Open visitation policy

  1. I am ADN/RN enrolled in the RN-to-BSN practicum at the University of South Alabama in Mobile Alabama. For my current assignment, I have been instructed to collaborate on-line with a nursing colleague in another region, about an issue within my practicum area. The area I have chosen is critical care in a seven bed ICU at a nearby rural hospital. In this particular hospital, the ICU has been a closed unit with visiting hours every two hours, beginning at 10:00 am and ending at 8:00 pm, for a duration of fifteen minutes each visit. About two weeks ago, the Director of Nursing has implemented an open door visiting policy for the ICU. According to the new policy, visitors will be allowed to come and go as they please with no restrictions of time per visit. This particular unit is a general ICU that cares for a wide variety of illnesses including patients on ventilators. The staff nurses are very upset with the change in policy and argue that confidentiality will be compromised and rest patterns will be disrupted. My questions for another critical care nurse:
    1. What type of visiting policy do you have in the unit that you work?
    2. Have you ever worked in a unit that has an open visitation policy, an if so, how well did it work?
    3. Were rest patterns disrupted?
    4. Was confidentiality compromised?
    5. Do you prefer a closed or open ICU?
  2. Visit Linda B. RN profile page

    About Linda B. RN

    Joined: Mar '03; Posts: 3
    Staff RN


  3. by   New CCU RN
    This a 14 bed CICU in a large teaching hosp

    1. Visiting hrs are 9a-9p. Ask for rest hr b/n 2-4p...not always followed. No staying over night over kids under 12(obviously..unless pt is questionably not going to make it through the night or the pt is going to be withdrawn on, etc) Only 2 visitors at a time. This is often not followed.

    2. Never worked in an open unit. However, I can see there being problems and people abusing this. While the patient needs visitors, the patient is also critically ill and needs rest. Unless there is a medical reason why the patient needs someone to stay there 24/7 (ie, one time I let a fam member stay bc the patient had been extubated and looked kinda crappy resp wise and everytime he was alone in the room he got really anxious and desatted) The family members also need to take care of themselves, go home, bath, eat meals, SLEEP.

    3. Rest patterns are already disturbed with the 12 hrs of visiting time our patients have. They will finallly be settled and resting when someone else comes in the room. (We are also horrible at doing this.... 4am labs, q1 vitals, frequent assessments, etc.)

    4. YES!!!!! Confidentialty def is already compromised. Everyone's uncle, cousin, neice, friend DOES NOT need to know the entire reason and every treatment that the patient is getting. That is up for the immediate fam and the patient to decide. Our rooms are all close together and you can hear everything even if that pt they are visiting's confidentiality is not compromised, the patient next door;s can be.

    5. Closed ICU. Without a doubt. While i may sound that I am not open to the family, and heartless...there are good reasons why the cousins, uncles, aunts, friends, exwife should not be witnessing everything. The patient also needs rest, peace,and quiet. I totally think family'sneed to be involved in the patient's care and updated, and be taken care of as well...there needs to be LIMITS.
  4. by   Linda B. RN
    It's interesting to see that some of the same problems exist in another unit. Prior to the recent change in the visitation policy, this unit had policies similar to the one's you mentioned. There were times when the nurses would ask a family member to stay with the patient if the outlook appeared grim or if the patient's anxiety level was reduced with a family member around. But as you probably know, with limited space and a lot of equipment used in ICU rooms sometimes there is a limited area for the nurse to function in making it difficult to accommodate family members. And you are right, the family members do need to take care of themselves. With open visitation and continual access to the patient we have already seen family members rotating through in order to have a constant family presence. This rotation provides time for the family to rest but they seem to forget that the patient needs to be afforded that same time for rest. It seems like each family member feels that their constant presence at the bedside is promoting comfort and rest. What they don't see is when the family member leaves the room the patient often recognizes that as an opportunity to rest. You also made a good point when you mentioned the frequent assessments, q 1 hr vitals, frequent repositioning, labs, baths, etc... An ICU is, by nature, not a good environment for rest.
    You mentioned the constant challenge of confidentiality. I am surprised at the number of visitors that I have seen come through the unit who look around for someone else they may know. The rooms in our unit have glass fronts to promote visibility for the staff. Unfortunately, these glass fronts increase the potential for a compromise of confidentiality. Every effort is made to provide privacy by pulling the curtains but that really defeats the reason for the glass fronts.
    By the way, I don't think preferring a closed ICU is heartless. Sometimes there are treatments and responses to situations that are too difficult for the family to witness. I worry that families are not emotionally prepared to witness a code response. If the family is resistant to leave the unit during a code response this could impair response time for the medical staff while taking the time to encourage the family to leave. Most of the time I have not seen this as a problem because families are willing to step out of the room. Unfortunately, they do not always leave the unit and congregate in front of another patient's room. This can disrupt the care and compromise the confidentiality of the other patients. With an open visitation policy I can only see this problem increasing. I do support family being present if death is imminent, but if life saving measures can save a life I am concerned the family presence may disrupt the sometimes necessary procedures.
    I noticed in your profile that you are a VA nurse. I too work for the VA. Although I am a student completing my practicum at the University of South Alabama, I also work full-time at a Florida VA CBOC. I had worked for a number of years in the ICU that I am doing my practicum in before accepting a position with the VA. The change from a critical care setting to ambulatory care has been interesting. I must say, although I do enjoy ambulatory care, the ICU is my first love.
  5. by   nimbex
    THere is a thread if you do a search on visitation..... a long one as I recall. My recollection is that there are many forms of visitation policies, even in one unit the nurses don't agree, let alone those nurses with their management.....

