Saturday, February 8, 2014

Behind Closed Doors Lurk Proxy Wars: Is Visitation Really About Visitation?

I decided to rewrite this today, on January 30th, 2016, after thinking about it for almost two years.

The previous post took on the heretical task of making the case against wide open visitation in the ICU without restrictions.  I took that stance for several reasons.  First, I'm a heretic and an iconoclast, and I believe that free thinking, rationality, and good judgment and decision making require all angles of a debate to receive their due - my goal is to keep the dialogue fire stoked.  Related to this, I sensed (and still sense) an agenda - open visitation is being pushed for ideological or financial reasons (yes, the almighty dollar - patient satisfaction scores are tied to Medicare reimbursement), professional associations such as the AACN are pushing the issue, and substandard data are being touted to support this agenda.  Next, it was and is my belief that because of the agenda, nurses' (and physicians') dissenting voices are being shamed into a collective hush by The Man, as it were, and that this censorship needed redress on this blog (it got redressed in 60,000 views and over 100 comments to the original post, still visible below.)  Furthermore, this institutionalized censorship may cause pervasive Hawthorne effects in any nursing survey that is done on the topic.  Finally, it was and is my view that if open visitation is the stated goal, there may be subgoals that are driving the desire for open visitation, and satisfaction of these subgoals through other means may be superior to open visitation for making everybody happy.  That is, desire for unrestricted visitation may be the symptom of an underlying disease and treating the underlying cause (such as poor communication) may cure both the disease and its symptoms.

Even if these considerations are cogent, reasonable and rational (which does not mean that they lead to the correct conclusions), there was a significant omission from my train of thought, small hints of which were peeking through from the text.  If some physicians and nurses don't want open visitation, maybe that too is the symptom of a deeper underlying disease that likewise could be addressed in other specific ways - and it thus follows that restricted visitation is not necessarily the solution that their symptoms demand either.


The previous post and the comments it generated point to two major categories of reasons that are offered in support of limiting visitation.  The most convenient reason requires the least candor:  it is a patient safety and patient care issue.  Like all reasons proffered to justify a position, this one has threads of truth in it, but I do think it rings as mostly pretextual.  Its popularity stems from the fact that it is hardest to argue against - nurses are simply concerned with patient safety and quality of care, how can you have a problem with that?

The next reason is, I think, the one with primacy, but its discussion does require a good deal of candor, perhaps because it has been made taboo by those who are setting the agenda.  It relates to the perception among many providers that ICU patients' families can simply be exhausting, for all the reasons in the comments below: emotional heaviness, denial, endless questioning, interruptions to the flow of care delivery, etc.  These taxes imposed on a nurse's finite resources can lead to compassion fatigue, burnout, exhaustion, mental illness, substance abuse, high staff turnover, failure of empathy,  etc.  Many providers want some occasional reprieve from the stress of constant vigilance, and closing visitation for limited epochs offers the possibility of what is perceived as a period of much needed escape.  Likewise, my own personal reasons for wanting some restrictions to visitation is that it is my judgment that my daily evaluation of the patient is between me and the patient (families should not be present during an examination), and that my efficiency is compromised when patients' families are continually present and able to see me in an open ICU and interrupt me as I sit at a computer or go between patient rooms.  (One might surmise that efficiency concerns are greater when you're a one-man-show in a private hospital, as opposed to a provider in a large academic center where you are buffered by multiple layers of "helpers" - one size may not fit all as regards visitation.)

But if mental exhaustion from tightly wound family members and physical exhaustion from hampered workflow efficiency are the reasons that are leading some providers to advocate restricted visitation, perhaps they could be addressed in other ways as effectively or more effectively than limiting visitation.  (And perhaps this is the reason nurses report in surveys that they are not a whole lot less satisfied after restrictions are lifted - because the thing they thought would reduce their stress [an hour of freedom from visitors here and there] does not indeed reduce stress.)  Perhaps we need more awareness of and sensitivity to the stresses nurses face in a high acuity high intensity environment, and strategies to mitigate these stresses.  My wife sometimes suffers through a 13 hour shift in a busy ICU without eating or going to the bathroom because she is too busy to attend to her own basic needs as a human being.  Instead of taking patients' families out of the room for an hour here and there, maybe we need to get the nurses out of the room for an hour here and there, giving them much needed breaks from the chaotic ICU environment.  Likewise, perhaps my own perceived inefficiencies induced by family presence in the ICU could be addressed by physical restructuring such that I have a place to work unseen and thus uninterrupted.  But these things cost money, so you can guess if they will be given as much attention as visitation and patient satisfaction scores, which make money for hospitals.

I think the fodder for most of these problems, though, is poor communication.  I recently attended to a man from out of state who had an out of hospital ventricular fibrillation cardiac arrest due to myocardial infarction.  His wife was an abject nervous wreck, beside herself with grief and worry.  She steadfastly refused to leave the room while I examined the patient and performed awakening and breathing trials.  Somehow, we coaxed her into waiting in the waiting room, and I was able to get the patient extubated and go and tell her the good news.  In the ensuing discussion I learned that the cardiologist had been callously dismissive of her and told her that "his heart is fine, there's noting to worry about his heart - the pulmonologist will take over from here."  This was transparently disingenuous since he had just had a cardiac arrest and two stents placed, and it was like a lever lifting her anxiety by multiples, making her feel abandoned by the specialist the patient most needed.  When a pulmonologist later expressed dismay at the cardiologist's position, her confidence in the entire healthcare team utterly disintegrated.  She was a nervous wreck in large part because the healthcare team had made her a nervous wreck.

