Bedside matters: A new look at visiting hours
Editor's note: This feature examines Joint Commission standards in greater detail with expert advice from BOJ advisors. This month, Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, a healthcare consultant in Trabuco Canyon, CA, and former Joint Commission surveyor, discusses Joint Commission requirements and visiting hours.
The relationship between hospital and patient is changing, and this evolution has been under way for a number of years. One sacred cow we find under scrutiny of late is the topic of visiting rights. In fact, as of July 1, The Joint Commission has been evaluating its compliance with CMS requirements in the area of visiting rights, specifically in the Patient Rights chapter and other areas of Joint Commission standards.
When I think of visiting rights and hours and their effects on patients and staff, I think back to my colleague Jeremy Swan, MD, PhD. Dr. Swan, a world-renowned physician, once wrote a first-person piece titled "Kath" for the Annals of Medicine in the journal's "On Being a Doctor" section. Dr. Swan describes, with heartbreaking honesty and a uniquely intimate perspective, the loss of his daughter Katherine Swan Ginsberg, MD, MPH, in 1992.
Dr. Swan is a gifted writer, but it is the singularly unique outlook-a physician at the bedside not as a professional but as a father, his daughter not the caring doctor she had been so highly regarded as but instead the patient-that has always stayed with me. He once told me that he knew he was fortunate to be afforded the time he had with his daughter. I often wonder whether it was because of his position as a physician.
No one stopped Dr. Swan from visiting his daughter at any hour, and perhaps this is how it should be for everyone. Visiting hours are a tradition in hospitals and have, in many ways, served a purpose. But do they do more harm than good? Are they a barrier to health?
Perhaps it is time we examine our own prejudices to better understand this concept and its future in our industry.
Visitors in the ICU
Emotion is certainly a factor in the exploration of visitation hours, but nothing can turn the tide of medicine the way cold hard numbers can.
A physician in Milan whose work I've admired, Alberto Giannini, presented a fascinating report in 2008 to the 3rd EfCCNa Congress and 27th Aniarti Congress in Florence entitled "Should we open or close the ICU to family members?" Dr. Giannini used information gathered from a number of polls regarding ICU patients' perception.
He led off with a discussion about what patients ranked as their most immediate perceptions during treatment in the ICU. Many of the items listed were logical due to their relation to physical comfort-being thirsty, for example, was most highly reported at 63%, and sleep deprivation, temperature issues (feeling too hot or too cold), and even hunger made the list. But an overwhelming 62% reported being afraid or anxious, and 46% felt lonely or isolated during their time in the ICU.
Giannini then quoted a 2001 survey looking at stressful conditions for cancer patients in the ICU. Again, physical discomforts such as sleep deprivation were highly reported, but the third most identified issue was limits on visitation by loved ones, with 29% of patients experiencing this condition as moderately or severely stressful.
Interestingly, Giannini then looked at a 2005 study listing what patients, as well as nurses and physicians, perceived as stress-inducing factors in the ICU. In this study, the most cited issue the nurses and doctors reported was seeing family and friends only a few minutes a day, with missing one's husband or wife ranked a close second.
In his research, Giannini found that both nurses and physicians were largely underestimating the relatives' need for proximity and information, and physicians were underestimating, to a lesser extent, those relatives' need for assurance.
ICUs with unrestricted visiting hours (2008)
- United States: 32%
- Sweden: 70%
- United Kingdom: 19%-22%
- France: 3%-23%
- Italy: 0.4%
According to his study, the United States was in better shape than much of Europe in opening up ICUs to unrestricted visiting hours (see the above box for the surprisingly low percentage of open units in Italy, for example), but other nations, such as Sweden, were found to be more progressive in this area.
Why close the ICU?
Perhaps it is worthwhile to look at ICUs with the most restrictive visitation policies to get a better understanding of the reasons for limiting family members' access to patients. In Italy at the time of Giannini's study, for example, only one ICU had restricted visiting hours, although those restrictions varied from facility to facility. The median visit time was 60 minutes, with no visitors allowed in 2% of those units. Other restrictions included number of visitors (92% limited this number), types of visitors (17% allowed only immediate family), and no-child visitation policies (a surprising 69% had this restriction). Twenty-five percent of the units, in addition, did not provide a waiting room for visitors.
What were the reasons behind such restrictions? Arguments were made that visitors:
- Increased risk of infection
- Interfered with patient care
- Increased stress levels for patients and family members
- Violated patients' privacy
- Increased the workload for ICU staff
All of these units were considered "open" ICUs in which it was a staff objective to make a "rational reduction or abolition of all not strictly necessary restrictions on time, physical aspects, and relationships," Giannini wrote.
How do healthcare professionals respond to these claims? While Giannini's presentation focused on Italian hospitals, the logic behind the above restrictions is not unreasonable-on paper, at least.
But many of the claims don't hold up to deeper research, he found. Septic complications were similar in both restricted and unrestricted ICUs, nudging the argument about risk of infection out of the picture. Sure signs of stress-cardiac complications, hormonal stress markers-have been found to be significantly lower in unrestricted ICUs. And studies have found that the stress levels of patients' family members, particularly patients' mothers, decrease significantly when ICUs are unrestricted.
A 2008 report entitled Perceptions of a 24-Hour Visiting Policy in the Intensive Care Unit found the following:
- Most visits occurred between 2 and 8 p.m.
- The median visit duration was 120 minutes per day
- Nurses and physicians did not perceive open visitation as disruptive to care
- 75% of family members reported lessened anxiety levels in unrestricted ICUs
As we prepare to look at our own visitation policies, including updated Joint Commission requirements that went into effect in July, we might look one last time at Giannini's research. Examining the cons of unrestricted ICUs, the challenges he identifies include several that boil down to culture. None of these challenges are reasons to write off the potential of a culture change. Rather, they require us to look within ourselves at our deep-seated preconceptions and expectations to better understand our patients and our own organizational culture.
To close, I'd like to quote another colleague who shares her view on how visiting hour restrictions affect nursing.
"With all the research that has been done on the positive effects of family/friend/significant others at the bedside that impacts patient outcomes, why do we continue to have these outdated visitor policies?" says Lynne Whaley, RN, MS, past president of the Association of California Nurse Leaders. "Common sense must prevail, and of course patient safety-yes, patient safety, not our comfort levels. My goal is to see open visiting hours in our ICU and hospital before I retire from this great profession of nursing."