    My answer would be whatever is in the patients best interest... or if the patient was nonresponsive... what ever was in the families best interest that was able to meet the needs of caring for that patient..... every situation varries.
  6. by   nimbex
    oh, yes and sorry patient confidentiality IS compromised during report in my unit, the families are in and out, standing at the doors of the rooms, and even being in the rooms alows conversations to be overheard...... a BIG problem for me.
  7. by   rnerin
    16 bed ICU; current visiting hrs.-9a-10a, 12p-2p, 1630-1830, 2000-2030; still have a lot of problems w/people complying-it is very frustrating!! I know the AACN supports open visiting, but-it is impossible to get visitiors to understand when it is appropriate/not appropriate to visit and not to wake up patients when they are asleep (that is my pet peeve!!) When we do have extenuating circumstances-we explain the scenario to the family-they have to stay IN THE ROOM, with the door closed during shift changes. AND-I will NEVER understand people bringing babies/toddlers to the ICU-What is the deal??!!
  8. by   USA987
    1. What type of visiting policy do you have in the unit that you work? Open

    2. Have you ever worked in a unit that has an open visitation policy, an if so, how well did it work? Honestly, for the most part, we don't have a lot of problems with it. Of course there is always the exception to the rule....

    3. Were rest patterns disrupted? Somewhat yes, but I think there are many issues with sleep patterns in the ICU....

    4. Was confidentiality compromised? No (new HIPPA regs...LOL)

    5. Do you prefer a closed or open ICU? I honestly don't have a strong preference
  9. by   Ruby Vee
    Originally posted by Linda B. RN
    1. What type of visiting policy do you have in the unit that you work?
    2. Have you ever worked in a unit that has an open visitation policy, an if so, how well did it work?
    3. Were rest patterns disrupted?
    4. Was confidentiality compromised?
    5. Do you prefer a closed or open ICU? [/B]

    We have an open visiting policy where I work, and I HATE it! In fact, in my next job, I'm looking for one where there isn't an open visiting policy!

    The theory is that having family around promotes patient comfort and a sense of well-being, and I suppose that in some cases, that may be true. The problem is, in many cases it is NOT true. Rest patterns are disturbed by family members who feel that their visit is more important than the patient's rest -- because "they can sleep all night." As all nurses know, that's not the case. I've seen patients literally exhaust themselves trying to interact with family members who didn't have the sense to leave them alone and let them sleep.

    Confidentiality is compromised as well. I've seen family members hovering around the nursing stations, trying to overhear conversations between health care team members -- both about their own loved ones and about the patient next door. (I've been sitting with his wife every day for a week, and we're really good friends now. I'm sure she'd want me to know.") If you ask a family member to step outside for a procedure, whatever, they often lurk in the hallway where they can overhear all sorts of confidential stuff even if they're trying not to. It's amazing what kind of information exchange goes on in the waiting room! While my father was in ICU, I heard all sorts of confidential information about him from the family members of the patient next door who were gossiping with each other and with visitors about other patients about "that nutcase in room 8." (Dad was hypoxic, very confused, and very loud about it.) Seems the doctors were standing right outside the other patient's door, talking about Dad. I'm sure that goes on in my ICU as well. In fact, I've had other patients' visitors trying to confirm stuff they'd heard about my patient! I've seen visitors ambling down the hall, looking into every room to see if they spot anyone they know, and some of them even ask "Why is that guy wearing that mask?"

