Employing a patient-centered approach to visitation.
Jeanette Michalak is vice president of consultation services and Sara Guastello is manager of designation and resource development at Planetree in Derby, CT. Nancy Jane Schreiner is director of acute care and Wendy Tennis is Planetree coordinator at Valley View Hospital in Glenwood Springs, CO. Lauraine Szekely is senior vice president of patient care services and chief nursing officer at Northern Westchester Hospital in Mount Kisco, NY, where Maria Hale is vice president of patient advocacy.
Contact author: Jeanette Michalak, email@example.com.
Patients First is coordinated by Susan B. Frampton, PhD: firstname.lastname@example.org.
"Visiting hours are over."
These words are heard at about the same time each evening in hospitals nationwide. Families leave patients' bedsides worried about their loved ones, and patients are left alone, many feeling anxious and isolated. Cultivating a health care environment that welcomes loved ones and recognizes that family involvement enhances health care delivery is fundamental to the patient-centered approach that characterizes the Planetree model of care. But is there evidence to support patient-directed visitation policies? What are the concerns and attitudes of patients, family members, and bedside staff? The experiences of two hospitals that adopted patient-directed visitation policies can shed light on those questions.
THE BENEFITS OF WELCOMING LOVED ONES
Many studies support the case for liberal visitation policies. Fumagalli and colleagues concluded that unrestricted visitation in the ICU doesn't increase infection rates; instead, it's associated with lower rates of cardiovascular complications and mortality, as well as lower stress hormone levels.1 Research has found that flexible visitation policies minimize anxiety and maximize comfort for patients and families.1-3 In 2007 an American College of Critical Care Medicine task force concluded, "Including and embracing the family as an integral part of the multiple-professional ICU team are essential for the timely restoration of health or optimization of the dying process for critically ill patients."4
Hundreds of patient focus groups conducted by Planetree over the past several years paint a vivid picture of what patients want from their providers.5 They're relieved and comforted when their loved ones are welcome to be with them. "Stroke patients have very little memory or understanding of what's happened to them," said one patient. "I have only my wife to remind me of what happened. Fortunately, she is a valuable and welcome part of my experience here." In contrast, when family members are excluded, they feel the pain intensely: "My mother was admitted [to the] ICU. She died. The thing that still hurts is they had such strict visiting hours and they only let immediate family members in. Sometimes they asked me to leave during visiting hours and they were cutting into my time!"
WHAT PATIENT-DIRECTED VISITATION IS—AND ISN'T
Twenty-four-hour patient-directed visitation meets the psychological and emotional needs of the patient and her or his support system by letting each patient determine who visits and when, yet many health care practitioners are resistant to it. Some of their concerns arise from misconceptions about what patient-directed visitation is. It's not an endless stream of visitors at all hours of the day and night, keeping practitioners from doing their jobs. It is being flexible in meeting the needs of individual patients in their unique circumstances.
Instituting such a flexible approach can be challenging for bedside staff. Commonly cited concerns include increased physiologic stress for patients, the possibility that family members will need tending to, the possible compromising of a caregiver's opportunity for respite, and even possible interference with nurses' ability to care for patients.6-8 If patient-directed visitation is instituted properly, nurses' and other staff members' abilities to deliver the patient's physical care will also be taken into consideration.
Although most hospitals will accommodate after-hours requests to visit, formally establishing a patient-directed policy makes it true patient-centered care rather than rule bending. With the latter, inconsistencies in enforcement can compromise the healing environment by sowing confusion among patients and families and tension among staff.6, 9 The case reports that follow make clear the advantages of implementing patient-directed visitation as hospital policy.
ELIMINATING VISITING HOURS AT A COMMUNITY HOSPITAL
The visitation policy at Valley View Hospital, an 80-bed, private-room, community-owned hospital in Glenwood Springs, Colorado, had always been lenient and inconsistently enforced. For instance, nurses would "hide" visitors after hours if a disapproving supervisor was making rounds.
Then in 2000, the hospital formally eliminated visiting hours. Recliners and sleeper chairs were introduced and family rooms were established, where visitors could go when the patient needed quiet. Lobbies were made more inviting and functional. Visitors were given access to snacks and drinks, as well as to linens and personal care items, to address the concern that nurses might have to "wait on" them. Patients were told to let their nurses know if they wanted a break from visitors so they didn't feel obligated to see them. They were reassured that the nurses would be the "bad guys" who asked visitors to leave.
The open visitation policy is not without challenges. For the rare occasions when nurses or patients feel that visitors are being too loud, unit directors coach their staffs on how to tactfully emphasize to visitors that patients need rest and quiet. To keep the number of bedside visitors manageable for patients with large families, the families are encouraged to congregate in one of several family rooms and take turns visiting with patients.
Immediately after the change, staff members noted anecdotally that patients were much calmer and slept better with someone at the bedside. Patient satisfaction scores have also increased on measures related to family involvement since the change, including a 24% rise for "accommodations and comfort for visitors," an 11% increase for "staff attitudes toward visitors," and a 12% increase for "visitors and family overall." Furthermore, nurses no longer have to hide visitors, making the hospital a safer environment in the event of a disaster.
24-HOUR VISITATION AT AN URBAN ED
Safety concerns and overcrowding are commonly cited barriers to open visitation policies. The ED at NewYork-Presbyterian Hospital–Weill Cornell Medical Center in New York City is a level I trauma center that cares for approximately 70,000 patients annually, yet its personnel understand the critical roles that loved ones play as patient advocates and sources of information. Although the ED often treats more than 80 patients in a space with 42 adult beds, eight urgent care beds, and eight pediatric beds, the staff there decided to abolish visiting hours as part of a patient-centered care initiative.
Overnight visitors are now offered the use of rollaway sleeper chairs that were purchased with grant money. Waiting areas are stocked with coffee and snacks so families unable to be at their loved ones' bedsides will remain comfortable and close by. Patients are consulted about their preferences, such as whether loved ones are present during examinations and procedures.
Because patient census, patient acuity, and space limitations sometimes make limiting visitation necessary, staff members are free to ask visitors to leave patients' rooms. As Brian Miluszusky, director of nursing for the ED, explained, "We tell them, 'Use your discretion, you're professionals.' We empower them." Whereas the previous visitation policy cleared the ED of all visitors at a set time, now limits are placed on a case-by-case basis and only if it's necessary to ensure optimal patient care.
In the year since the change, patient satisfaction scores rose by approximately 5% in several matters related to visitation, an indication that welcoming and involving a patient's loved ones helps to meet the patient's needs—and that's the central theme of patient-centered care.
This is the fifth in a series of articles from Planetree, an international nonprofit organization founded in 1978 that's "committed to improving medical care from the patient's perspective." For more information, go to www.planetree.org.
1. Fumagalli S, et al. Reduced cardiocirculatory complications with unrestrictive visiting policy in an intensive care unit: results from a pilot, randomized trial. Circulation
2. Garrouste-Orgeas M, et al. Perceptions of a 24-hour visiting policy in the intensive care unit. Crit Care Med
3. Simpson T. Critical care patients' perceptions of visits. Heart Lung
4. Davidson JE, et al. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004-2005. Crit Care Med
6. Lee MD, et al. Visiting hours policies in New England intensive care units: strategies for improvement. Crit Care Med
7. Berti D, et al. Beliefs and attitudes of intensive care nurses toward visits and open visiting policy. Intensive Care Med
8. Berwick DM, Kotagal M. Restricted visiting hours in ICUs: time to change. JAMA
9. Simpson T, et al. Implementation and evaluation of a liberalized visiting policy. Am J Crit Care