There are several morals to this story.  The first is that, when the communication is poor enough to undermine patients' families' confidence, they sometimes want to be as close as possible to that patient and never leave his side, because, I think, they want to protect him and they don't trust the doctors and nurses to protect him - at least that is what I guess was happening in this anecdote.  This is a dreadful shame.  The other moral and insight is that allowing this woman to stay in the room around the clock did not succor her anxieties.  Addressing her questions, attending to her emotions, being candid and not appearing to obfuscate, trying to address discrepancies in what other providers told her - these things began to salve her anxieties (as did extubating the patient and the reassurances that provided.)  After we addressed these underlying issues, she no longer insisted on remaining in the room around the clock.

So, in my current analysis (I don't doubt that I may revise this analysis as I think about it even more) I think that saying that you want something does not necessarily tell me what you really want, or what your needs really are.  That goes for patients' families and nurses and doctors alike.  I'm willing to wager that if we did some honest research into what everybody really wants, opening up already liberal visitation policies is not going to satisfy their underlying wants.  Those are harder to discern and articulate, but more primal in the pathways to satisfaction for all stakeholders.  I'll further guess that patients' families want better communication from doctors and that nurses just need a simple break.  (And relief from documentation burdens, and....a lot of things that are not being adequately addressed.)

Finally, I will maintain my original position about compromise.  Even if we do decide that the root cause of satisfaction for nurses or families is related directly to visitation policies, I see no reason to be absolutist in either extreme.  Some compromise in visitation policies to address concerns for all stakeholders seems reasonable.  Meanwhile, I think we should explore other ways everyone's satisfaction can be increased. One possibility is that visitation has become a proxy war for more fundamental underlying issues that have yet to be addressed in this debate.

115 comments:

  1. In the medical intensive care unitt the Hospital of the University of Pennsylvania in Philadelphia, we consider family as integral members of the critical care team. They come and go at will and actively participate in morning work rounds. The effect is transformative, as described in this article by a family member:

    David B. Freiman, Arlene O. Freiman, Nuala Meyer, and Barry Fuchs "A Most Irritating Awakening", Annals of the American Thoracic Society, Vol. 10, No. 2 (2013), pp. 175-177.

    For a contemporary, comprehensive review of family presence on ICU work rounds, see:

    Judy E. Davidson "Family Presence on Rounds in Neonatal, Pediatric, and Adult Intensive Care Units", Annals of the American Thoracic Society, Vol. 10, No. 2 (2013), pp. 152-156.

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    1. I wonder if these "transformative" feelings are shared by the bedside staff.....

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    2. Clearly you are not at the bedside for 12 hrs, being constantly barraged by irrelevant questions and being followed to other patients rooms because they want to know what the monitor means. Don't get me wrong Iam empathetic to their fears and concerns but 12 hrs is a long time to try and care for a patient and teach ICU nursing to multiple family member who feel entitled to it

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    3. Is that MD behind your name? You are not at the whim of the family/patient for 12 hours straight. You have no clue. Try it for one month ... just one month. You would never make it.

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    4. "Is that MD behind your name? You are not at the whim of the family/patient for 12 hours straight. You have no clue. Try it for one month ... just one month. You would never make it."

      RN here. Why would you say that to another colleague? Of course he has no clue what it is to be an RN. We have different responsibilities and commitments. Instead of putting him down and saying "you would never make it" you should probably explain your side instead of sounding like an asshole. Yes I said it. Asshole.

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    5. As a 10 year ICU/Trauma RN at HUP the doctors do spend 12 hours at the bedside sometimes more (and that is attending, fellows and interns). The transformation is actually not a feeling. It is a paradigm shift that changes the view that the essential force needed for patients to heal is their family/loved one (not the omnipotent nurse/doctor/medical professional). The entire attitude and usefulness of the family shifts. The family members behavior actually changes when they know they are respected and their presence is honored. After all, who is the biggest stakeholder in the outcome of the patient other than the patient? I have experience after experience after experience to validate the difference when the paradigm shifts. Another aspect that you have not noted in this blog is that AACN has had a practice alert since 2011 http://www.aacn.org/WD/practice/docs/practice alerts/family-visitation-adult-icu-practicealert.pdf At the bottom of that alert are 32 articles that document factual data including a patients ICP/HR/ectopy/infection rates IMPROVE WITH open visitation. It takes confident, open caring medical professionals to cross the line of just seeing the importance you are to the ICU patient. This is very hard in ICU because you know and have experienced that the patients life and death at times balance is in your assessment and actions. The true transformation of who family/friends are in the healing and experience of the ICU patient is coming. I invite you to open your views and just imagine for a second that there is something else possible. Otherwise your life will be a path of ego depletion and I think you already have some compassion fatigue.

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    6. Rachel, please list the hospitals you have worked at other than HUP. Please also do a brief analysis for us: How many "doctors" visit a patient during a 12 hour shift, based on number of patients in the ICU and doctors moving through the ICU? And finally, if you have only worked predominately at HUP, and if the doctor:patient ratio is high, how can you possibly say that your experiences are relevant to other scenarios where things may be different?

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    7. It is exhausting whether u may be a doctor or a rn in the icu or on the floor. I am both for several years!!!! More and more responsibiities more and more paperwork less and less staff less and less time just to hold a pts hand because they r scared we all became medical orofessional to do just that!! Care and comfort fix and get better to send them home. Families that need to realize that we care about ur loved one too but the man next to u that is coding and dying trumps ur question of when he will eat today after he just had an open belly!! I ask please remember its not just about u and only u everyone is getting sicker and sicker so please have patience when we can't come right away because if ur family member was coding would u want that nurse or md to stop to answer a question?