    Management seems to love the open visiting policy, most staff nurses hate it. It doubles, even triples our work load. As we care for the patient, we're also forced to chat with the family, explain procedures several different times (once for the patient and once for each member of his or her extended family), and listen to stories about great-aunt Esther's gall bladder problems. Anxious families come boiling out of patient rooms, shrieking for the nurse because "Dad needs something!" (Usually nothing.) To be fair, this seems to be the behavior they learn from watching television shows, where any change in the patient's condition heralds the hero's bellowing for help. Anxious family members follow you into other patient rooms. I've been assaulted by family members, and once tackled by a prison guard who was trying to protect me from a visitor's home-made machete. (A very LONG story!) More than once, I've had to deal with calling the police because an agitated family member was bringing a gun to the hospital to enforce his wishes. (It's always a him!) One wanted to kill himself, some wanted to kill the family member and one wanted to kill the doctor. (He did, but not on my time.) My husband, who had just drawn blood on a Hep C + patient stuck himself with the needle when the patient's husband grabbed him to demand the reason for the blood draw.

    In short, I hate the open visiting policy.

    Ruby Vee, who thinks that the best patient is an intubated, sedated orphan with no friends. (Mostly joking!)
  10. by   TraumaNurse
    1) We have an open policy now, although we used to have a much more strict visiting policy. We only keep family members out of the unit during shift change.
    2) I think it works well only if the family is easy to get along with and respectful of nurses wishes. Most families respect the nurses wishes and step out when needed for procedures or patient rest. You will always have exceptions.
    3) I find very few families hang out all night. If they do, we ask them to not disturb the patient. Most abide, and sometimes when families just won't leave the patient alone, we will ask them to stop or leave. Even some nurses have to learn to let the patients rest more.
    4) Confidentiality is not compomised any more by open visiting than at any other time.
    5) Honestly, I am better able to care for the patient without family members buzzing around. Some family members require more of my time than their critically ill family member does. So I personally do not like open visiting, but I guess you can argue that it is good for the patient.
  11. by   zambezi
    1) The visiting policy in the facility that I work is pretty much open. The only times we are a closed unit is from 630-730 both morning and night for change of shift/patient confidentialy...there can be exceptions made but the door to the room is closed during this time if there are family members in the unit. The rest of the time, the family must call prior to coming back into the unit. This also the RN a chance to the pt is sleeping, you can come back and peek to see that they are ok, but you may not wake them up...or if a procedure is going on, the family can come back in 15 minutes or whatever the case may be. I think that the system works well...not really closed but not really open. It is also up to the individual RN and patient...
    3)Rest patterns are usually not disruptued because of family having to call first. We just explain that in order to heal, people need to sleep...then we mention their own sleep (why are they here at 300am??)
    4)Confidentiality maintained (usually) because of the closed visiting times at change of shift...Unit also closed for codes...
    5)I like the system we have because it is left up to the individual rn who can make assessments based on situation. I tell my families that just because I let you come back here now at this time does not mean that tomorrow night it will be the same depending on the situation, that way if someting changes, the family won't be totally suprised. Granted, i have not worked in another system so I don't know anything else.
  12. by   CV CNS CCRN
    To Ruby V... let me say this to you. As an ICU nurse, I was every bit as adamant against open visitation as you are. To say I hated it was to put it mildly. As I progressed in my experience and education, I was forced to look at actual research (some very good research on this topic came out of Australia some years ago) and not just rely on my own experiences and feelings. The USA is largely the last remaining country in the first world where open visitation is not more the norm than otherwise. The data show that family members tend to visit less often and "impose" on the nursing staff less when they are allowed at least some control over visitaion. Perhaps you could try open visitation during daytime hours, with "patient and family rest time" at nights. Anything to help the family stay involved. I remember the first time I suctioned a patient with his wife at the bedside, and much later the first time I had a patient with an open chest (pediatric) with his parents at the bedisde as I changed the dressing, with them gowned and masked as well. No fainting, shouting, or mishaps. I cannot say that there is one right answer Ruby, but I can tell you that I hope you will be more generous if you are ever my mother, father or family member's nurse. I know you remember what it was like when your dad was in ICU, but I suggest to you that much of what you related could have/would have happened whether there was open visitation or not. Now that I am "older", I cannot imagine it any other way. I very much respect your beliefs and thoughts and hope that you will mine as well as one colleague to another!
  13. by   grits
    I am currently working in a unit that decided to go to the open visitation policy. I am so unhappy with this that I am leaving after 25 years in critical care. !. Patients do not get the proper care. 2. Infection rates increase second to multiple family members who do not wash their hands and the ones that eat in the rooms. 3. confidentiality is compromised both for this one patient as well as the rest of the unit. My new manager will not even listen to our concerns. She is so busy climbing the ladder of success that she forgot how to be a nurse. Please tell me who to complain to now that may listen /?
  14. by   melrey11
    In 7 years of nursing, i just started a per diem position in my first "open" unit.

    I was pulling out my ladies femoral arterial line...with the curtain pulled, and her neighbors walked and saw "everything" exposed.
    She was mortified and so was I.

    I completely disagree with "open" units. Lenient visiting hours....YES, but open units....NO WAY!