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]

mgchat76 said:

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.

We've always made exceptions for patients who don't speak English and have a family member at bedside to translate for them. Unfortunately, MOST of the time, those family members expect to sleep all night and won't wake up, get up and translate for us when we need them to. In that case, they might as well go HOME and sleep.

I've had family members go and hide when Mom or Pop starts getting agitated and combative -- just disappear. I've had family members pull the blankets over their heads and ignore attempts to wake them to translate. I've seen them "sleep" through codes. Or wander into another patient's room to "use the bathroom because there's so much activity in Dad's room."

24 hour visiting is a monster that our wonderful management teams have created. Sure wish they could deal with the consequences.

[Here.I.Stand, BSN, RN]

I'm not sure how it works everywhere, but where I am it's not like that at all. Open visitation does not mean the family has free rein. It doesn't mean that they are free to pester the pt at 0200--in the case of heads needing low stimulation, we explain why. If their ICPs aren't tolerating any stimulation, we advise the family that they can be QUIETLY in the room and not touch the pt. If they refuse, then they are removed for the safety of the pt. They are advised that pt cares happen round the clock, and they can't have expectation of uninterrupted sleep and that they will need to leave the room for tests and pt cares. This includes night shift bathing; if the RN is bathing the pt at 0200, the family member will be awoken and asked to go to the family waiting room during the bath. If they ask for something to eat or drink, we give them directions to the cafeteria. Now if it's an 80-year-old in a wheelchair, we'll get them some water from our ice machine; if the pt is dying, we'll request a hospitality cart from the kitchen--we're reasonable. :) But none of this waitressing stuff. We do have the policy that one adult is allowed to sleep in the room. No gaggles of third cousins-in-law twice removed camping out on the floor. :) Overnight visitors are required to remain clothed with shoes on....nobody washing their drawers in the sink!!

What it does mean is that the family--the overwhelming majority of which are reasonable people and appreciative of our efforts--is not kept away from their critically injured or ill family member, in what could be the last day of his/her life. And personally, I'd rather give the close family member a running update on what's going on while not leaving the bedside, than to have to take a daily phone call asking, "How's my husband?" and then have to recap the entire day.

[Here.I.Stand, BSN, RN]

Ruby Vee said:

Or wander into another patient's room to "use the bathroom because there's so much activity in Dad's room."

Hope there wasn't any C. diff in that bathroom...

[Here.I.Stand, BSN, RN]

oahufish said:

Our Facility has recently implemented the 24/7 open Visitation Policy as well. It was put in place by management, hospital wide without and input from staff. We were originally told that it would be at the Nurses discretion, but are now being reprimanded by management if we ask visitors to step out for report or procedures!

The other scenario where I prefer not to have visitors is during the immediate Post operative period until I'm certain the patient is somewhat stabilized. If my patient is has uncontrolled bleeding, Tamponade, unstable CO/CI, unstable rhythm, CVVHD etc...I need to be focused on the immediate care and task's at hand and don't have time to navigate around visitors and be interrupted with multiple questions.

I wonder how these managers would love it if it was them in the beds, and their families were invited to stay in the room for their incontinence care and bed baths? Seriously, that is a patient dignity issue, and no professional should be pandering to that nonsense.

Agreed 100% about the post-op period. What my hospital has done for fresh admits and other situations like this is utilize our chaplains. The chaplain escorts the family up from the ED to the SICU waiting room and sits with them while the RN gets the pt settled. If they're unstable, we stabilize them before allowing the family in. Lots of times the chaplain will come and peek his/her head in to see where we're at; that way they can go back to the family and tell them a bit of what's going on.

This past Summer we had a family wait a LONG time--first the pt got lines and a ventric, then we had to go for a head CT, then I had to start cooling him and start the drips that go with cooling... It was a couple of hours out of the ED before they were able to see him. The chaplain came in 2 or 3 times just asking for a quick update, which I loved because the family knew we were working hard for their loved one and not just being mean and not letting them in. They also knew that the length of time didn't mean that something had gone terribly wrong. It's a really good system.

[Crtstr]

I disagree. As with any policy ever created, there has to be exceptions for it to function properly and support the nursing staff. Of course, a fresh TBI with unstable ICP's would be one of those exceptions. In the hospital, we are the experts, leaders and educators. We need to foster an environment and culture in our units where this is true. If we tell a family member they need to either follow our instructions not to stimulate the patient or step outside, they need to do so or we need to have backup from our chain of command to help enforce this. I am thankful to work in a place that helps foster this environment. We also strictly uphold a 2-visitor policy, except for actively dying AND patients.