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    8. I can see where for a PICU or NICU baby this would be a good thing, to allow the parents time to hold, stay with, but not for adult patinets. When they have everyone and their neighbor, 3rd grade teacher who "heard they were in the hospital" I cant even get a doctor to come talk to them 9/10 times. The doctors do not round until after visitation. and then give them 2 minutes. If the families round with you then you must have a break until night shift. Because otherwise you would be crazy. I am sure there is more to your story....... another piece of the puzzle you're not sharing to make it sound like all doctors want to sound like....perfect.

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    9. EXCELLENT!!!! I totally agree!! Many of the nurses who don't want open visiting hours don't want to bother with families, lack good communication skills, want to control others not necessarily work with them. Individualization of care is important. It's about the patient--they are the reason we are there! My comfort with families in ICU and teaching & letting them see the reality of the situation grew and I encourage my student nurses to attend to family and the patient!

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    10. You're delusional.

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    11. ~*NOTHING and no one is more important than the excellent care of the patient. Take your place, caregivers. Stand and be counted as you let your heart lead you to be the BEST you can be for us. ~"
      God Bless our Hero's. Every one. ~ <3 ~

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    12. The emperor has no clothes....

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    13. I think all ICU areas are different but as an ICU nurse of 14 years I can say that sometimes families take away too much of our time from caring for our sick patients. I also agreed that the family presence is key to the recovery. Just at the designated times. I would want to be at the bedside of my family member but i would be respectful of nurses because I know they are under alot of stress. 12 hours is a long shift.... those of you who post anonymous don't bother, no one wants to hear what you have to say.

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    14. The family is absolutely paramount in the recovery of the patient. How are you supposed to get their buy in to help keep the patient on the treatment plan you have prescribed if you dont have someone to help them stay on track. Exclude them by forcing them into the waiting room is a way to certainly not get their help. The family is also a great advocate for the patient. I have coded numerous people and when physician wouldnt go talk to the family because they "knew" the family wanted to continue resus .... then they finally talk to them and the family stops the code. RNs and MDs do NOT always know what the family would want or what the patient would want. We are to advocate for them and who knows them better than family. The family should be there during their care ... wouldnt you want someone with you? Im an advocate for them being present during codes too. They arent as critical as you would think. They actually leave with a better knowledge that everything was done even though their family member passes away. I know for one I would want my family there even if its my last moments. I dont know the MDs or RNs ... my family knows me and Id feel better knowing they are there. A lot of this is fear that the patients would sue but we have to get over that fear and deliver the same care in front of the families. Answer their questions ... they are scared for their loved one. When you forget the family or exclude the family you should stop practicing.

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  2. Perhaps we need to also consider the families' guilty need to be present at all times possible.....leading to more exhaustion and stress for them as well. They need to be made to take a break from the bedside just as we do. The rules of visiting hours do just that.

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  3. Very interesting article. I would say 75 percent of my stress in the sicu comes from family members (as we have open visiting hours). But with the customer service model that is going on in health care at this time due to reimbursement and satisfaction scores ect, it is only going to get worse in regards to this topic.

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  4. You are egotistical and single-minded. Please don't pretend that your feigned concern for 'the staff' overrides your complete ignorance of what it feels like to have your family member in that bed.
    I could tell you were a physician even before I read your credit at the end. I know there are families who ask too many repetitive questions, but you should realize that this may be because you have not fully explained the situation and they are asking again because they really don't understand. Who are you to dictate exactly how much explanation they need? Have you ever been in their shoes? If you have I am sure you were an absolute pain, demanding to exert your "M.D" status to obtain the information you needed, regardless of HIPAA or anything else.
    I do, however, agree that a liaison between the family and staff helps a lot. In my facility, the chaplains and Supportive Care team fulfill that role, providing a conduit between them. That does not relieve the physician and staff of their responsibility in providing information, compassion and patience.
    I hope you are not the doctor who gives a 2-minute 'doorway' lecture to the family about what is happening and then scoot away at the first opportunity, leaving the nurse to interpret your diatribe. Of course, then the stressful part is all on the nurse. Who, by the way, works in the department for fifty weeks of the year for twelve hours at a time.........

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    1. Clearly Life in General has not had shifts in ICU interrupted by family members who want ICU nursing 101 taught to them so that they understand every tiny detail of their loved ones condition.....family should absolutely be supported and helped during a difficult time but that DOES NOT MEAN explaining every minute lab value, monitor reading, etc...it means helping them to show love and support and prayer for their loved one

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    2. I am a very experienced ICU nurse, so I feel qualified in saying that it is very stressful answering tedious questions whilst critcally thinking and putting the medical puzzle together. And as an ICU nurse, I will answer all of those questions for you, with a smile!!! That does not mean that I am not stressed out with the family asking a plethora of questions. This article is looking at the 12 hour bedside nurse's perspective, not necessarily the family visitors! Please continue to love, pray and support your loved ones, just know that the END caring for your loved one is enduring stress at the same time!!

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    3. And how many of said family members were appraised of their loved one's medical condition before they fell ill? And how many of said patients awakened from critical illness and surfed their iPad for information on how to be healthier rather than flip through the channels on the TV? How many family members looked up things on wikipedia so as to make their questions more informed?

      No, they don't have these responsibilities. But the nurses and doctors have to bend over backwards and leave their shifts a hot mess of stress in order to satisfy every whim of every person in a patient's extended family.

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    4. I am an ICU Rn and have been an ICU pt as well as a family member. I don't like open visitation. I love my families and my patients but the bottom line is that 10 people crammed into an ICU room at midnight is not conducive to healing. you can act indignant all you want. I have two critically ill patients to care for and the doctor may have ten. I know I'm exhausted and I can't imagine the way the Dr. feels. Put those shoes on yourself sister and start walking. I want my Dr. focused on getting me well. Not my family members melt down in the hallway. Chaplains and liaisons are not present at night. I believe in compassion and patience as well but there needs to be a happy medium achieved. Quite frankly you come off a bit bitter towards doctors.

