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Visitation policies on the adult ICU

Nurses' satisfaction and preferences

DeLano, Alissa R. DNP, NP-C; Abell, Cathy H. PhD, MSN, RN, CNE; Main, Maria E. DNP, APRN-BC

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Nursing Management (Springhouse): February 2020 - Volume 51 - Issue 2 - p 32-36
doi: 10.1097/01.NUMA.0000617020.50320.d1
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Many ICU nurses have encountered situations in which they've struggled with following visitation policies while doing what they think is best for the patient and/or family. It may be an instance when the nurse thinks having a family member at the bedside will be calming for the patient or a moment when the nurse believes that the patient may not live much longer and he or she wants to provide the patient and family with the opportunity to spend more time together.

Despite emerging literature that supports open visitation on the adult ICU, visitation guidelines and policies vary among facilities. The American Association of Critical-Care Nurses (AACN) recommends open visitation for optimal patient outcomes, arguing that it can help decrease patient anxiety, agitation, confusion, and cardiovascular complications.1 Furthermore, the AACN suggests that open visitation helps the patient feel more secure while increasing safety and quality of care.1 Open visitation can improve communication between healthcare providers and the patient's family and create additional opportunities for patient and family education and teaching. This results in increased family involvement in care; improved perception of care; and establishment of a professional relationship between nurses, patients, and families.1

ICU nurses experience high levels of work-related stress and dissatisfaction, often due to an increased workload and visitors' perception of care, thus increasing turnover.2 Additionally, nursing dissatisfaction may contribute to decreased retention and increased organizational costs. The average turnover cost for a single clinical nurse can range from $40,300 to $64,000, resulting in a potential annual loss of between $4.4 million and $6.9 million for a hospital.3 The average turnover rate for critical care RNs was 18.2% in 2018, which is consistent with the overall national turnover rate of 19.1%.3

Open visitation may increase patient and/or family satisfaction; however, less is known about ICU nursing staff preferences and satisfaction in relation to visitation policies. This is a fiscal issue for hospitals and a satisfaction factor for nurses, patients, and family members that warrants further evaluation. This article describes a study that used a nurse visitation questionnaire and demographic data to examine ICU nurses' satisfaction with current visitation policies.

Research overview

The primary research questions for this descriptive correlational study were:

  • In adult ICU nurses, is there a difference in satisfaction for those who are employed in a setting with open visitation versus those employed in a setting with closed visitation?
  • Is there a correlation between years of ICU experience and satisfaction with the current visitation policy?
  • What are examples of situations that ICU nurses believe warrant an exception to visitation policies?

Methodology. The Institutional Review Board at a university located in the southern US approved the study before it began. Approval to modify and use the nurse visitation questionnaire was also obtained from an original author of the instrument. In this study, the ICU included all generalized and/or specialty adult ICUs.

Sample. Twenty-four healthcare professionals (22 women and 2 men) were asked to participate in the study at an AACN chapter meeting. Twenty-one of them—17 clinical nurses, 1 charge nurse, and 3 ICU directors—responded to a question regarding their current position. Inclusion criteria for participants included the ability to speak English, an active RN license, and current practice within an adult ICU. Participants also needed to have 6 months or more of nursing experience.

Years as a nurse ranged from 1 to 48 years (mean = 19.21, SD = 14.87), ICU experience ranged from 1 to 44 years (mean = 16.0, SD = 13.45), and participants' ages ranged from 23 to 68 years (mean = 45.97, SD = 13.72). When asked for their highest level of education, 5 participants reported holding an associate of science in nursing degree, 12 indicated a bachelor of science in nursing degree, and 7 specified a master of science in nursing degree.

Instrument. The nurse visitation questionnaire was adapted with permission from a published report by Hart and colleagues.4 First established by a panel of experts at the University of Arkansas College of Nursing, the tool was revised for this study to pertain to critical care practice, which better reflected the study's purpose.4 The modified instrument consisted of 13 questions asking how the participants felt about visitation on their adult ICU. The participants were also questioned about their satisfaction with current visitation policies and their preferences regarding visitation practices, such as when visitors should be allowed, how long visitors should be allowed to stay, the maximum number of visitors in a patient's room at a time, and whether they felt visitors were detrimental or beneficial to the well-being of the critical care patient.

Data collection. The study's principal investigator (PI) attended two AACN monthly chapter meetings in the southeastern US. The PI explained the research study and its purpose to attendees before the beginning of the meeting and distributed the questionnaire and a consent form for inclusion in the study. The estimated time to complete the questionnaire was approximately 5 to 10 minutes. To encourage participation, individuals taking part in the study could enter a drawing for a $25 Amazon gift card.

Results

Open visitation is described as having unlimited patient access to visitors, whereas closed visitation includes specific time frames during which visitors are permitted.4 Two items from the questionnaire were utilized to examine the difference in satisfaction of nurses employed in an open visitation setting versus those employed in a closed visitation setting.

