Open Visitation Research Articles

Intensive care nurses’ beliefs and attitudes towards the effect of open visiting on patients, family and nurses

The policy of family visits to patients admitted into intensive care units (ICUs) has been liberalised in recent years. This change has been progressive in our unit from a restricted to an open visiting policy. We have carried out this study based on Ajzen and Fishbein reasoned action theory. The aim of this study is to analyse the relationship between nurses' beliefs and attitudes towards the effect of an open visiting policy on patients, family and nurses. A descriptive correlational design was used. The sample included 46 intensive care nurses from a teaching hospital in Spain, who completed two self-administered anonymous questionnaires. One of them, derived from empirical results of Kirchhoff et al. (1993) and Simpson et al. (1996) studies, was a Likert-type scale including 26 items divided in three subscales (patient, family and nurses). This scale was used to obtain the nurses' beliefs regarding the effects of open visiting. The second questionnaire was a differential semantic scale (used by the previous authors), which analysed nurses' attitudes towards visiting on the patient, family and nurses. Nurses' beliefs about the effect of visiting were positive, achieving a mean value of 3.001 (patient 3.04, family 3.23 and nurses 2.78) on a scale with a maximum value of 4. The mean score obtained on the scale of attitudes toward an open visiting policy was 6.005 (patient 6.41, family 6.37 and nurses 5.22), with a maximum of 7. The correlation between beliefs and attitudes was significant and positive (r = 0523, p < 0.0001). Comparison of sociodemographic variables with beliefs and attitudes disclosed no statistically significant differences, except for the two following variables: attitude and having children (t = -2.254, p = 0.03) which obtained a higher score. There is a correlation between nurses' beliefs and attitudes regarding the positive effects of open visiting on patients, family and nurses.

Nursesʼ Perceptions of Open Visiting Hours in Neuroscience Intensive Care Unit

A quality improvement project was undertaken by Neuro-ICU nurses to determine possible effects from open visitation. From a quality improvement perspective, nurses' concerns were investigated along with their perceptions about open visitation to determine a need for visitation policy revision. Vast variability in nurses' interpretation and implementation of individualized open visitation policy suggested a need for the following: staff education about the policy and its implementation, a review of the literature to determine the validity of concerns about deleterious physiologic effects on neuroscience patients from visitation, and improved communication among nurses about visitation.

Process Helped Gain Acceptance for Open Visitation Hours

One nurse’s vision that, in addition to quality care, patients need the support and reassurance that only family members can bring them resulted in implementation of an open family visitation policy in the intensive care unit (ICU) at St. John’s Mercy Medical Center, St. Louis, Mo.Recognized as a leader, mentor and compassionate nurse who provides excellent end-of-life care, BJ Hipsky, RN, BSN, headed the campaign to enact an open family visitation policy in the ICU. As a true patient advocate, Hipsky considered the restrictions placed on family members whose loved ones were patients in the ICU as a detriment to both the patients and their families. She cited several reasons for opening the visiting hours:When the yearlong process to implement open visiting hours began, unit staff was split on the issue. As a nurse manager, Hipsky knew she needed the full support of her staff to ensure the policy change was successful. So, she set out to create a structured approval and education process that allowed input from all coworkers.For example, a task force was charged with leading the way in educating staff and gaining consensus. The first step was to educate the staff on the importance of families’ “need to know.” Hipsky selected 2 coworkers—a physician and a nurse champion—to lead the effort to gain acceptance and respect for the idea. She says the main opposition from nurses revolved around 2 concerns—either they were uncomfortable carrying out certain procedures in front of family members or they were not comfortable interacting with family members.In response, the team, which included Dr Robert Taylor, Jennifer Baetz, RN, and Father Phil Krahman, spent a lot of time communicating with coworkers about appropriate ways to talk with family members and ways to ask family members to step outside of the room briefly when certain procedures were needed. Hipsky and the team spent a lot of time “scripting” the staff on different scenarios they may encounter with families and appropriate ways to respond. They also shared information on the effort with other departments, making it a collaborative effort. During the process, Hipsky acted as a mediator and educator.Fortunately for patients, studies have shown that open ICU visitation is an asset, instead of a hindrance, to patient care. According Berwick and Kotagal,1 resistance among nurses and physicians regarding this topic focused on 3 worries: increased physiological stress for the patient, interference with the provision of care, and physical and mental exhaustion of family and friends. But, Berwick and Kotagal assert that when hospitals took a challenge from the Institute for Healthcare Improvement to totally unrestrict the ICU visiting policy, the results refuted these concerns. Instead, visits from family and friends did not increase patients’ stress levels; having family members present actually facilitated communication between patients and clinicians, and family members tended to feel less anxiety when allowed to visit according to their desires. Hipsky says that St. John’s Mercy Medical Center has experienced similar results with its open ICU visitation.Although implementing open ICU visiting hours was a fairly smooth, albeit lengthy process, Hipsky says that if she had it to do over again, she would have formalized the educational aspect by scheduling workshops on talking with families and giving the appropriate information. Nonetheless, she thinks everyone benefited from the time spent on communication. And, according to Toni Kanne, RN, trauma nurse manager, the open visiting hours embraces the nurse-patient-family AACN Synergy Model for Patient Care, allowing for a balance between the needs of each party. Without Hipsky’s leadership, management, and communication skills, the policy could not have been realized.“In Our Unit” highlights unique practices, innovations, research, or resourceful solutions to commonly encountered problems in critical care areas and settings where critically ill patients are cared for. If you have an idea for an upcoming “In Our Unit,” send it to Critical Care Nurse,101 Columbia, Aliso Viejo, CA 92656; fax, (949) 362-2049; e-mail, ccn@aacn.org.

