Dec. 3, 2006
The Impact of Hospital Visiting Hour Policies on Pediatric and Adult Patients and Families
Centre conducting the review
Queen's Joanna Briggs Collaboration
School of Nursing, Queen's University
Name: Lisa Smith, RN, MSc and Margaret B. Harrison, RN, PhD
Telephone: (613) 533–6000 ext. 78668
Facsimile: (613) 533–6331
Name: Jennifer Medves, RN, PhD
Telephone: (613) 533–6000 ext.74740
Facsimile: (613) 533–6331
Name: Joan Tranmer, RN, PhD
Telephone: (613) 533–6000 ext. 77670
Facsimile: (613) 533–6770
Other panel members
Name: Brett Waytuck, MLS
Telephone: (613) 533–6000 ext. 77694
Facsimile: (613) 533–6892
Contact for the review
Name: Lisa Smith, RN, MSc
Telephone: (613) 533–6000 ext. 78668
Facsimile: (613) 533–6331
December 3, 2006
Expected completion date
June 30, 2007
The overall objective is to examine the impact of hospital visiting hour policies on pediatric and adult patients and families.
The specific review questions to be addressed are:
- What is the physiological, psychological, or emotional impact of hospital visiting hour policies on pediatric and adult patients.
- What is the physiological, psychological, or emotional impact of hospital visiting hour policies on pediatric and adult visitors of either pediatric and/or adult patients.
Policies around restricted or open visiting hours appear to be a controversial subject in health care practices internationally, with no apparent consensus (Knutsson, Otterberg, and Bergbom, 2004). These rules which govern practice are often based on the assumptions of hospital staff, and in one review the authors concluded that they may have little or no evidence to support them (Clarke & Harrison, 2001). Policy and practice related to visiting hours is of pressing concern in Canada, and in Ontario specifically, following the reaction to the severe acute respiratory syndrome (SARS) outbreak and subsequent changes in visiting policies in most health care settings. Locally our clinical partners have requested a synopsis of the current state of knowledge in order to ensure their policies are guided by best available evidence, however this area will be of interest more generally for many centres.
Historical Overview of Visiting Policies
Restrictive visiting policies are carry-overs from the early 1800s when the first hospitals were established as almshouses for nonpaying patients. Visitation was often limited in an attempt to establish order in the general wards. It was not until about 1910 that hospitals became places that middle- and upper-class people would enter, and these paying patients were often free to have visitors at almost any time in their private or semi-private rooms. In the 1960s when neonatal intensive care units were established, there was grave concern about communicable disease involving immature immune systems, and there was also an effort to protect patients and families from exhaustion or stress caused by too many visitors, so hospitals instituted restrictive visiting hours broadly for both paying and nonpaying patients in ICUs and the general ward (Berwick and Kotagal, 2004; Giganti, 1998; Heater, 1985).
Practices involving visits to adults and children are still considered and judged from different perspectives throughout the world, in part established depending on cultural differences and principles, the size of the hospital, the hospital's geographic location, the daily admittance of patients, the distance to the hospital for visitors, the hospital's access to and implementation of current technology and the hospital staff's ability and willingness to adopt new knowledge and routines. For example, in critical care settings practices were varied, as some units requested no children could visit, while others had a fixed age for visits (Quinio et al., 2002). In one multi-centre survey it was found that many ICU settings (70%) had no policies or guidelines regarding child visits, several restricted child visits (34%), with a few actively encouraging child visits (Knutsson et al, 2004). A survey by Browne, Sanchez, Langlois and Smith (2004) suggested that in the United States, despite an effort to promote family centered care in 29 Intensive Care nurseries between 1995–2001, 13 of 16 nurseries (81%) still limited the number of visitors at the bedside in 2001, and visiting hours were sometimes restricted during staff shift change from one to four hours. Other studies have suggested there are incongruencies between unrestricted hospital visiting policies, and the actual restrictions imposed on visitors (Plowright, 1996).
In Neonatal Intensive Care settings, unrestricted parental visitation varied from 11% in Spain to 100% in other areas such as Great Britain (Cuttini et al, 1999). Visiting involving parents in decisions ranged from 19% in Italy to 89% in Great Britain, and it appeared that these variations could not be explained by differences in unit characteristics such as level, size, and availability of resources (Cuttini et al, 1999). Another recent study revealed that unrestricted access to mothers was allowed in only 29% of NICUs in Italy, with the main reasons for these restrictions being structural and organizational limitations and interference with staff activities. No relationship was found between visiting time (hours/day) and variables such as the unit's size, mean number of newborns, patient crowding and nurses’ workload (De Vonderweid et al, 2005).
Many hospitals in North America maintain both restricted visiting hours and restrictions on children's visits (Knutsson et al, 2004). In addition, sudden emergence of severe acute respiratory syndrome (SARS) caused much concern and as a reaction, strict visitation policies where imposed in regions affected by SARS during an outbreak (Rogers, 2004).
