open visitation in icu??

ZASHAGALKA, RN · Dec 3, 2005

2 things.

First, bluesky, my apologies - the sarcasm wasn't aimed at you but at open visitation in general.

2nd, you aren't bending the rules of any closed visitation unit I've ever worked in to allow a family member back at non-visitation times. Every policy I've ever seen has a 'nurse's discretion' clause.

When you have rules, you have the option to relax them.

When you don't have rules, it's practically impossible to enforce them.

Once you allow open visitation, you can talk all you want about placing limitations: it's a practical impossibility. Why? Because every time you do, someone will complain. And healthcare today is driven by improving pt surveys.

So, as a nurse, you are now in a position of having to justify to some pollster in management why you are doing something in your pt's best interest.

Problems w/ open visitation:

1. places expectations on family members - especially the 'greatest generation' to be there - thereby exhausting them so they can't take care of these pts when THEY are the primary caregiver.

2. places expectations on the staff to always be "piddling" in the rooms to look busy. I'm sorry, but some of my best shifts from a pt care perspective is sharing a seat w/ my tail for 8 of my 12 hrs watching the monitors while someone sleeps.

3. puts nurses in a 'justify your actions' role. I'm all for pt teaching. I'm adamently against having to defend my actions to family members.

~~~

True story. My manager asked me to allow a 30something sister to a 30 something guy stay in the unit to be w/ her brother. Some VIP thing. I complained, but agreed. 7p-7a shift. @9pm, the guy (dying from liver failure - but not dying that day, terminal visitation is another matter, and even closed visitation units allow families back when someone is dying -, on lactulose for hep enceph. did exactly what lactulose causes, and made a heck of a mess to be cleaned. I politely asked the woman to step out of the unit while I got him cleaned.

"NO."

"What do you mean, no. This isn't your spouse, he's your brother, and I need to get him cleaned."

"I've seen him naked before."

"Nevertheless. Can you please step out for a few minutes?"

"NO."

"Why not?"

"I'm here to make sure he's taken care of right."

"Whoa! back up, did you just say you're here to make sure I do my job? I'm sorry, visiting hours are over, and I have to ask you to leave for the evening. The next visiting hours are in the morning."

"You can't make me leave, your boss already told you to let me stay."

"And I'm sure you'll take it up with her. In the meantime, leave now, or I call security."

My manager and the DON were there at midnight trying to straighten this out. My take: you want her back here - I'll be happy to give YOU report.

Ultimately, she was allowed to come back for 10 minutes every hour. I was actually OK w/ that. After the first 10 minute period, she didn't come back the rest of the night. Seems if she can't 'make sure I do my job', there wasn't much point of being there.

(I'm not much someone to use anecdote to support my position - but this becomes an all too common attitude when no limits can be placed. There are reasons why Units have been closed.)

~faith,

Timothy.

RN34TX · Dec 4, 2005

That story about the brother and his sister staying over is sick and wrong.

That said, I'd also like to add that it's the visitors who protest and complain the most to administration about restricting visiting hours that are the very ones you end up not wanting in there in the first place.

When I was a lot newer at this, when visitors would call wanting to come in and acted "anxious" or "very concerned" (euphamistic labels I used for rude, inappropriate, demeaning, obnoxious visitors) I used to think that letting them in to see their loved one and explaining everything that was going on, listening to their concerns, keeping them informed, etc. etc.- everything I was taught in school, that it would help aleviate their anxiety and hence, minimize the bad behavior.

Very seldom did I actually see this happen in real life vs. textbook.

99% of the time, if they act up on the phone, they'll act up even worse once you let them in.

I still make plenty of exceptions and it still bites me in the rear later at times, but as a rule, the more you demand to be let in, the less likely I am to actually let you in because it becomes a game of ordering me around, demanding to see the doctor right now, accusing me of either under-medicating the patient for pain, or over-medicating them to keep them quiet, and second guessing everything I do.

I end up having no nursing judgement left and all of my actions become dictated by what the visitor wants.

I'm sorry, but I don't need either some big CEO of a major company nor some 7-11/Circle K cashier telling me how to be a nurse.

Just because they are related to the patient doesn't mean that they necessarily know what they are doing or know what's best for the patient.

Ruby Vee, BSN · Dec 4, 2005

you know what, i bent the rules the other night for one of those "nice" families. they knew it was against the rules, i told them so and said i was making an exception just this one time. the next night they have another nurse who enforced the rules, so what did they say "well, the other nurse let her come in".... last time i make an exception for anyone. i'm sick of it coming back to bite me in the butt because of an ungrateful, manipulative family.

all it takes is one nurse "trying to be nice" to make it difficult for the rest of us! if everyone enforced the rules, it wouldn't become such an issue. it's a shame it has to be that way, but that's the way it's been becoming for the last 10-15 years! 20 or 25 years ago, visitors were cooperative and respectful -- now it's all about "customer service" rather than "patient care." personally, i think we ought to have more rules, not fewer. you can come in for five visits a day at these times and for this many minutes, and only two at a time. immediate family only, no one under 16 unless they're strictly supervised by an adult. you can't sit in a wheeled chair; those are for staff. (had another visitor fall off one the other day). no eating or drinking at the bedside, especially if the patient is npo. and i make the rules and decide what's best for the patient, not you.

