Family visitation in ICU

bluesky, BSN, RN · Jan 23, 2005

RN34TX, I think that's a big problem with our society today. We try to excuse everything. I don't expect families to be angels and behave perfectly, but somethings are unacceptable and I will never make excuses for them. I have actually heard a parent tell a nurse manager "Bite me! F--- off!" and people make excuses for it. Once that's been allowed once, you can bet no nurse will ever get any respect from her. I can't imagine that was tolerated 30 years ago, so I don't see why it should be today. People are no different.

Gosh what really also blows is when your manager won't back you up after you've been abused because the hospital is currently entertaining the "pt is always right" philosophy undoubtedly started by someone with NO nursing experience!!! :rolleyes:

ayndim · Jan 23, 2005

Two things I would like to comment on.
Family is the patient. I think that while not physically the same, emotionally and mentally, family members are just as vulnerable, if not more vulnerable, as a sick ICU patient. Just like the patient, they have lost all control of their own autonomy when it comes to their loved one.
Believe me, I'm not denying that families can be a pain in the butt but I think sometimes they "act up or out" because that is the only way they do have some control.
Frequently, instead of dealing with this problem directly by getting social services, the chaplain, or helping provide some other form of support (simply talking frankly about it) that can maybe help families deal with this loss and helping them understand what is best for the person lying in the bed, they are allowed to continue to dysfunction.
My intention is not to minimize the problem. I would be very unhappy with open visitation on our busy unit. I've had my share of downright obnoxious family who no matter what you do, nothing is good enough. But it also bothers me when I hear nurses say that family is not my patient or family does not need nursing care.

I am only a student so I am still looking at it from an "outsiders" point of view. But from where I sit nurses have one job and that is to care for the patient. I'm sorry but I don't consider it a nurses job to help out the family members. They are already overworked why on earth should they be expected to meet the emotional needs of family members. They are adults and if they have issues with their loved one then they need to seek help with a clergy member or counselor and not take it out on the nurses. They are adults for goodness sakes. No wonder nurses are treated like crap. It is because some nurses take it and excuse it and make it bad for the rest. Nurses should not be used as emotional punching bags because someone is understress. Can you yell at a cop because you won't be able to afford the ticket or because you are understress after something was stolen. I think not. As far as I am concerned nurses are skilled professional medical people. Not social workers. And I am not an unkind person. If there is a calm person who is dealing with a tragedy I can lend emotional support. But to have to deal with an irrate person because "well we are nurses" is bs. I lost my mom to a very sudden death. But I managed to not yell or scream at the nurses. Why? Well because as an adult I have learned how to behave and control my anger.

**canoehead, BSN, RN** · Jan 23, 2005

I wonder if we had a webcam updated picture in the waiting area, and cameras in rooms, far away enough so faces were not clear but you could see that people were in the room whether it would satisfy family and friends enough to avoid the crowds of people hiking in and out. Maybe if people could make a quick check to see that their loved one was asleep, and that their was no current crisis....

bfjworr · Jan 23, 2005

I am only a student so I am still looking at it from an "outsiders" point of view. But from where I sit nurses have one job and that is to care for the patient. I'm sorry but I don't consider it a nurses job to help out the family members. They are already overworked why on earth should they be expected to meet the emotional needs of family members. They are adults and if they have issues with their loved one then they need to seek help with a clergy member or counselor and not take it out on the nurses. They are adults for goodness sakes. No wonder nurses are treated like crap. It is because some nurses take it and excuse it and make it bad for the rest. Nurses should not be used as emotional punching bags because someone is understress. Can you yell at a cop because you won't be able to afford the ticket or because you are understress after something was stolen. I think not. As far as I am concerned nurses are skilled professional medical people. Not social workers. And I am not an unkind person. If there is a calm person who is dealing with a tragedy I can lend emotional support. But to have to deal with an irrate person because "well we are nurses" is bs. I lost my mom to a very sudden death. But I managed to not yell or scream at the nurses. Why? Well because as an adult I have learned how to behave and control my anger.

Don't apologize for being a student ... I have been a nurse for 15 years and I am still a student... we can never stop learning.... that is what is so great about these forums... we are learning from each other in an informal forum... and experience is the best teacher....You will find in today's classroom, instructors teach caring for the patient includes the family....Their environment has a lot to do with how the cope with stressors... not all families cope well... and that is true everywhere..... How we deal with the families sometimes impacts directly on the patient. If the family is aggitated they pass on their feelings to the patient....and so on.... We re the patient's advocate, however, and if the family causes problems or interferes with patient care... we are the one's that need to act.... :rolleyes:

bfjworr · Jan 23, 2005

I wonder if we had a webcam updated picture in the waiting area, and cameras in rooms, far away enough so faces were not clear but you could see that people were in the room whether it would satisfy family and friends enough to avoid the crowds of people hiking in and out. Maybe if people could make a quick check to see that their loved one was asleep, and that their was no current crisis....

