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.

[tigerRN2013]

I think open visitation is a terrible idea; family members become so entitled and don't want to leave even when they are being disruptive or emergent situations/sterile procedures are happening that require them to step out. I recently had a family member who I asked to step out to the waiting room while her husband and I had to travel to ct scan; she became furious that she had to leave the room while her husband was away in ct scan even though it is the unit's policy and so she had her son report me to the charge nurse with a complaint of making her leave the room.....I can't even begin to imagine what goes through some of these people's heads. 1. the room is for the patient (not the family member) -> the family member is there to support the patient -> if the patient is not in their room, there is absolutely no indication for the family member to be in the room (playing with the IV bags and pump that was left behind). Of course, there are always exceptions to the rules and in any kind of end of life/palliative care situation I think that however many family members want to stay with the patient continuously at that point should be allowed.

[Stalirris]

I'm not a fan of 24 hour visiting, either. It's exhausting for the patients, families and the nurses.

Many patients feel they have to stay awake and entertain their visitors. Many have thanked me for suggesting to their families that the patient needs some quiet time for a nap. It is not conducive to rest, and recovery, when the physical body is fighting to gain just a bit of reserve to continue to survive. I resent the family reunions. Are all these people going to be available when the patients are discharged and need help at home?

We all come from dysfunctional families, well most of us, but it's at the worst in a crisis. I try to remember that when dealing with irrational family members, but they are not doing themselves any good being at the bedside nonstop. It seems all the anger comes out sideways at the staff. I had a family member shove me against the wall because I was talking on the unit phone, outside the room, about another patient to a doctor. He was in the early stages of dementia and thought I was talking about his wife on my personal phone. Another spouse flipped out and screamed at me because the patient had a bath blanket on them as a sheet instead of a regular sheet. "This is not a sheet!" she kept screaming. He was piled high with blankets because he was hypothermic.

My dad has gone through 2 extensive surgeries for his thoracic aneurysm. I know what it's like to be on the other side of the bed with a family member vent dependent for a week. I wasn't happy with the care he rec'd the second time around at a well known university city hospital. The first day post op he went into VT while I was visiting and I had to go get his nurse to tell them. I guess they would have noticed, eventually. At least he was still mentating, and had a blood pressure, because he give them the finger as they flattened his bed to shock him, which they didn't medicate him for....I got to witness all that before they shooed me out.

It doesn't matter what we think of the visiting hours, in the end. We can no longer advocate for the patients in what would benefit them. Having a nurse not be distracted by a million questions, and requests, from family members that has no relation to the patient. It's exhausting.

[emb92250]

It was my impression that the open visiting hours were mandated by law by President Obama. This is probably the only thing I agree with Obama, especially in critical care. Being a night shift worker, I can't imagine finding out that a loved one had been admitted to the hospital and being told that I should have visited earlier (instead of sleeping after a night shift). With today's crazy schedules, 24 hour EVERYTHING should be available :)

The problems described were problems with dysfunctional families, not visiting hours. Restricting the visiting hours isn't necessarily going to keep the family members from being disruptive, but may keep them from camping out. It's about enforcing rules. If the family members cannot follow nursing direction, they should be asked to voluntarily leave. If not, call security. It would be the same if there were or were no visiting hours.

[kayjayess91]

We have a general visitation rule that provides us a closed unit at night and during times of shift change. Not only does this prevent the situation as you have listed above, where the families may overstimulate a critically ill patient, it also protects patient privacy. Report, while given at beside, often has to be augmented with information from the nursing station and sensitive information is discussed in these areas. Limited visitation prevents that inevitable straggler family member from standing around when our patient's information is most vulnerable - or, for that matter, when touchy information (such as attitude or family complications) have to be discussed.

That being said, if a patient is actively dying or if there is a massive change in status (such as being intubated, or becoming a CMO/DNR), we allow visitors on a case by case basis.

[Morguein]

I believe there should be limited times when family members can come in. Exceptions would be if the patient was dying. I feel that most patients don't rest as well when they have people staring at them or waking them up. Each person who comes into the room usually tries to talk to the patient. So, the patient wakes up each time a new person comes in....let alone every time we come in to do something. And they never get enough rest. When I'm sick at home (and not even critically sick), I don't want anyone waking me up; and I certainly don't want to entertain anyone at my bedside. So, when I'm at my sickest and require more rest, I MOST DEFINITELY don't want to be woken up, stared at, or feeling the need to smile and entertain everyone! I personally think that the patient gets less care when families are there. I've heard from many nurses that they go in their patient's rooms less because of family presence. They will often delay giving meds or doing dressing changes because they don't want to interrupt the family conversations going on; or if the family is difficult and picky, the nurses will feel intimidated and delay having to go in the room to do anything. I've had patients ask me how they can avoid having family come all day. One time, I made my patient pretend to be asleep. And when visitors came and saw that she was "asleep," they decided to leave since she wasn't going to be up talking/entertaining them. She was ever so grateful.

[CandiceNTexas]

We really need to inject common sense back into nursing, or we may as well be hospitality services, ie really expensive hotels!

I recently had a patient ask me about her neighbor, she knew all the details of this patient, pmh,diagnosis, family business, everything, from the family talking in the hall. It was like she was missing her daily soap opera.

another time, I walked into my patients room to find a family member taking selfies with my incubated ventric patient. How pretty do you think that pic was?

and the best one was my h1n1 patient, grand kids, toddlers, crawling everywhere, barefoot drooling. Omg, imagine them going to daycare the next day.