First, participants indicated the type of visitation policy present where they're employed and then indicated their satisfaction based on a scale of 1 (lowest satisfaction) to 10 (highest satisfaction). Seventeen of the respondents indicated working in an environment with open visitation, and seven indicated working in an environment with closed visitation. (See Demographics for open vs. closed visitation groups.)

Table
Table:
Demographics for open vs. closed visitation groups

The satisfaction score for open visitation ranged from 2 to 10 (mean = 6.0, SD = 2.65) and the satisfaction score for closed visitation ranged from 1 to 9 (mean = 4.28, SD = 3.59). The mean was somewhat higher for open visitation, but no statistically significant difference was noted between the two groups (P = .21).

The correlation between years of ICU experience and satisfaction was examined. Because the participants varied widely in terms of their ICU experience, they were divided into three groups based on cumulative percent. Group 1 represented nurses with 1 to 7 years of ICU experience (n = 8, mean = 5.38, SD = 2.26), whereas nurses in group 2 had 8 to 14 years of experience (n = 7, mean = 5.57, SD = 3.31) and group 3 represented nurses with 15 or more years of experience (n = 9, mean = 5.56, SD = 3.57). When comparing the groups, no statistically significant difference was noted (P = .99).

Twenty of the 24 participants indicated that they support certain exceptions to the visitation policy, including imminent death, patient emotional needs, a request to speak with a physician, as a restraint alternative, for discharge preparation/instructions, and the presence of out-of-town family members or those with a job conflict.

Discussion

The aim of this study was to describe nurses' satisfaction with current visitation policies on adult ICUs. The results suggest that nurses may be satisfied with both open and closed visitation policies. It's been reported that 78% of ICU nurses prefer unrestricted visitation policies because of better clinical outcomes; increased communication opportunities; and improved rapport between staff, patients, and families.1 Findings from this study demonstrated a higher mean satisfaction score for open visitation than closed visitation; however, they didn't indicate a statistically significant difference regarding satisfaction. This may have been due to the small sample size and/or the unequal distribution of participants in each group.

Although this study didn't yield statistically significant results pertaining to years of ICU experience and satisfaction with current visitation policies, in a previous study, nurses with 15 to 20 years of experience were more likely to perceive families as interfering with clinical care as compared with nurses who had less experience.5

Nurses continue to have varied perspectives on whether open visitation should be allowed on an individual basis.4 Twenty of the 24 participants in this study supported exceptions to visitation policies that included imminent death, requests to speak to the physician, and for discharge preparation/instructions.

Limitations

Although this study shows that there are important indicators regarding visitation policies and their significant implications for patient well-being, unit operations, and staff satisfaction, it did have limitations. The sample size was relatively small, and the discrepancy in sample size between participants from open visitation units and those from closed visitation units also limited the study due to the disproportionate group size.

Recommendations

Recommendations for future research include replicating the study with larger, more heterogeneous samples. Qualitative research asking nurses to share stories of experiences with both open and closed visitation would also be of interest.

Nurse leaders should be aware of nurses' preferences and take them into consideration when developing visitation policies within ICUs. This can increase nurses' job satisfaction and, thus, decrease costly turnover. An integrative review by Monroe and Wofford concluded that although open visitation is valued by patients and families, nurse leaders need to keep in mind that increased interactions with patient visitors may increase nurses' workload. If this is the case, leaders need to consider interventions necessary to overcome the additional workload.2

More research needed

Although open, flexible patient-centered care benefits patients, families, and nursing staff, there's little evidence pertaining to nurses' satisfaction with visitation policies, specifically regarding perceived barriers, visitation preferences, years of nursing experience, exceptions to visitation policies, and how many visitors should be permitted in the patient's room at one time. For many decades, research suggested that nurses restricted visiting hours because they believed visitors were unintentionally detrimental to the patient.4 This research is contradicted by more recent studies suggesting that family presence at the bedside improves physiologic function and psychological well-being by decreasing patient anxiety.4 Despite this shift in research findings from the 1970s to the present, little is known about nursing satisfaction and specific visitation policies. Further clinical inquiry is needed to examine nurses' preferences regarding ICU visitation policies, which may help inform policy changes to enhance nursing satisfaction and retention.

REFERENCES

1. Family presence: visitation in the adult ICU. Crit Care Nurse. 2012;32(4):76–78.
2. Monroe M, Wofford L. Open visitation and nurse job satisfaction: an integrative review. J Clin Nurs. 2017;26(23-24):4868–4876.
3. NSI Nursing Solutions, Inc. 2019 national healthcare retention & RN staffing report. http://www.nsinursingsolutions.com/Files/assets/library/retention-institute/2019%20National%20Health%20Care%20Retention%20Report.pdf.
4. Hart A, Hardin SR, Townsend AP, Ramsey S, Mahrle-Henson A. Critical care visitation: nurse and family preference. Dimens Crit Care Nurs. 2013;32(6):289–299.
5. Mitchell ML, Aitken LM. Flexible visiting positively impacted on patients, families and staff in an Australian intensive care unit: a before-after mixed method study. Aust Crit Care. 2017;30(2):91–97.
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