Restricted visiting hours in ICUs: time to change.

THE SICKEST PATIENTS LIE IN INTENSIVE CARE UNITS (ICUs) facing fearful illness; surrounded by overwhelming noise from pulsating ventilators and monitors; invaded by the necessary ministrations of nurses; and overhearing, if they are awake, strange and portentous conversations. Professionals buzz about them, but these patients are mostly alone, separated from those who love them by restrictive ICU visiting policies, except at rigidly specified times or with the doled-out permission of the ICU staff. Restricting visiting in ICUs is neither caring, compassionate, nor necessary. Restricted hospital visiting hours began in the late 1800s for nonpaying patients in an attempt to establish order in the general wards. For many decades afterward, paying patients remained free to have visitors at almost any time in their private or semi-private rooms. In the 1960s, however, in an effort to protect the patient and the family from exhaustion caused by too many visitors (Kenneth Ludmerer, MD, Washington University, oral communication, April 23, 2004), hospitals instituted visiting hours broadly for both paying and nonpaying patients in ICUs (which were then being introduced) and the general wards. Today, most hospitals have liberalized visiting policies on intermediate care units, but strict ICU visiting hours are enforced despite increasing awareness that families have an active role in care, and despite increasing recognition among hospital staff of the rights and abilities of patients to make informed decisions. Perhaps the question to be answered is “Who is visiting whom?” In an effort to stabilize the details of ICU operations, health care institutions and professionals neglect the plausible assertion that they are the visitors in patients’ lives, not the other way around. Several months ago, the Institute for Healthcare Improvement (IHI) challenged a number of hospitals working on improvement of care to open their ICUs by instituting a totally unrestricted visiting policy. Several took up that challenge and have come forward to share what they learned from their tests of open visitation policies. Even proposing the idea of liberalizing ICU visiting hours, let alone implementing it, generates considerable resistance among nurses and physicians, who are largely focused on 3 worries: increased physiologic stress for the patient, interference with the provision of care, and physical and mental exhaustion of family and friends. While these concerns may seem reasonable, the evidence from the recent experiences at hospitals working with IHI, as well as from a small but growing body of literature, tell quite a different story. Physiologic Stress for the Patient. The concern that the patient should be left alone to rest incorrectly assumes that family presence at the bedside causes stress. The empirical literature suggests that the presence of family and friends tends to reassure and soothe the patient, providing sensory organization in an overstimulated environment and familiarity in unfamiliar surroundings. Visits of family and friends do not usually increase patients’ stress levels, as measured by blood pressure, heart rate, and intracranial pressure, but may in fact lower them. Nursing visits, on the other hand, often increase stress. However, liberalizing visiting hours may not be good for every patient. The goal is not universal implementation of unrestricted ICU visiting policies, but rather the achievement of patients’ control over the circumstances of their own care. It is important that patients be able to decide who can visit them and when, and accomplishing this requires that there not be a universal restriction outside the control of individual patients and families. Instead, patients who can do so should be allowed to determine their own visiting hours, and this information should be relayed to their family and friends. In other circumstances, family preferences may appropriately control the decision. Barriers to Provision of Care. The second concern is that the unrestricted presence of loved ones at the bedside will make it more difficult for nurses and physicians to do their jobs and may interfere with the delivery of care. The evidence suggests, however, that the family more often serves as a helpful support structure, increasing opportunities for patient and family education, and facilitating communication between the patient and clinicians. Family members may also be able to provide feedback to nurses and physicians more effectively than the critically ill patient can, creating a better working relationship for all.