As nurses, we are responsible for educating and protecting the public from health threats, and I wish we were given room to assess some of these situations for ourselves, instead of following a one sized fits all solution to address the visitation policies.

[FlyingScot, RN]

emb92250 said:

The problems described were problems with dysfunctional families, not visiting hours. Restricting the visiting hours isn't necessarily going to keep the family members from being disruptive, but may keep them from camping out. It's about enforcing rules. If the family members cannot follow nursing direction, they should be asked to voluntarily leave. If not, call security. It would be the same if there were or were no visiting hours.

I couldn't agree more. I had an experience as a patient that I think supports open visitation. I contracted pneumonia culminating in a left lung total whiteout. I was desperately air hungry and scared to death because I was teetering on the edge of needing intubated. Trust me, there aren't too many things scarier than not being able to breathe. My family and friends stayed by my side and helped keep me calm which I firmly believe kept me from ending up on a ventilator. The caveat here is there was only one or two people at my bedside at one time. They were quiet and respectful. There was one person who was the designated question asker so the staff wasn't bothered by a million questions being asked over and over. They made no requests for their personal comfort. Managed to find their own food and drink and used the visitor bathrooms. They were happy to sit in hard backed chairs and get out of them when the nurses needed access to me. All in all my family/friends were pronounced perfect by the nursing staff who wished all visitors behaved like mine. Most importantly though, their presence and support probably saved me from having my already bad situation getting worse!

[Ruby Vee, BSN]

emb92250 said:

The problems described were problems with dysfunctional families, not visiting hours. Restricting the visiting hours isn't necessarily going to keep the family members from being disruptive, but may keep them from camping out. It's about enforcing rules. If the family members cannot follow nursing direction, they should be asked to voluntarily leave. If not, call security. It would be the same if there were or were no visiting hours.

Dysfunctional families are the REASON for visiting hours. If a family is quiet, respectful and (I cannot even imagine this, but I'll put it out there anyway) helpful and/or supportive, let them stay. But if they're dysfunctional, disruptive or dangerous point to the bolded rule that says "No visiting after 10 PM" or "Only two visitors in the room at a time" and usher them on out. It's easier if there are guidelines.

If the rules said "Overnight visiting allowed on a case by case basis only," there would be far fewer exhausted family members thinking they're SUPPOSED to be camping out at the bedside, fewer dysfunctional familes camping out in the waiting room and more rest for the patient.

[Ruby Vee, BSN]

Tonight I found a visitor wandering around in the restricted area near the pharmacy and the central lab. Access is by badge swipe only. The woman REEKED of alcohol and cigarettes and when questioned, said vaguely "I left my purse in the waiting room and I can't find it." Our 1000 bed inner city teaching hospital is not the place where you leave anything unattended if you hope to see it again. I found out who she was, was dismayed to find out that her husband was in MY ICU, and helped her find her purse. Then I sat her in the Family room of our ICU and told her "Wait right here and I'll find out if your husband is ready for visitors." Five minutes later, I couldn't find her again. I had the misfortune of answering the phone when she called our unit to find out "How do I get back to see my husband?" Turns out she had been so frantic about finding her purse not because of valuables, which were in her pocket, but because she needed a smoke and a nip and had stepped OUTSIDE (in our inner city, unsafe neighborhood) to take care of those needs. She asked for directions to our unit, but couldn't tell me where she was. In the end, I called Security and they found her and brought her up to the unit, flask and all. She then sacked out in the recliner in her husband's room, slept through a couple of codes and only roused enough to complain when someone turned on all the lights to open the chest.

That same night, a man (it's ALWAYS a man -- I've never seen a woman do this) dropped off his mother to "Visit Dad" who was still in the OR at 11 PM. He went home to sleep but left his mother in the OR waiting room. I found her after a random janitor brought her to the unit after finding her squatting to pee on the floor in the hallway because she couldn't find the bathroom that was clearly labelled and about six steps away. She couldn't give us her son's contact information, but when her husband got out of the OR and woke up 12 hours later, he was able to. (The wife was clearly noted in the chart as next of kin and primary decision maker.) One of our techs spent the night keeping an eye on this poor woman so she wouldn't wander off or squat in the hallway again.

I think we need to allow overnight visitors on a case by case basis only and encourage family -- especially elderly and drunk or demented family) to go home for a good night's rest. We've created a monster by telling people they're "welcome to stay all night." They seem to believe they're not sufficiently proving their love if they go home.

[canoehead, BSN, RN]

Intoxicated or demented family members need to be escorted to the ER if they need caretaking, and family cannot be contacted. We aren't babysitters, and an ER bill might help family realize that.

[mgchat76]

I haven't read through every page of this thread, so I apologize if i'm repeating something already said. In my opinion, families should have 24 hour access to the waiting room and be able to come in periodically to check on their loved ones for short visits (i.e. 10 minutes). I have found that even with respectful family members, it can be detrimental to the pt to have them at bedside 24 hours. Pt's can feel obligated to interact with their family if they are there rather than rest. Obviously, there are exceptions. Pt's facing end of life, or pt's who don't speak english but have a relative who does would be the first two exceptions that come to mind. Also pt's with dementia sometimes respond better to familiar faces.

[TeacupPom]

The hospital I go to does not have 24 hour visiting and for me, that was okay. One parent was allowed to stay with me (except for shift changes) all the time. When shift change came around, they went and got food or went home; then the other parent would come in and stay for the night. We were a quiet bunch, not much partying going on.