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    5. R. Jones, RN, BSN, CCRNFebruary 10, 2014 at 9:16 PM

      Add to the above a requirement that the ICU nurse in a North Carolina hospital must carry a spectralink phone so that the telemetry monitors in another part of the hospital can call the ICU nurse to tell them their patient just had a rhythm disturbance 5 minutes ago that the ICU nurse already knows about. Also, add to this that most of the time the unlicensed monitoring personnel wrongly read the rhythm strips. Add to this, the ICU nurse gets in trouble if the monitoring employee feels "offended" by the way the phone is answered by the ICU nurse who is wearing a mask and gown and gloves and trying to deal with the patient, lead a situation, plus answer the phone that he/she is made to wear by the North Carolina governing system. That is why I will not work at Forsyth Medical Center ICU in Winston-Salem, NC. All of this came about apparently because someone on a monitored floor somewhere in this hospital died while being monitored without monitor technicians calling the wrong rhythms. R. Jones, RN, BSN, CCRN

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    6. I feel your pain...been there

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    7. Life in General. You've never stood in the shoes of the staff, obviously. I like open visiting for families--with several caveats--the family needs to know when they are interfering with care, and I make it very known. "Family I can't focus on your husband/wife/sister/child because you have asked me the same question for 45 minutes straight. It's on you--I can still and talk to you for 45 minutes and answer with the same answer--I don't know when he will get better, we have to take it minute by minute. Under the stressors, families don't get it. So I am patient. I let them dictate to a point. When they hear that they are in the way, and I make no bones about telling them, "hey, you are in my way." Polities, schmoliteness. A pragmatic, and logical statements sometimes needs to be said to put things in perspective. I do not do it unprofessionally, but I usually make my point. Families belong there, to a point, when you are interfering the healthcare providers need to say it.

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    8. I agree. That is how I've taken care of my pts for years. Questions answered politely, then I tell the family what I expect from them as well. Most families (even the difficult) work well with us. We also practice continuity of care, families learn to trust us. Our ICU is closed for 2 hours at shift change.

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  5. I have worked in both an open ICU and one with visitation hours and completely believe that an ICU with visitation hours works much better for the staff and the families. It gives the staff a chance to decompress and also the families. Thank you for this article, very well though out.

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  6. There are lots of logical as well as irrational statements. Lots assumptions. One person speaks on here assuming that they've never been a family member to a patient in the ICU which is exactly as ignorant as the statements you claim the physician made. Trust us. We understand the concern you may have for your loved one (trust us. 90%+ of us have been in a position similar) however, a job needs to be done. A job that deals with lives. A job for which WE are responsible. Our "presumed" sense of insensitivity is nothing more than a mechanism we use to determine what needs done and when it needs to be done. I understand certain situations where a patient benefits from a family member being there, however there are many situations in which it can be a distraction from proper care being performed. Since we're the objective persons involved, we are the ones that determine when it's best. I don't believe it should be administrators or managers. It should be the patient care staff and physicians. PERIOD

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  7. I think this is very true in all settings, not just ICU. Throughout the hospital, people need care, and it is slowed down by family requests (some of them warranted others, not so much). I think at times it is important to have the family handy, and we have to make them welcome, if just to provide the information medical professionals need to do their job (history on non-responsive patient). But the interruption of true care for explanation of why the cot is a minute late is tedious....

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  8. If nothing else, no matter how unobtrusive they may be, families are physically underfoot. Going back and forth around a patient's bed, especially in a small room, while constantly "excuse me", "let me just reach around you", "do you mind if I get in there for just a second"....it's exhausting. And frustrating.
    In addition, "Life in General", these are my opinions AFTER having had a member of my immediate family in my OWN unit. When not at work I sat my ass in the waiting room and adhered to all rules and hours, knowing my loved one needed the care of my coworkers more than she needed to entertain me. When AT work I stayed in my area and only popped in briefly during visiting hours. Not fun times, but necessary.

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  9. My all time favorite question to be asked by my 30 something aged family members "can you get me a cup of coffee?" Why yes, I would love to. Don't mind that my other patient has already coded twice today. I would love to stop what I'm doing to get you a cup of coffee because you are too lazy to walk to the cafeteria.

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  10. I work for 12 hours.... I can use that time to care for my 2 critically ill/chronically ill/dying patients- let alone that ones that transfer out and the new admits, the code browns, the code blues, the umpteen phone calls, or I can attempt to explain why the patient who yesterday was making no urine but today is making urine still needs to be dialyzed because they are in high output renal failure.....and then re-explain it when the rest of the family traipses in 45 minutes later. Do patients need family support- yes, do they need nurses to care for them- well if not, I better find another job. But until then, there is still only one of me- so perhaps we need a new position- one of family care RN to teach, get pillows and warm blankets and make those ever so important pots of coffee.....so I can actually do the patient care I was taught to do, hired to do and have 35 years of experience doing....

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  11. I think the less distraction a nurse has from doing his or her job, the better off the patient is. Answering a barrage of questions from family members while you are trying to administer medications to the patient is not safe. There is tons of literature on nurse burnout, but nobody cares. I work in a very busy CVICU, with the sickest patients in the region, and we are going to open visitation soon because "it's what the families want". I honestly don't mind families around except when you get that one crazy family member who wants to be in control of everything and tell me how to do my job, and then I just want to quit and become the walmart greeter.
    Thanks for being a doc who cares about how nurses feel, and the impact this issue will make for us. It seems not many do. Maybe after open visitation is implemented on our unit, I will research the impact it has on our stress level and burnout.