Vigilance: The experience of parents staying at the bedside of hospitalized children

Although the incorporation of a family-centered model of care delivery and open visitation policies have supported parents at the bedside of hospitalized children, little research has been conducted exploring the daily experience of vigilant parents. The purpose of this qualitative ethnographic study was to explore the experience of vigilance and specifically to examine the meaning, patterns, and day-to-day rhythms of parents who stay at the bedside of their hospitalized children. Ten parents of hospitalized children on a general pediatric unit were purposively selected to participate in the study. Qualitative data analysis supported the themes generated by previous studies of vigilance: commitment to care, resilience, emotional upheaval, dynamic nexus, and transition (Carr & Clarke, 1997; Carr & Fogarty, 1999). The knowledge generated from this study helps to support the theoretical understanding of vigilance and enhances the ability of health care providers to provide care that is congruent with the needs of parents and their children.

Avoid PCU Bottlenecks With Proper Admission and Discharge Criteria

In addition to freeing up precious ICU beds, PCUs have many positive implications. Nurses in PCUs report increased job satisfaction because they’re developing new skills. Patients and families are comforted as they perceive signs of the patient’s progress and enjoy more open visitation. Primary care providers (PCPs) appreciate the continuous monitoring of their patients. And hospital administrators support a two-tiered, critical care approach because it lowers costs and employs less-invasive technology. PCUs have a lower, less expensive caregiver-to-patient ratio than Progressive care units (PCUs) optimally provide care for patients with lower to middle levels of resiliency, vulnerability, stability, complexity, resource availability, care participation, decision making ability, and predictability. PCU names vary according to the patient acuities they encompass. Typically, a PCU name describes its predominant patient population, such as cardiopulmonary care unit or neurological stepdown unit. In larger facilities, these units can be structured to care for specific patient populations, or the unit is more generic and encompasses many diagnoses and patient populations. Often, caregivers must prepare for overflow from one PCU to another. As the patient population diversifies, nurse managers must clearly define appropriate care protocols for each PCU. ProgressiveCare

Family-Centered Critical Care: A Practical Approach to Making It Happen

Family-Centered Critical Care: A Practical Approach to Making It Happen

Visitation in critical care: processes and outcomes of a performance improvement initiative.

When family members became dissatisfied with a restrictive visiting policy in a combined coronary and medical intensive care unit, this situation was seen as an opportunity to better meet patient and family needs. A review of the literature indicated that open visitation policies enhance patient and family satisfaction, while a survey of patients, families, and health care team members revealed a desire for a more open visitation policy. Nursing staff, with input from other disciplines, developed and implemented a less restrictive visitation policy. Post-intervention surveys revealed higher patient and family satisfaction and a marked decrease in formal complaints.

Effects of Insect Tripping on Seed Yield of Common Bean

Insect tripping might enhance seed production in common bean (Phaseolus vulgaris L.). The effect of flower visits by insects on seed production was studied during 3 yr, 1992 to 1994, in Riverside, CA, using four cultivars with different growth habits: Linden, Pindak, PI 164778, and Ferry Morse 53 (FM 53). Each year, a factorial experiment in a randomized complete block design with four replicates was used. Each cultivar was grown under three treatments: (i) exposed to open visitation by all insects, (ii) in insect‐proof cages, and (iii) in cages with bumblebees. All pods produced by bean plants were collected and counted, and seed yield was determined. Year‐to‐year variation had signiticant impact on cultivar performance and treatment effects. The bean lines were significantly different for seed yield. The treatment effects were not consistent across years. The old cultivar FM 53 and line PI 164778 had no clear trend for seed yield response to insect visits across years, whereas Linden and Pindak showed a more defined and positive response to visits. Seed yield of Linden was similar in the open visitation and caged‐with‐bumblebees treatments but was significantly higher than that of caged plants, by 13% in 1992 and by 35% in 1994. Pindak showed a 9% increase in seed yield when plants were visited by insects in the open or in caged treatments compared with caged plants in 1992. The results indicate that cultivars such as Linden and Pindak, which behave as determinate plants, may respond to bumblebee tripping by increasing seed yield.

