open visitation in critical care units

[grits]

I would like to respond to all the nurses working night shifts in critical care units. I have been a nurse for 25 years and I am now leaving my area of expertise because of the "open Visitaion" policy. That has been umplemented by young nurses trying to climb the ladder of management without the knowledge of patient care. Open visitation not only robs the patients of their privacy, it increases the liklihood of infection and overall poor outcomes for the patients. How many times have you been busy with your patient and your patient not properly clothed when another nurse allows visitors that come by your patient and look/ How do you feel about family camping out in your patients rooms-- food and beverages everywhere. Unable to get to your patient because of the visitors. Also, because of the scrutiny of the visitors, the patient doesnt get turned every 2 hours or suctioned as frequently and the overall care is less than optimal because of the mear presence of visitors. I am so discouraged that I wish I could leave this profession. I cannot do my job professionally and I do not feel good when my shift is over and I know that my patient did not recieve the care he could have or would have recieved if visitors were limited..

[NICU_RNwantsFL]

Hi - I work in a NICU, and while our visitation isn't as open as yours, it is certainly more open than I think it should be, for all the reasons you state.

When I have to give care (depending on how intricate or how disturbing I think the family/visitors might find it to observe), I don't hesitate to ask everyone to step outside.

Plus, food or drink is prohibited in all rooms (except the rooming-in ) for sanitation purposes.

How does your nurse manager feel about such open visitation? And how many visitors are allowed at a time? If you can't get to your patient, that is too many visitors, certainly.

You sound like a caring nurse who puts her patients first. Our profession cannot afford to lose nurses like that. I hope things will work out so that you feel you can stay.

[renerian, BSN, RN]

Personally as a former hospital patient, I 1. barely can stand my visitors due to being so ill and 2. I really do not like having total strangers in my room all day long.

renerian

[fergus51]

I also work NICU and we allow parents in 24 hours a day. That said, I have no problem with telling them to step out when I need to get things done.

[CCU NRS]

To OP I would just make it clear to all visitors that they will need toleave without argument or hesitation any time you ask them to I would explain all rules which include no food or drinks in rooms, no more than 2 visitors at a time and anytime the Pt seems to be not getting the proper rest s/he needs then you will be asked to leave.

We are going to a 24/7 visiting policy soon and I am already working on fine tuning my speech. I will not however violatew the new HIPPA regs by doing report in what is to be a public area so I do not see how they can ever do away with at 30/min around report times for confidentiality, I mean it's not like we can leave the unit to do report.

Feeling your pain

[Nurse Julie]

When I started working in a CVICU in Kansas, they told me of the open visiting. Being a "seasoned" (older :) ) nurse I was appalled. The rules were.......visitors, anytime night or day. The brochure asked loved ones to either stay in patient rooms or out of the unit from 6:45 til 7:30 am and pm. I hate to be the minority in this thread but....what I found was that families were understanding, compliant, respected nurses more when they saw what we actually do, would leave IMMEDIATELY when asked, they were more comfortable when they went home with the patient, we had more opportunities for family teaching, we had better relationships with families than I had experienced anywhere else, and satisfaction scores were through the roof. I did not have ONE negative incident. The families were so appreciative of being back there, they would bend over backwards to comply with our requests, including asking for some "quiet time" for the patient if we felt they needed it. I am now a director over several departments, including CCU. I have opened visitation and my staff remarked how we have less visitors in the unit at one time now that we have opened the unit up. Not every family member can come at the prescribed times, they have jobs, kids etc. I think families are more comfortable leaving the patients when they see the quality, compassionate care the patient receives. Maybe I have been lucky with positive expreriences in the two places I have seen this policy.

Julie

[ZASHAGALKA, RN]

A truly bad idea.

Fortunately, the only place I saw it tried, the CV docs did all their cases across town for 6 months - 2 open hearts every weekday to zero - x 180 days.

And then management 'saw the light'.

This is part of what I wrote to the President of the Amer Assoc of Crit Care Nurses:

Howdy from Texas and Congratulations on becoming

President. I was present at NTI when you accepted the

reins. I politely listened to your views on open

visitation and would like to offer a different

position.