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    1. Walmart greeter is my next job!!!!!

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  12. Christine Sortino R.N. CCRN Bsn,MsFebruary 11, 2014 at 9:41 AM

    perhaps there might be a compromise between the nurses who do not prefer to have family about and they should be given the choice of having a liaison with their family members where as a nurse is who are proficient at dealing with family members can have him come in at the appointed time visitation or when the patient is settled

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  13. The problem is with the hospital systems and how they have not handled this situation. The need a family member feels to be with a loved one in ICU is very real. The family has to live with the outcome for the rest of their lives, wondering if they did everything they could. The bond of love is very healing and should not be discounted by a system that is suppose to 'care' for us. Yet, that is what the system has done, ignored this need patients and families have. Families do need a lot of education in the ICU environment as it is a working environment. Families want to know and should be taught, what to do (do not wake up a sedated patient, or, when it is okay and therapeutic to speak softly to let the patient know you are there....and even that it violates other patients privacy to stand in the doorway and stare.) The problem is the hospital industry has never attended to these needs properly. A resource person should be available to families in the ICU. The physician and the nurse cannot attend to these needs all the time as their most important job is attending to hemodynamically unstable patients and this takes a lot of concentration and work. Medical errors go up with frequent interruptions. Administration needs to solve this problem by giving the families a resource, or liaison, instead of turning away and dumping it on the nurses that should be concentrating on safe medication administration, or CPR, or whatever fire needs put out. This is the industries failure, not the patients and families.

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    1. Suzan that is very well put- the for profit organization that I am employed by is much more concerned with the bottom line than the satisfaction of their staff. So we are continually asked to do more with less- and disciplined when it is not finished on time.

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    2. As an ICU nurse of 37 years, that has worked in various regions of the country.I can say that there are some people that can not be educated. I spend time with families explaining equipment, treatments, medicines ,etc, just to come back the next day to do it again. I have told them if the curtain is closed, it means we are trying to provide privacy for your (mother , father, brother, son, enter appropriate term) while a procedure is going on. Inevitably family members will just enter as if nothing is occurring.. I have told them "Dad needs at least an hour of rest in the afternoon, after his morning of tests, PT/OT, dialysis, just to have them come in with family, friends and neighbors, and the pt gets no downtime.. I've asked them to please keep visitors 2-3 at the bedside, with an explanation why, (limited space, severity of pt's condition) just to have them complain to my boss that I am keeping them from their family. I've explained to families of pts with head trauma and ICP's why its important to decrease the amount of stimulation the pt is receiving, only to enter the room to find tv blaring, and 8 people holding 4 different conversations over the pt. These are the people who make the job difficult. Depending on where you work, you may only see a few of them or you may have a lot of them.

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  14. I agree with Susan. I cannot tell you how many times I have walked through hospital hallways and heard a feeble "help me" coming from a distressed patient. Maybe they needed a drink of water or the overhead light turned out or were in pain.

    I have also lost count of how many times I have been with a relative and watched a medical error -- major and minor -- about to occur because the Doc was too much of a bully or the nurses were completely overworked or the tech misunderstood the orders.

    Visitors can be a helpful resource if treated as allies instead of hinderances.

    An industry failure indeed.

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  15. What you're hearing here from multiple nurses is that the way families can help is by giving them some peace and quiet for several hours each shift.

    And, I'm surprised that nobody has yet mentioned that if you want to help, put on a gown and some gloves and prepare to clean up the diapers and the bedsheets, etc during bath time and during a "code brown."

    The problem is it's just take take take, and the nurse is supposed to give give give. I would say that there's a point when s/he has given enough. If you wanna help, ASK THE RN what you can do to help, don't pretend that you're suddenly an auxiliary unit clerk or call light monitor.

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    1. In my unit, we have 24/7 visitation, and it is a double edged sword... if the family is helpful, and personable, I teach them, engage them in conversations about their live outside the hospital, they love it... But, I have learned many "tactics" to get problematic family to leave... It has been encouraged by management on my unit (and, I do it) to involve families in patient care. I am notorious for having family members help me turn the patient, clean the patient, pull the patient up in bed, feed the patient... etc... where as others may elicit the help of a college, I use them as my personal techs, and if they don't want to do it, most of the time they leave. I'm not having them sit there and stare at me, nope, they are going to be useful. I also encourage the family members to go home and rest, take a nap, shower. Sometimes they just want to hear that... now the REALLY problematic families... well, they are screwing their loved one over. I cluster my care, try to enter the room as little as possible, and kill them with sarcastic kindness. I also am very strict with these individuals as far as the "two at a time" rule. Knock on wood, I haven't had any problems too recently, so I will continue to employ my tactics. :)

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  16. @ Dan, are you reading the comments here? Folks are saying that the doc and RN are too busy answering redundant family questions - it's not that they're bullies. And YES the RNs ARE overworked and the TECH did misunderstand the orders, and thus the family needs to stand back and rest their curiosities so this situation can simmer down.

    Please don't be so arrogant as to think that as a totally untrained person you can strut around the ICU and prevent errors.

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    1. OMG? if the family "stand back and rest their curiosities" you really think it would be safer? Less accidental mistakes? You are a killing machine and worse the kettle calling the pot black (egotism). Patients don't come to your ICU to be honored by your "trained expertise" they come to see you because they would die if they don't. And you think because you have the upper hand of "training" you don't have to answer questions? Or you are SO BUSY your job wont get done? Like you are doing it now? Do you know how many people die in hospital care due to medical mistakes? Really, someone needs to strut around ICU and prevent errors!!!!!!!!

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    2. Some die as a direct result of crazy families distracting nurses from their jobs. Visiting is best done at the nurses discretion.