Patient, visitor, and nurse evaluations of visitation for adult postanesthesia care unit patients

Although PACU visitation for children is sometimes encouraged, most families of adult postoperative patients continue to be excluded from PACUs in this country. At an academic medical center, an open visitation policy for adult postoperative patients was evaluated by eliciting patient, visitor, and nurse evaluations of visitation for adult patients from 181 families. Commonly cited reasons for restricting PACU visitation were not identified as problems by the vast majority of respondents. Even when some aspect of a PACU visit was disturbing, patients and families expressed a desire for visitation. The results of this evaluation of a change in practice led to permanent implementation of an open visitation policy in this PACU.

Pollination Requirements of Three Highbush Blueberry (Vaccinium corymbosum L.) Cultivars

The effects of pollination treatments on fruit set and five berry characteristics [mass, diameter, number of apparently viable seeds (well-developed, plump with dark seed coat), total seed number (includes apparently viable and partially developed seeds), and harvest date] were examined on three highbush blueberry cultivars. Pollination treatments included unpollinated, open pollinated, emasculated, and three hand pollinations that used pollen from the same flower, from the same cultivar, or from a different cultivar. Berries matured earliest and were smallest with the most apparently viable seeds in `Northland', `Patriot' had the greatest fruit set and smallest seed number, and `Bluecrop' matured the latest. Fruit set was greater, berry size larger, seed number smaller, and maturation later in 1990 than 1991. For all three cultivars, berries were generally smallest, latest maturing, and had the fewest seeds when pollination was prevented and were largest with the most seeds and earliest maturing in open visitation. Emasculation resulted in berries similar to those from unpollinated flowers. For berry characteristics, cross-pollination was of benefit for `Patriot' and possibly `Northland' but not `Bluecrop'. Thus, commercial highbush blueberry planting designs must be based on the pollination requirements of the particular cultivar. `Northland' berries almost always had seeds, while `Patriot' showed high levels and `Bluecrop' low levels of parthenocarpy.

Current practices regarding visitation policies in critical care units

Previous research has emphasized the importance of visitation in critical care units and its beneficial effects on patients and their families. However, nurses' attitudes and beliefs about visitation did not correlate with those of patients and their families, nor did actual visitation practices correlate with written policy. To investigate nurses' perceptions about open vs restricted visiting hours and the effects on the patient, the patient's family, and the nurse. Quantitative and qualitative data were collected from 201 nurses who completed a survey instrument about nurses' perceptions of visitation at five metropolitan hospitals in a midwestern city. Seventy percent of official policies for visitation were restrictive. In practice, 78% of nurses were nonrestrictive in their visitation practices. Variables that affected practices regarding visiting hours were the patient's need for rest, the nurse's workload, and the beneficial effects of visitation on patients. Requests from patients and their families were ranked least important. Significant differences in practices were found regarding restriction of visiting by immediate family members and of the number of visitors. Restricted hours were perceived to decrease noise (83%) and promote patients' rest (85%). Open visitation practices were perceived to beneficially affect the patient (67%) and the patient's family (88%) and to decrease anxiety (64%). Perceptions of ideal visiting hours included restrictions on the number of visitors (75%), hours (57%), visits by children (55%), and duration of visits (54%), but no restriction on visitation by immediate family members (60%). Qualitative data revealed recurrent themes in visitation practices, policies and exceptions, control of visitation by patients, and nurses' wishes. Data indicate that most nurses do not restrict visitation, regardless of whether restrictive policies are in place. Most nurses base their visitation decisions on the needs of the patient and the nurse. Needs of the family were ranked as less important in decision making about family visitation.

Visitation in the Pediatric Intensive Care Unit: Controversy and Compromise

Much controversy has arisen in the last few decades regarding parental and family visitation in the intensive care setting. The greatest needs of parents while their child is in an intensive care unit include: to be near their child, to receive honest information, and to believe their child is receiving the best care possible. The barriers that exist to the implementation of open visitation mostly are staff attitudes and misconceptions of parental needs. Open visitation has been found in some studies to make the health-care providers' job easier, decrease parental anxiety, and increase a child's cooperativeness with procedures. To provide family-centered care in the pediatric intensive care unit, the family must be involved in their child's care from the day of admission. As health-care providers, the goal is to empower the family to be able to advocate and care for their child throughout and beyond the life crisis of a pediatric intensive care unit admission.

A Family-centered Critical Care Unit

Although care of the family has long been a focus of nursing, there has been an increased emphasis in recent years to provide opportunities for families to be an integral part of the hospitalization experience. This has been difficult for many nurses who perceive themselves as competent to care for a patient in "medical crisis" but feel unqualified to provide family care. This article will address issues related to implementing a family-centered philosophy of care in a critical care unit. Implementation strategies that will be discussed include: formulating a staff-led family support group and family committee, instituting a family visitation contract within open visitation parameters, and developing clinicians with expertise in family care. Tools such as a performance plan for a Clinical Nurse II specializing in family care and the family visitation contract will be shared.

