nurses had continually asked the wife to step out of the room as they tried to prevent the patient from arresting and while the code was in progress the wife was in the back of the room washing her underwear and asking the physicians to quiet down.

Oh lord...I remember one time in the CVICU we were in the middle of a code and a family member came over from the next room asking if the dad next door can have a glass of water! Chest open and everything!! will never forget the CV surgeons words screaming... "get the hell out of here! Can't you see we are busy? " ugh the nerve...

[ShereenL]

I am a critical care nurse. Open visitation is, in general, one of the things that makes caring for my critically ill patients much more difficult. There are so many reasons to limit visitors from a TBI being overstimulated to not being able to get to the patient without climbing over people, chairs and their personal items to simply get to the patient much less get equipment into the room should they code. Another factor to consider is that most illnesses in critical care could be compared to a marathon not a sprint. Families that sleep in chairs for days on end are now not merely stressed by their loved one's illness but are now lacking sleep making them increasingly irritable and even unreasonable when difficult decisions need to be made. Rarely ever is their irritation taken out on the patient but almost always the nurse. Open visitation looks great on paper but, in my experience, rarely benefits the patient.

[mamax3]

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.

[OrganizedChaos, LVN]

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.

So this person just strolls around the hospital in his underwear like he's at home??? WOW!.

[LadyFree28, BSN, LPN, RN]

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.

Quite ridiculous and weird....ugh.

Just no sense...