I know that the national AACN is advocating open

visitation.

Here's the thing: I am first, very first, prime

directive first, a patient advocate. As a very close

second, I'm a family advocate.

In the ICU that I have work in, the open

visitation experiment (or should I say fad) was tried

and ultimately abandoned. So I have some experience

from both sides of this practice. Now mind you, I work

nights, so my opinions are colored by a non-9-5,

non-academic, in the trenches mentality that often

times gets lost from drawing board to actual design.

There are two major drawbacks to open visitation.

1. Sick people need to rest, ESPECIALLY AT NIGHT.

I remember many years ago a young mentor telling me

when I was a still younger nursing student that there

are two types of people you should never wake up:

babies and sick people. That left an impression on me

a few years later as an eager new night nurse trying

to prove to the world that I was capable and ready.

As a result, I came to realize that taking hours away

from a patient's much needed sleep cycle in order to

prove that I could assess every nook and cranny was

wrong. It was not the ultimate in patient advocacy, it

was erroneous - a wrong dose error - not enough sleep.

And so, I have become a sleep advocate.

Often times, I consider my best shifts to be composed

of benign monitoring of sleeping patients (well, as

benign as cyclical NIBP/12-Leads/Lab draw/neb

tx/alarms/etc. can be). I design my care around

sleeping periods and I strenuously defend those

periods - from noise and light pollution, from

unorganized multi-disciplinary care (I work hard to

ensure that most care is done at the same time in

order to avoid frequent interruptions of sleep), and

from eager, if detrimental, disruptions. Doctors

expect it of me to ask if our improving patient really

still needs hourly blood pressure readings, or if q2

or even q4 would suffice. Resp TX is in the habit of

calling me in advance after 9pm to find out if and

when their therapies can coincide with mine.

No matter how you dismiss a critically ill patient's

need for sleep: it is important. In more situations

than not, it is the best care.

The thing about open visitation is that families feel

obligated to have somebody there all the times. This

has two extremely negative effects on sleep. First,

there is always somebody fidgeting and fussing in the

room. Second, even if a patient CAN sleep through such

doting, there is an expectation from families (and

unfortunately some nurses) that critically ill

patients need constant critical modalities performed.

Sometimes, the best medicine is being left alone. If I

spend four hours away from the beside of a sleeping

patient that I am nevertheless continually monitoring,

I am being a sleeping patient's best advocate. A

family member at a sleeper's bedside creates the

expectation (in both them and the nurse) that critical

care is comprised of frequent interactions. Sometimes,

this could not be further from the truth. It's easy to

say that more education is a key to resolving this

issue. My experience is that it is virtually

impossible to distinguish benign neglect from simple

neglect in the eyes of well meaning family members

that are deeply involved with the first phases of

grief (anger and denial).

2. Families need sleep, too.

I am also a family advocate. I have seen all too often

frail spouses morally obligated to spend night and day

at the bedside to prove their loyalty. Like their

critically ill soulmates, these clients of mine are

also being deprived of necessary recharge. Even if

they feel compelled to stay at the hospital, closed

visitation gives these dear ones access to the plush

couches in the waiting room to sleep. And this

exhausted spouse that WE are creating in our misguided

attempts to be compassionate: this is going to be our

patient's primary caregiver in the days to come. We

are setting them up to fail from simple exhaustion.

Closed visitation gives a much-needed structure for

sleep. Abandoning that structure is the opposite of

patient and family advocacy.

I simply cannot fathom how exhausted patients and

exhausted family members improve outcomes.

At the point end of life comes into play, I have never

seen family members deprived of access. Every closed

visitation policy that I have read or worked under

includes the provision: at the discretion of nursing

staff. It is simply inaccurate to portray denial of

access at end of life as a true component of a

comprehensive closed visitation policy. . .

In truth, you are dismissive of my point of view. To

bring that point home, let me tender that, at some

point during this letter, you have already dismissed

my opinion as neanderthal to modern nursing. You are

so sure that I am out of step with the times, that my

rationale and compassionate viewpoint on this issue

has fallen on deaf ears.