Reviews on Visiting Policies
During an initial review of the literature, no reviews were found in either Cochrane or JBI databases, but we located four reviews examining different aspects of visiting policies; Andrade (1998), Johnstone (1994), McIvor (1998), Clarke & Harrison (2001). Three of these reviews explored the needs of children visiting family members who were receiving treatment in intensive care unit settings (Johnstone, 1994; McIvor 1998; Clarke and Harrison, 2001). The Andrade (1998) review focused on sibling visitation. Thus the populations examined were narrow in scope, and there were methodological limitations; i.e. search methods, or search strategies were not described. During the mid-late 1990’s there was a paucity of studies on the effects of visiting policies and not all studies focused on visiting hour “policies”, but looked at various needs of visitors.
In conclusion, no systematic reviews were found that focused on and examined the effects of visiting hour policies on patients and families in general with adult and pediatric populations. The late 1990’s and early 21st century have brought profound changes in this area due to world-wide infectious outbreaks; therefore, a current review of the research literature is required to provide a relevant synopsis.
The objective of our review is to examine the effect of hospital visiting hour policies on patients and families of all ages and in a variety of in-patient settings focusing on the quantitative evaluative research on this topic to date.
Types of participants
This component of the review will consider studies that include both pediatric and adult hospital patients and/or their families. Participants can be patients or visitors in the following settings: general medical/surgical units, critical care (ICU, NICU), chronic care, pediatrics, maternity, labour and delivery.
Articles will be excluded if participants came from the following settings: post-operative care, post anaesthesia care unit, dementia wards, long term care settings, studies focused on presence only during emergency procedures or resuscitation.
Types of interventions
Studies will be considered for inclusion in this review if they evaluate the effect of visiting policies. This includes interventions targeted at limiting or expanding patient visiting.
Types of outcome measures
For this review, outcome measures related to both patients and families as a result of visiting hour policies will be considered, including, but not limited to: patient and/or visitor satisfaction, attitudes, beliefs, perceptions, mood, or patient physiological outcomes. These could also include health care provider beliefs and perceptions about effects on patients and/or families.
Types of studies
Since the search question is about the effects of visiting hour policies, the review will primarily consider any experimental or quasi-experimental studies.
In the absence of Randomized Controlled Trials (RCTs), other research designs will be considered for inclusion, such as, but not limited to: non-randomised controlled trials and before-and-after studies where the focus is the evaluation of the effect of visiting hour policies.
The search will seek both published and unpublished studies. Using a defined search and retrieval method the following databases from 1995–2006 will be accessed: Medline, CINAHL, Embase, PsycInfo, HealthSTAR, Cochrane Database of Systematic Reviews, AMED, and ERIC. Relevant subject headings will be exploded where appropriate, and keywords truncated. Since each electronic database has its own indexing terms, individual search strategies will be developed for each search. For example, in CINAHL and Medline, “Visitors to patients”, “patient-family relations”, professional-family relations” will be useful keywords, as well as a search for terms in the title, abstract, subject heading such as “restrict$ or unrestrict$ or limit$ or unlimit$ or regulat$ or unregulat$ or reduc$”, “visit$ adj2 hours$”, “visit$ hour$”, “hour$ of visit$”, “hour$ visit$”. All references will be exported to RefWorks and then transferred to Endnote if necessary.
The search for published studies will include the following sources:
- Cochrane Database of Systematic Reviews
- Embase (for the European literature)
- Web of Science
- Reference lists of identified studies and review papers
- Direct communication with key organizations and key researchers in the area.
The search for unpublished studies will include the following sources:
- Dissertation abstracts
- New York Academy Grey Literature site http://www.nyam.org/library/grey.shtml
- Google Scholar
Electronic searching is expected to result in the lists of articles with details of title, author, source, and sometimes abstract. All identified articles will be assessed on the basis of the abstract (or title if abstract not available) by two reviewers, and full reports will be retrieved for all studies that meet the inclusion criteria for the review. Where doubt exists, the full article will be retrieved.
Assessment of methodological quality
Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instruments for evidence of effectiveness, from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information Package (SUMARI) (Appendices B and C). Any disagreements that arise between the reviewers will be resolved through discussion with a third reviewer.
Data will be extracted independently by two reviewers, using the standardized data extraction tool from the Joanna Briggs Institute System for the Unified Management, Assessment, and Review of Information package (SUMARI) (Appendix A).
Where possible quantitative research study results will be pooled in statistical meta-analysis using Review Manager software from the Cochrane collaboration (Review manager 4.2.8). All results will be double entered. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form.
Should the JBI MAStARI software be developed and ready for use at the commencement of the review, it will be used.
The Ontario Ministry of Health and Long Term Care for the provision of funding for the Queen's Joanna Briggs Collaboration demonstration project.
Conflicts of interest
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