I don't think that the disrespectful or difficult families should take away the possibility of open visitation from families who are respectful to unit policies and staff instructions. Communication between ICU staff and families is already difficult without the added barrier of closed visitation policies.

[CeciBean, ASN, RN]

xoemmylouox said:

I am biased in this. My father was in the ICU years ago after an accident. I lived in his room those first 3 days when we didn't think he was going to make it. I left at shift change and when they did procedures. I was quiet and often sat with the lights off, tv off, etc. As he slowly recovered and was in and out of the ICU - Med Surg I returned to work, but was there every day for hours. Again I always left at shift change or when they needed procedures done. You know what it was the best thing for my father and myself. He ended up succumbing to a sepsis infection after a month of fighting. We reconnected over that month which I am so greatful for (we had always had a strained relationship at best), I prevented many med and other errors (like he was NPO due to an inability to swallow and they kept bringing in trays of food and water to his bedside), andI was able to make tough desicions when no one else (including my father) could.

While I understand that I am not the norm as many families are not respectful, are very needy, and are way inappropriate, I think visitation should be handled with a case by case situation. If a family abuses the visitation staff needs to be allowed to ask them to leave. Management must support their staff and back them when the family gets upset and complains because at the end of the day it is about the patient.

I am definitely on the side of "case by case". Having worked in ICU, step-down, cardiac, neonatal, and even peds, I have seen it all. I am definitely not in favor of unrestricted 24-hour open visitation; that leads to way too many people and way too many problems. Been there, seen that. In peds, one parent, grandparent, adult relative, or a sibling over 16 was expected to stay with the patient at all times. Occasionally this meant there was a party in the room, not always appreciated by the patient! Fortunately we could kick out non-relatives after 9 pm, which helped some. But in other hospitals where they had 24 hour open visitation, it could get pretty raw. Big urban ones are definitely the worst...and can be scary too. Inappropriate family members were the least of our problems. Thank goodness for security, although there were never enough of those sometimes. In smaller hospitals where the occasional "dignitary" is treated like royalty you can really have major problems if you have open visitation. I remember one prominent politician who was a patient in a smaller, but still urban hospital in our cardiac unit, whose family took *full* advantage of 24 hour open visitation even when it wasn't standard for everyone else, and demanded to be waited on even though he didn't. They frustrated attempts to get him up and moving, and when he crashed post-op, as open hearts often do, they were totally in the way, screaming and crying and carrying on. After they took him back to CVICU the charge nurse had to bar them for awhile until they settled down, and they went to management, but the man himself, when he got better, spoke up on the nurse's behalf (to his credit--that doesn't always happen!). I could tell a lot more stories, but I'll stop for now.

When my dad went to the hospital with pneumonia at 90, my brothers and I stayed with him. He was in PCU and was DNR/DNI, but otherwise was being treated pretty aggressively, which we later recognized as probably not the best course. He had dementia and CHF and we took shifts so there was always at least one of us with him. I'm a nurse and one of my brothers is an internist so we knew pretty much what was going on and could help the nurses as well as explain to the doctors, and we tried to stay out of the way as much as possible. I've been in the hospital with my kids and my mother as well and generally try to be of assistance because I know how things are on the other side. On balance, how I feel about 24 hour visitation is that the nurse needs to have the discretion to set parameters and say no without fear of reprisals from management, and that families/visitors need to be told what the rules are and that if they can't follow them, they are OUT, period.

[canoehead, BSN, RN]

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 wont 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.

[Vana21, ADN, BSN, RN]

My ICU is in a little community hospital. We have 2 person visitation from around 7am to 9:30pm, and one person can stay overnight.

We haven't really had any issues with it other then people trying to have more then 2 people during the day

[imbatz, BSN, RN]

Ultimately, the decision should be at the nurse's discretion and in consideration of the pt's welfare. It is easy to have the rule in place and make exceptions allowing visitation, than the other way around. For every experience I have had of obnoxious family (and oh, sweet baby Jesus, do I have some stories), I have another one, where the family truly helped, kept the pt calm, were able to re-orient them quickly, etc. In the ICU, where things happen and change so quickly, I believe this should be a nurse's call.

[zappae63]

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.

[Salter444]

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.

[zappae63]

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