I cannot believe that I am in the extreme minority with

my beliefs. What I do believe is that AACN wishes my

beliefs to become an extreme minority.

Let me finally add that this letter is not written in

an agitated or angry tone. The tone you pick up on is

frustration. Frustation because I also believe that I,

too, am being a patient and family advocate.

~faith,

Timothy.

[rstewart]

Open visitation has been in effect in my CCU for the past several months. In my opinion, it is a disaster. But then again nobody asked my opinion.

The overall effect on our particular unit is an "anything goes" environment. Mind you on paper we still have rules but the reality is otherwise. We have more family members eating and sleeping in the tiny, equipment filled rooms. In fact, getting to the patient to assess or to perform care has become an obstacle course of bodies and stuff brought into the rooms. The noise level is noticably higher with the screeching of infants (we have no minimum age requirement for visitation) not at all uncommon. Cell phone ringing and usage are up. Families routinely disregard the 2 person limit and even those who are compliant frequently cause continual disruption as one group leaves to be replaced by the next. Privacy is a thing of the past. I have been interrupted on a frequent basis during conversations with physicians and with families of other patients, during report and while performing care. Security is non existent since people have a right to be in the building at all times. The repetitive questions and concerns are extremely time consuming and distracting. The effect on infection control although unstudied can not help but be a negative one for our fragile patient population. Resources to accomodate the increase in visitation were not addressed so there is no place to sit etc. Neither patients nor families can get uninterrupted sleep leaving them confused and irritable, not to mention the well known importance of sleep in the healing process. Etc Etc Etc

Now certainly many of the problems could be minimized but that would involve in some form saying "No, Mr/Mrs. visiter you can't do exactly what you want when you want to do it," or cost money, or require support from management. And we certainly could not have that since the the primary reason for open visiting is increased patient satisfaction scores without financial expenditure. The ancillary effects of the policy can easily be ignored or dismissed.

From the literature one would think that open visiting is totally without drawbacks. And "puff" pieces about the successful transitions to open visiting rule the day.

Increasing the number of patients per nurse is NOT the only way to reduce actual care hours provided. Increased paperwork and policies like open visiting reduce both the quality and quantity of nursing care in a manner that is undetectable by the usual/traditional productivity measures. However, the powers that be do not want to know the possible truth, so these issues will remain unstudied.

[RNSuzq1, RN]

Hi Grits, Thanks for your post - yours is the first I've seen discussing this issue. I'm a student nurse in NC - graduating in May and during our times in Clinicals was "shocked" at the number of visitors that are crammed into some patients rooms. You mentioned "camping out" and that's exactly what it's like in some of the rooms.

I'm finishing up my last rotation in Med/Surg and last week was the most interesting. I went in to do a morning assessment on my patient - saw something move on the other side of the bed and out pops his half-naked girlfriend from under the sheets. The entire room stunk of cigarette smoke, they both swore they weren't smoking in the room - but one of the Nurses went in there later and the girlfriend had the window open and puffing away - good grief. Later in the day the patients friends were hanging out, eating, making a mess, etc. We found out the pt. was trying to break into his PCA pump - just an odd bunch. I have nothing against hippies - but hey, the room looked like a campsite from Woodstock - :uhoh21: no joke, it was disgusting.

I work as a CNA at night and have had tons of visitors in rooms as late as midnight, laughing and carrying on (no respect for the other patients who are trying to sleep). I practically have to climb over them just to get to the patients - it's nuts. I absolutely understand all the family wanting to be around if the patient is terminal or it's touch and go, etc., but most of these people with all the visitors are in for very minor procedures and only hospitalized for a day or 2. Being a student, it's especially hard trying to do some new procedure on a patient with "100 eyes" on you - really unnerving.