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  17. Who wants to be the unwelcome houseguest? What person, who knows they have worn out their welcome, elects to stay nonetheless?

    Why is limited visitation (Note: this is NOT no visitation) not viewed as a compromise rather than an infringement on the rights of patients' families for full visitation?

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  18. How can you honestly say family members are part of the critical care team? Are you insane?

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  19. Thank you for addressing our concerns; the RNs. The following is what I would like to say to all family members:

    1. Do not hover over me and speak in a loud voice as I titrate critical drips. I'm not deaf, and for the fiftieth time, your family member is very sick and heavily sedated. We are trying to get him better. Please lower your voice. Please hear me, as this behavior serves no purpose other than to make me want to punch you. In the face. With my fist.

    2. I am not pleased with your breath on the back of my neck, or your face practically in my behind, as I am trying to concentrate on my job,as you are either too rude or too stupid to get out of my way. Which is it, as I have repeated myself over and over again not to clutter the room with chairs and why?

    3.Don't take notes. This is going to make me not like you, and you won't be getting any coffee or extra favors from me.

    4. Do not come hunting me down in my very critical patient's room because Daddy's systolic BP is 150. I am aware of that, and every detail of his care, thank you. Perhaps it would come down if you would stop picking and prodding at the old man and let him rest. At three o'clock in the morning.

    5. Do not put your feet up in the recliner in front of my pumps and then innocently say: oh, gee, am I in your way?, as I walk in to titrate one of ten drips currently infusing. Yes. You ARE in my way.

    6. Don't come hunt me down in a blind panic because Daddy is choking. No. He is not choking. His Sats are 100%. He is talking. Now you have convinced HIM he is choking. Bravo. Good job. Now my patient next door who has just gone into A Fib with RVR can just wait, huh?

    7. Do not call me back in a room I just left to tell me Daddy needs to be shifted 4cm to the right.
    When he can do it himself. And do not flip out because his temperature is 99. Could it be the eighteen blankets you have insisted he have? Hmmm.

    8. Don't expect me to engage you in meaningless chit chat at your pleasure. I'm busy. I have other things I need to do. Like save lives.

    9. This is an ICU.I am here to do my best to get your loved one better. And to prevent, and fix any number of troublesome things than can, and do occur.
    I can do this much more efficiently if you would kindly not hound the life out of me. And please, do not stare, and stay out of my face. I don't like it. And I don't like you.

    Your Nurse.

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    1. Totally agree. I'm also an icu nurse and these are my biggest aggravations and it happens all the time.

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    2. Thank you. It's good to hear my feelings are validated by a colleague. I love what I do. My patients and families. I just think we are being pushed far beyond what is reasonable. We are given no peace. No time to decompress. This open visitation has turned into a free for all, and as another poster mentioned, the families behave as if its a hotel and we are the service staff. Its insane. I have just been pushed beyond limit.

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    3. I too can relate with all of these. My personal favorite is when a family member follows me into another patients room, instead of using the call light, or waiting for me to come back in. That is a serious pet peeve of mine.

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  20. As a 10 year ICU nurse, I think the OP highlights many relevant issues surrounding open visitation. In no way is he stating that it's a bad idea for patients and their family members, he's merely questioning the methods in which hospitals choose to employ open visitation. Yes it can have wonderful impacts on the patients and their family members, as some of you have evidenced with peer reviewed journals. However, to simply negate the impact it has on staff is a HUGE oversight. I can't tell you how many times I've had patients families interrupt my report over an artifact alarm or a request for water, or a blanket. I know it's artifact, the patient is wide awake and communicative as I'm looking right at them, but to the family the urgency of the alarm or their needs for some comfort commodity , is relevant enough to interrupt my report. My report and vital information exchange is interrupted, and simultaneously my train of thought. " where was I?" Becomes a frequent sentiment, and the potential to leave something important out increases. Similarly, I've had family members follow me into rooms violating another patients privacy, as their urgency trumps me seeing another patient. These families are emotionally draining, and to deny that is an abomination. Im not saying I don't want to deal with family members, nor is the original poster. We are in public service, we are supposed to deal with families. It's just that there are scenarios, where it's appropriate for family members to be present and integrated, and there are scenarios where it's not. Point in case the original poster mentions a pilot. The pilot may greet you as you're entering the plane, but he/ she sees no one during take off, in flight or landing. Why? Probably because the distractions could cause a fatal crash. Similarly, you might not want to ask me for the 500th time what the weight based medication I'm hanging does, as I'm dialing numbers into an iv pump. There is an increased margin for error in this scenario. It's the methods of employing open visitation that bothers me. Many hospitals have just opened the doors, and turned open visitation into a free for all, placing the responsibility of liaison on the bedside nurse/physician. I will gladly spend time with my families, educating them to the vest of my ability. I just can't be at their beckon call, which many of then cone to expect. As a side, I would love to see what studies have been done surrounding the ever prevalent and obvious ICU psychosis issue that we deal with, especially in light of open visitation. I'm not exactly convinced that having family members asleep ( or not asleep due to my hourly rounds / med admins), or at the bedside stroking a patient's hair at 0300, doesnt contribute to full blown delirium and psychosis- both for the family member and the patient. Add to that the families who take up temporary residence in the ICU waiting room, failing to shower, eat, sleep or take care of their own medical issues. I once had to ship a mother to the emergency room because she passed out in DKA, from failure to manage her diabetes properly, while living at her daughter's bedside. All of the above scenarios serve as distractions in my care from the patient. The idea of a patient advocate as a liaison isn't a bad one either. Many hospitals employ them as volunteer positions, and they minimize demands of families from nurses and physicians.