Sources of Stress in Nursing Terminal Patients in a Hospice

A study was undertaken in the hospice unit at a large, midwestern community hospital to investigate the sources of stress experienced by hospice nurses. The case material reported in this article is based on observations, interviews with nurses, written stressful incident reports completed by nurses, and support group discussions. A number of sources of stress experienced by hospice nurses are identified. Physical characteristics of the unit as well as staffing policies designed to improve the quality of care resulted in conflict and feelings of alienation from other hospital personnel. Procedures followed in admitting patients to the hospice created stress when they were not fully supported by hospital administrators and physicians. Other policies related to the preparation of meals and open visitation increased the nurse's work load. At the same time, greater involvement with the patient and family during the dying process resulted in increased emotional demands on the nurse. Nurses experienced a sense of loss when a patient they had grown attached to died or was discharged to another institution. Stress also resulted from the nurse's exclusive involvement with terminally ill patients. Continual involvement with dying patients precipitated anxiety and superstitions concerning the nurse's own vulnerability and was particularly stressful when the nurse had experienced the death of someone close to her outside of the hospital.

Social and psychological care before and during hospitalisation

Hospitalisation is a stressful experience, especially for children. While maternal separation has been as a major cause of distress among younger children, a broader perspective is required to understand the links between the individual, familial, professional, institutional and structural levels of hospital care affecting children. This can be seen in the changing attitudes in hospitals to parents as visitors, and the gradual introduction of open visiting. A model of discontinuity is proposed to analyse the experiences of children, parents, and professional staff in the ward. A variety of ameliorative techniques are discussed, in terms of their implications for change to hospitalised children or to hospital organisation. Studies in the development of children's concepts of illness show the need for providing information relevant to their developmental level. It is suggested that more should be done to involve parents in the care of their children in hospital, and to offer them support during this time. The effects on nursing and other staff are considered. The introduction of play schemes has benefits for children, but may lead to organisational complications if the priorities between therapy and welfare are not reassessed. More attention should be given to the psychological risks of treatment in assessing effects of medical intervention. A move towards more child centred care should in particular involve a change in the role assigned to the family within the medical sphere, and a reduction in the insularity of hospitals and fragmentation of treatment derived from existing medical and nursing practices.

Preparation of healthy children for a hospital environment: A suggested method for preventing negative reactions by children on admission to hospital

Hospitalisation is a stressful experience, especially for children. While maternal separation has been as a major cause of distress among younger children, a broader perspective is required to understand the links between the individual, familial, professional, institutional and structural levels of hospital care affecting children. This can be seen in the changing attitudes in hospitals to parents as visitors, and the gradual introduction of open visiting. A model of discontinuity is proposed to analyse the experiences of children, parents, and professional staff in the ward. A variety of ameliorative techniques are discussed, in terms of their implications for change to hospitalised children or to hospital organisation. Studies in the development of children's concepts of illness show the need for providing information relevant to their developmental level.It is suggested that more should be done to involve parents in the care of their children in hospital, and to offer them support during this time. The effects on nursing and other staff are considered. The introduction of play schemes has benefits for children, but may lead to organisational complications if the priorities between therapy and welfare are not reassessed. More attention should be given to the psychological risks of treatment in assessing effects of medical intervention. A move towards more child centred care should in particular involve a change in the role assigned to the family within the medical sphere, and a reduction in the insularity of hospitals and fragmentation of treatment derived from existing medical and nursing practices.

THE “PANEL PARENT” AS AN ADJUNCT TO THE SPECTRUM OF NEONATAL INTENSIVE CARE

Early maternal-newborn interaction and the concept of maternal infant bonding is stressed in neonatal ICU'S today. Parents are encouraged to touch, fondle and visit their infant immediately. An organized support program can play a prominent role in maintaining family stability during this period. Only the parent who has gone through the experience can appreciate all of the fears and doubts which must be understood and explained. We have designed a “Panel Parent Program” to augment our open visitation policy. These parents have been through the experience and are chosen on the basis of infant diagnosis, ethnic, social, educational and financial background. The panel parent contacts the family within 48 hours and subsequently communication varies depending upon the problem and parent availability. After the infant is discharged from the ICU the family evaluates their “Panel Parent”. Since adopting this policy we have noted less grief response and a greater degree of total family stability both during and after the infant's stay in our neonatal intensive care unit.