I hate to think that after 25 years you'd feel forced to leave your position, but I understand your dilemma and hope you find a place you prefer working. Sue

[pickledpepperRN]

When I started working in a CVICU in Kansas, they told me of the open visiting. Being a "seasoned" (older :) ) nurse I was appalled. The rules were.......visitors, anytime night or day. The brochure asked loved ones to either stay in patient rooms or out of the unit from 6:45 til 7:30 am and pm. I hate to be the minority in this thread but....what I found was that families were understanding, compliant, respected nurses more when they saw what we actually do, would leave IMMEDIATELY when asked, they were more comfortable when they went home with the patient, we had more opportunities for family teaching, we had better relationships with families than I had experienced anywhere else, and satisfaction scores were through the roof. I did not have ONE negative incident. The families were so appreciative of being back there, they would bend over backwards to comply with our requests, including asking for some "quiet time" for the patient if we felt they needed it. I am now a director over several departments, including CCU. I have opened visitation and my staff remarked how we have less visitors in the unit at one time now that we have opened the unit up. Not every family member can come at the prescribed times, they have jobs, kids etc. I think families are more comfortable leaving the patients when they see the quality, compassionate care the patient receives. Maybe I have been lucky with positive expreriences in the two places I have seen this policy.

Julie

I've had mostly good experiences too.

Timothy, If I am ever critically I want someone like you to be my nurse.

Open visiting eliminates the problem of the immediate family member unable to visit at all because of work or other obligations.

With open visitation, especially a new patient each RN assesses not only the patient, but the family. Many loved ones especially parents and spouses need a good honest explanation of the condition. I often have them just come and look.

As was said many families truly "get it" when they see the care. Of course no eating or smoking. Our hand outs make that clear.

We claim to have 22 out of 24 hours visitation. That means the RN decides what is best for the patient. Certainly not that the patient doesn't get turned or suctioned because a loved one is in the room.

This last weekend I had a patient whose spouse left every time I suctioned because the sound caused nausea.

Still the patient smiled and communicated better than to me and was not disturbed when asleep.

Of course the family member who would try to get something out of the sharps container, oris continually disturbing the patient must leave.

It is the decision of the registered nurse based on assessment.

[P_RN, ADN, RN]

My Dad and my MIL are the only two instances I've had with critical care visitation. Mama would go to the hospital and sit in the waiting room all day long for the priviledge of seeing him 5 mins every 2 hours. I spoke with the doc (old friend of mine) and he agreed to a floor transfer as Dad was getting no better.

My MIL in her 80s was subjected to hoards of visitors to her and to the other patients in the area. It is humiliating to someone of that age to have their private times seen by all.

I think open within reason is the best policy. As for me, wherever I am, leave the sheets on a chair, bring me pain med on time and otherwise nursing care only.....hub and dtr ONLY visitors.

[PoppaD]

When I started working in a CVICU in Kansas, they told me of the open visiting. Being a "seasoned" (older :) ) nurse I was appalled. The rules were.......visitors, anytime night or day. The brochure asked loved ones to either stay in patient rooms or out of the unit from 6:45 til 7:30 am and pm. I hate to be the minority in this thread but....what I found was that families were understanding, compliant, respected nurses more when they saw what we actually do, would leave IMMEDIATELY when asked, they were more comfortable when they went home with the patient, we had more opportunities for family teaching, we had better relationships with families than I had experienced anywhere else, and satisfaction scores were through the roof. I did not have ONE negative incident. The families were so appreciative of being back there, they would bend over backwards to comply with our requests, including asking for some "quiet time" for the patient if we felt they needed it. I am now a director over several departments, including CCU. I have opened visitation and my staff remarked how we have less visitors in the unit at one time now that we have opened the unit up. Not every family member can come at the prescribed times, they have jobs, kids etc. I think families are more comfortable leaving the patients when they see the quality, compassionate care the patient receives. Maybe I have been lucky with positive expreriences in the two places I have seen this policy.

Julie

I am a CVICU nurse...we have an open visitation policy except from 6a - 9a; 12n - 1p, & 6p - 8:30p. After 11P visitation is every 2 hrs x 15 min & limited to 2 visitors. I think that you either love open visitation or you hate it. I like it. I think that it eases the anxiety of families. We do have the discretion to close visitation for a particular pt or to the unit in general if needed. I have found family members to be understanding of the demands of the pt and the unit.