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  21. I have been an ICU nurse for more than 25 years. I have also been a family member and an ICU patient. As an ICU nurse, I have seen families who have hit nurses, and have myself been threatened and verbally abused by family members. That being said, I have had family members who were cooperative, and did their best to be helpful while I did my best to keep all of my patient's families as informed as possible. When you have 2 patients, and one is very critical, you do not have time to get coffee or ice water for family members of your patient who is leaving ICU tomorrow. I have also had family who complained when I woke them at 3am to check on their VERY critically ill family member in the room with them. 12 hours with people this sick is very stressful. When I have a shift with familiies like that, I go home feeling the worst I ever have when not sick myself. I do want families to know what is going on, but people who follow me into my sicker patient's room to tell me they need a blanket are violating that patient and family's privacy, and taking away from their care. When you have a family member who you literally can't get away from, that is a problem. I have also had patients who told me they were so tired, but just didn't want to tell their family they wanted them to go home so they could rest. Hospital customers (according to my employer) are supposed to include the staff. When "customer satisfaction" is the goal, the staff are not even considered in the situation. The additional stress is just tough luck. When we are being asked to do more and more and more documentation all the time, and often with less staff than we are supposed to have by the hospital's own staffing requirements, constant questions and scrutiny by family is just another thing to distract from the patient. The patient, not the family, has to be the first concern. As a family member of an ICU patient, I complied with all visitation and tried to be as helpful to staff as possible. As an ICU patient, (several times) I did not want anyone- even family, in my room all the time when I was so sick and felt so bad.

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  22. I still think someone needs to look into studying the impact that having round the clock open visiting policies has on patient and family delirium/ psychosis. Maybe it's just me, but I feel as if this patients and their family members become more irrational, as their stay is prolonged. Lack of sleep, or even appropriate sustenance of adls/ hygiene.

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  23. Once again the people who don't do the work are the ones making the decisions for those that do without any regard to the consequences that ensue. Nursing has become something so totally different than what it was when I chose this as my career and it saddens me to observe the complacency of my co-workers when it comes to standing up for what we believe in and WHY we are doing this to begin with. It is becoming more and more about open ended "customer satisfaction" than it is patient advocacy.

    Being an ICU nurse the "customer" is NOT the patient who is unresponsive, intubated and/or sedated but the countless number of "new" family members who show up demanding attention and courtesy as if they were checked into a 4 star hotel somewhere. The rooms become overfilled with family meal trays, family member shoes, sleep cots, linens, clothing, toiletries, magazines and the collections of snacks, sodas and fast food items for the "family" often making my search for an alcohol wipe a near impossibility.

    They are loud with laughter and the catching up of family events and social media ongoings and have no regard to the care we are TRYING to provide not only to THEIR family member but to the rest of the unit's patients. I am pulled away from the bedside countless number of times during the shift to answer the doorbell to allow entry, repeated phone calls requesting information about the pt causing me to have to stop what I am doing to verify their identity and REPEAT the same information that I just gave out to the previous phone call 5 minutes earlier. Add to this barrage of interruptions the family presents, the administrative requirements of accurate and thorough computer charting on computers that are faulty, the time frame limits of administering medications that aren't often even available due to back-logs of the pharmacy staff, the documentations of same, the wait times for securing new orders from physicians who fail to call back in a timely manner, and the absence of needed equipment and supplies and ancillary help from other departments. Linen and trash containers become overstuffed and overflowing creating a visual source for family complaints and because of cutbacks, nursing is NOW expected to assume housekeeping duties to keep the "customer satisfaction" levels high.

    We are inundated with policies and procedures that must be followed/documented redundently, pt care goals that must be updated and audited each shift, and the constant double checking of other departments and physicians orders to ensure their accuracy/completion of their jobs. And if errors are found these are expected to be corrected and/or completed by us.

    NOW if there is any time left over we can tend to our patients????????????????

    If surveys and studies reflecting customer satisfaction are of interest to hospital administrators and those mandating these changes why aren't they pursuing the ones for nurses...... meal breaks, rest breaks and the combining of these to allow for a "sleep" break for those of us working these 12 hour shifts??????? They wonder why the "burn-out" rate of nursing is increasing as is the shortage on nurses coming out of school.......They should SERIOUSLY contemplate the changes they are making regarding "customer satisfaction" because for most of them it 's not going to be long before THEY are the patients and we certainly wouldn't want THEIR family members to be unsatisfied !!!!!!!!

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    1. Well said. Our hospital now has us tripling our patients, if they feel that one pt is "less acute". Just because they are less acute doesn't mean the paper work is less. Often because they aren't as ill also means there needs may be more ie: they need to be fed,
      need at least 2 people sometimes three to get them OOB and ambulating, since they are in a mobility program. (Try finding help when,half your staff is tripled). They admonish us for working past our shift end trying to get the paper work done, because we have made the decision that patient is first and paperwork is 2nd.

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  24. I too am an RN I have worked day shift in an open unit and a closed. I went to night shift on the open unit because visiting ended at 7:00PM. I could not get anything done, I was stressed out and I would stay for several hours trying to chart! I work on a closed unit now. Visiting at 9,1,5, and 9 for 30 minutes. And that 30 minutes can not come soon enough. The families are horrid. They have no idea what is wrong with the patient. Even after you try and take the time to explain. The ones in Comas they try and wake up. They ask if I "gave" them something....As if they were different than the last 10 times they visited them. 12 hours is a long time. And when I get 13 calls from 13 family members in 30 minutes, I think I have a right to get upset. The patient deserves my attention. Not some 3rd cousin that "someone" gave password to. I could go on and on. Thank you for your post. It was 100 percent accurate. And I pray the family members that read this remember we are doing the very best we can, we have doctors that are less than nice, and its a hard job. If it were easy there would be an abundance of ICU nurses,

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  25. If I am paying thousands of dollars for my loved ones healthcare then I should have the right to respectfully ask questions and be treated with respect in return. My father was prepped for surgery and my mom and I were called in to say our best wishes as he was being put under...as we were leaving his side my mom noticed a folder that read he was to have an abdominal surgery (I don't recall what kind) and my father was in for a surgery on his nose. We then noted that the folder had someone else's name on it... Mistakes can happen...family can help inform nurses of a patients meds, eating habits etc. Again, politely and respectfully...