Somebody somewhere would cry HIPPA violation or the staff would become paranoid probably. I feel most of us would be secure enough to handle it... what about the doctors during a code.... our physicians don't let family members attend a code. I am not sure if this is related to the fear of law suits or just that it would interfere with their jobs....even camera peaks would have to be limited.... they would need to call on the red phone in order for the camera to be turned on....I wouldn't want the patient to be observed during a bath for example and that would probably not satisfy all...

bellehill, RN · Jan 23, 2005

Maybe all of this boils down to a lack of trust that families have towards the nurses. We already know that if anything goes wrong during the hospital stay it is blamed on nursing whether it was our doing or not. Maybe if we could instill a level of confidence in the families they wouldn't feel the need to stay 24/7 and "watch" everything we are doing. I don't think nursing can achieve this alone, it takes the whole healthcare team...something that will never happen. I will admit there are some nurses I work with that would never be able to make me leave the room if they were taking care of my loved one because I don't trust them. Fortunately they are few and far between, so how did we all get labeled with this untrustworhy title?

CathRN · Jan 23, 2005

I have been on both side of this issue as several of you have. My mother is a 10 year heart transplant receipient. She recently was in ICU in 3 hospitals, and thank GOD, the nurses were very kind and understanding. While mother was at the first hospital in ICU, which was over 3 hours away, the nurses would allow me, my husband, and my dad to "peek in" on mother when ever we felt the need. We went out of our way to help these kind nurses, feeding them (pizza, cookies, cokes, etc), staying out of their way, assisting with procedures (me only), turning mother, etc. The nurses were so kind and understanding.

The second hospital that mother was transferred to was a "locked" unit. It was closer to home, but rules were strictly enforced. My parents are elderly, and dad was having a hard time understanding why he just couldn't look at her once in a while. I explained this to mothers nurses and they gave dad the code and allowed him to come in and just look at her for a few minutes and then he would leave. Made both of them very happy. Mother was on a vent, and dad understood not to stimulate her in any way. He would stand at the doorway and just look at her for a minute, or if it was during visitation, he would go in and hold her hand. The nurse noted that when dad was there, her VS would level out.

The last hospital (their home town) has visitation, but since they know mom and dad so well, they allowed him to come in whenever he wanted. Mother finally had an ileostomy at the second hospital. The first hospital did abdominal surgery, but did not feel that she was a good candidate for an ostomy due to her general health and told us that she had a less than 1% chance of survival. The second hospital did the ileostomy and now she is in a nursing home temporarily getting rehab and is doing fine.

As a nurse, I have had to call security for unruly families, sometimes they get out of hand and threaten the staff. I try to explain to them the rules and why we need them to understand and adhere to the rules. Most of them do, but there are always exceptions. And yes, we do make exceptions for the families who have traveled to see their loved one, and the families that try to help, and stay out of the way, and understand why we are doing what we are doing to their loved ones.

Sorry this is so long, I'm rambling now, but I wanted to say that there are exceptions to every rule, but, at the same time, the rules are there for our patients, and so are we.

Ruby Vee, BSN · Jan 24, 2005

wow you said it pj mommy! everytime i read a nurse supporting open visiting i wonder where they work and what position they hold. while i do get some lovely cooperative and helpful visitors (some i would love to let stay with confused granny cuz it is helpful), i increasingly encounter hostility, threats and violet outbursts. today's general public cannot seem to handle crisis without acting out...and i am not staffed to deal with this and patient care.

i can't believe this! two posters in a row who agree with my pov! i expressed pretty much the same feelings about a year ago and was flamed up one side and down the other! i think today's general public is taking their cues about how to behave in a crisis from television: jerry springer behavior is increasingly common. but even "er" shows families acting out. better drama, i guess.

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[color=#483d8b]consistency is hard to come by, but it's tough to explain to jerry's fans that that other family is allowed to stay longer because they aren't causing any problems! the problematic family gets angry, and anyone who tries to enforce the rules becomes the bad nurse. and it's all about customer approval ratings these days. patient care seems to get lost in the shuffle.

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[color=#483d8b]ruby vee, bad nurse

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Ruby Vee, BSN · Jan 24, 2005

i think all icu's should have a large bold sign that says "we reserve the right to refuse anyone" right on the front of the locked entrance.
11

amen to that! and it should be enforced on a regular basis! i recently had a very bad patient outcome that was related to abusive family members. our charge nurses pay lip service to the idea that security can escort out disruptive visitors, but i've never actually seen it happen in this institution, and only once in my previous two jobs. (after a patient's son brought in his german shepherd and attacked two nurses. he was allowed back up to visit twelve hours later.)

[color=#4b0082]interesting thing is, disruptive family members are much worse than they were 27 years ago when i started nursing.