ruby (obviously not the "nice" nurse, but the one who has the patient's welfare at heart!)

fergus51 · Dec 4, 2005

]ruby (obviously not the "nice" nurse, but the one who has the patient's welfare at heart!)

umm... so did i. our visitation is pretty strict when it comes to non-parents especially but our routine is to let the non-parents step in to see the baby after visiting hours on the first day they are admitted to the unit. it's a little cruel to prevent grandma from comforting mom at the bedside of her sick baby the first time she's seeing him when dad isn't there to do it. they knew that's why grandma was allowed in for that one night, they just decided to try to be manipulative the next day. it annoys me, and i spoke in anger, but i really can't see punishing all the other families because of people like this.

suetje · Dec 20, 2005

i work in a a small 10 bed unit icu. we still have set visitations of 5 visits per day, 20 minutes each 2 people at a time. the hospital is considering open visitation. this is new to me and the staff that i work with.
i would love to hear your opinions of open visitation in a busy icu!!!
thanks so much!!!

I have been working in a large teaching instuitution for more than 20 years, and we instituted open visiting back then. Research does support that families are much more trusting and it promotes better discussion with them about pt. status than if they are kept out. And many of our pts are in dire, (read: total life support as in ECMO etc!) You need to take time and explain what is going on, but they often help with turning, bathing, and mouthcare, and that is helpful! We RARELY have any problems. Most of the time they sit on the side, reading, watching TV etc. And then they can catch the docs when they come in, so there is open communication with them. It is also advantageous if there is little hope of survival, for them to actually SEE the huge wound, or the fact that there is no response etc. It reinforces that we, the professionals, are assessing them and there is no response. They are more willing to start seeing the big picture when day after day there is no change or improvement. I say, don't be afraid! If you have to ask them to step out for a dressing chagne, or a line placement, they know you'll come in to get them when you're done.

CrunchRN, ADN, RN · Dec 21, 2005

Well................if my mom or dad or spouse was in ICU I would fight very hard to be present. Of course I would stay out of your way, help as needed, bring the nurse coffee and treats, and be extremely well behaved. If you did try to limit me to 10 minutes every 2 hours and my husband was that sick I must admit I would be down in administration in a heart beat. I would treat you right, but expect to be accorded some flexibility in return. I have hesitated to post this for a long time because I totally see how many families are unforgivably disruptive, but that wouldn't be me.

RoxanRN · Dec 21, 2005

Well................if my mom or dad or spouse was in ICU I would fight very hard to be present. Of course I would stay out of your way, help as needed, bring the nurse coffee and treats, and be extremely well behaved. If you did try to limit me to 10 minutes every 2 hours and my husband was that sick I must admit I would be down in administration in a heart beat. I would treat you right, but expect to be accorded some flexibility in return. I have hesitated to post this for a long time because I totally see how many families are unforgivably disruptive, but that wouldn't be me.

In order to adequately enforce a policy, it must be equally enforced. While exceptions are made on a case-by-case basis, you should not expect to be the exception.

In my unit, the most common exception is expected death. In fact, in this instance, we go out of our way to make the family comfortable during this vigil as these are the last moments they will be together with the patient.

Other common exceptions include conscious patients (read: not sedated) who are unable to call for help (unable to use the call light due to high-level quadraplegia and unable to use their voice due to a vent) and the extremely demented patient who is 'uncontrollable' (short of snowing them into next Christmas) except when family is present. We allow family (though only one at a time outside of visiting hours) for patient safety reasons as we are unable to keep absolute constant eyes on the patient. If these family members become disruptive, we ask they find another person to come sit with the patient.

Otherwise, if the patient is stable, 'the next visiting hours open at ______. We thank you for your understanding and cooperation.' And we do not hesitate to call Security when needed.

CrunchRN, ADN, RN · Dec 21, 2005

That is why I have trouble supporting restricted visiting. If I am not causing a disruption then I want to be able to be there more than that. I am not saying it is right, but wait till your loved one is in ICU and see how you deal with that policy.

RoxanRN · Dec 21, 2005

but wait till your loved one is in ICU and see how you deal with that policy.

Been there, done that, respected the rules...........

I am the one my family comes to for 'interpretation' of medical 'what-not' and facility policy. Therefore, I should also set the example with compliance to the rules.

CrunchRN, ADN, RN · Dec 21, 2005

I just cannot meet your standards, I am sure you are a great example, but I would really, really have a hard time with that inflexibility.