[color=#4b0082]ruby

CritterLover, BSN, RN · Jan 24, 2005

i started my nursing career in a step-down unit, where i often had to maneuver around family members (and their significant others) sleeping on the floor when trying to assess vent settings, the patient, give meds, etc. not to mention trying to empty foleys and drains in the morning only to find the family member in the shower with the door locked.......i didn't last there very long.

after that, i worked in icu until recently. the hospital system that i work for decided (based on customer satisfaction surveys) to go to open visitation in the icus. in the first hospital they tried this in, it failed miserably. keep in mind, this hospital is not in the best part of town. they had family members basically living in the patient rooms, often because they had no other place to stay. they would complain that the nurses coming in and out of the room was keeping them up at night. they wanted to be fed ("well my mother is on the vent and she isn't eating. can't i have her tray?") and they wouldn't always leave when asked to leave. i think it lasted 4 weeks. and this unit lost several of its veteran nurses because of this policy.

i have a really hard time understanding the seeming shift in control from the nursing staff to the patient's family members. i don't understand why hospitals think that having great "customer satisfaction" scores is what makes them a good hospital and should be their primary goal. what about great clinical outcomes? family members are too emotionally involved to determine if their loved one is benefiting from their visit or not. nurses are objective, and should have the final say on visitation. period. hospitals should have a policy that if the nurse says it is not a good time for a visit, it isn't. no ifs, ands or buts about it. when i was little, and my mother told me "no," and i pushed and asked why, she often replied "because i said so." i didn't like it then, and i understand that families don't like that type of answer,either. but sometimes we have to defer to those who know more than this.

while i can't cite any specific instances where one of my patient's was harmed by something a visitor did, i do know that i have spent volumes of time trying to explain small things to visitors. and while i love to do patient/family teaching, sometimes families are not ready to hear the information that they are asking for, and i can't give them the answer they are looking for. nor do i have the time to go over my answers again and again, while they are fishing for the answer that they want. it eventually takes away from the direct patient care that i need to give. not to mention, that some family members are sooooo draining, that i need time away from them.

rstewart · Jan 24, 2005

Our critical care unit initiated an open visiting policy at the first of the year. In my view, it has negatively impacted our ability to deliver care.

It is interesting to note that the referenced/linked article extolling open visiting policies was not written by a bedside critical care nurse, nor was it clinical research; Indeed, it was not written by a nurse at all. The author is associated with Press-Ganey, the well known patient satisfaction survey folks. It seems that they found that restricted visiting in ICUs was a source of patient dissatisfaction among 30-40% of the respondents. Health leaders in their infinate wisdom disregarded the inference that a clear majority of their respondents had absolutely no problem with the policies as they were. Presumably, these status quo folks had valid reasons for answering as they did, but no matter.

Our open visiting policy was instituted corporate-wide, top-down under the "patient focused care" banner. But clearly, if the Press-Ganey percentages apply to our system/facility, we aren't focusing on all the patients and families, or even the majority---- only the complainers. Sadly, consideration to the ramifications of open visitation will only occur when they are reflected in declining facility loyalty numbers.

What are those ramifications? All one need do is read this thread for starters: Increased environmental noise, decreased confidentialty, decreased REM sleep, decreased security, decreased infection control, increased equipment tampering, increased staff interruptions/distractions, decreased employee satisfaction etc. etc. In it's zeal to pacify patient A's disappointment that their 5 year grandaughter could not visit previously Management neglected to consider that patient B might not appreciate a 5 year old's squeeling at the top of their lungs, or their uninvited appearance while attempting to use the bedside commode.

One might argue that these negative byproducts are in no way inevitable...... The "If only the nurses would announce and enforce the rules consistantly everyone would be happy" mindset. Were it that easy. I noticed with some amusement that many hospitals are now relaxing their no cell phone policies; according to the article I read, the health leader's explanation (paraphrased)was that the rules were so blatantly ignored by the public, surely there would have been more patient deaths/incidents if they posed a significant threat. Plus trying to enforce the rules just made the public mad. So let's just make them happy.

Frankly I believe the all or nothing approach is fatally flawed. I believe that experienced professional nurses are capable of implementing flexible visiting policies which truly reflect the wishes of the individual patients/families, yet are fluid as circumstances change, and do not disrupt the unit as a whole nor infringe on the rights of the silent/currently satisfied majority. That is, given appropriate support I believe we are capable of using good judgement in these and other matters. Of course that would mean giving up some control and placing more decisions at the bedside. Think that will happen soon?

bluesky, BSN, RN · Jan 24, 2005

Wow you said it PJ Mommy! Everytime I read a nurse supporting open visiting I wonder where they work and what position they hold.
Well I work as a BSN in the region's biggest teaching hospital right smack in the middle of the ghetto. We get heart transplants, VADs, IABPs, bad heads (we are the level I trauma center for the area) and all other trauma. I think that except for the most neurotic cases which are few and far between, families can be managed with a little tact. Just my 2.
I guess what I'm trying to say is that I'd rather deal with the occasional jerk so that all the other nice families CAN visit than the opposite, which would be nice families not getting good access on account of a few bad seeds.