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    1. Shirley Kinmaters MSN, RNFebruary 13, 2014 at 8:57 AM

      Cece,

      I am so sorry for your experience and so grateful you had the courage to read that your father file. That may have been sent to have a horrible medical mistake. It is what you did that provides the essential guardianship that family members can and do provide!

      I think you found the wrong blog. This is nurses and doctors complaining about their feelings and fears or the big boogie men family members. These are people venting and being hateful about the career they choose and are making a living by collecting a paycheck. The facts about family members with open visitation is that the evidence clearly mitigates all the crushing exhausting experiences these nerve racked, over burdened, stressed out, unheard by the CEO wanting customer service, staff members are complaining about (If you do research and not just read a blog about feelings!)

      And yes the ICU staff think nothing of you paying thousands of dollars and your insurance paying hundreds of thousands of dollars (sometimes more) for the "life-saving" stay. And if your family member had died even at the fault of those medical staff you would still get the bill unless you filed a law suit.

      Cece please look at Trisha Torrey's blog it empowers family members and has factual information in it. There are many articles and facts that are accessible if you look at the American Critical Care Nurses association in 2011 they put our what is called a practice alert to have hospitals open up visitation to all the time because for one thing people like you. Cece,you made sure a horrible mistake did not happen. Can you see most of these nurses on this blog would be irritated at the fact you asked a question and then pissed off for how nosy you were and then rationalized that they would have had the time to be the one who caught that mistake. If you want a list of articles that provide the proof that family members are the essential part of the critical care team go to the AACN practice alert and at the bottom are the evidence that validates what you did.

      This is not a blog for family respect or medical staff being polite this is a negative feelings dumping ground.

      And one last note, I see so many nurses complaining of family staring at them. Why is such an unconceivable leap to know that the family is terrified, has no control exhausted, and looking for anything to connect to? And then when it doesn't happen people get angry and well if the nurse is already pissed off that the family is staring. It is a vicious cycle that unfortunately causes medical mistakes.

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    2. @ Shirley

      1.) You miss the point that undeniably, SOME families are just unsavory. And if you deny that, well we can't even agree on the basics and there is not point in further discussion.
      2.) Regardless of how much "you" [your insurance] pay, it does not automatically give you the right to do as you please.
      3.) Nobody is arguing against visitation, just some limits on it.
      4.) We don't care what the ACCN says, that's the point of these comments
      5.) Most of the "research" ACCN cites is poorly conducted, biased, agenda driven mumbo jumbo. Cite your best original study and maybe the author of this blog can comment on it on his medical evidence blog.
      6.) Are you really suggesting that we enlist family members to prevent medical errors? Ever heard of sensitivity and specificity and ROC curves? How many "false alarms" are we willing to tolerate? Why do we need families to police for errors? If these are a problem, shouldn't we investigate other ways of avoiding them, rather than assuming that well-intentioned but medically untrained family members are the solution?

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    3. Cece, You are wrong. Making a living off collecting a paycheck? No, ma'am. All these statements you are making about nurses being rightly upset are lies. All we are asking for is respect and a reasonable peace to do our jobs. Are you on the front line in the unit taking care of critically ill patients 13 hours a day? Are you constantly barraged by families while trying to do your job? Do you have to deal with this because administration says so? Have some empathy for your colleagues here. This is a safe place to vent for us, God knows we have little opportunity to vent anywhere else. It doesn't make us uncaring, cold, and paycheck-driven. In fact I say with confidence we are the nurses who get the highest customer satisfaction scores.

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    4. My previous comment was directed at Shirley, not Cece.

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    5. Shirley and Cece, you have both missed the point of the original post, and have attacked the "Straw Man" as a result. (and Cece's story doesn't sound like it even applies to a sick ICU patient...the ICU is a whole different ball of wax).

      Nobody here is saying that there shouldn't be open communication with patients and their families, or that there should be no visitation. All we are suggesting are reasonable limits. As an intensivist, I do my best to update families on the prognosis, and care plan as frequently as possible. And the vast majority of families I encounter are nice, reasonable people. But the minority who are not can cause a tremendous amount of damage with open visitation. I've had families disrupt rounds, violate the privacy of other patients, and disrupt the care of other patients in the unit (once right before another patient was about to code).

      Why is there no room for compromise? This doesn't have to be a zero sum game. I think it's okay to place reasonable limits on visitation, while still allowing the families to feel like they're being kept in the loop (and keep the "customers" satisfied, as the administrators like to say).

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    6. I don't think anyone is asking you not to ask. And If the hospital is not checking bracelets or getting an accurate history, etc, etc, etc....Than it most definitely is appropriate, and I am sure you are one of our favorite families!! I don't think ANYONE on here wants a mistake to happen. But we just wish more people had accurate and pertinent information like you would share. We handle a lot of drama......Drama nobody is aware of. Supplies not being where we need them, drugs not available when we need them, Sometimes we have a 3rd patient. Discharges, admits, paperwork, charting , doctors, calling doctors, waiting for doctors, and in their defense they see a lot of patients...... There are days I barely eat a 5 minute lunch because my patient is so sick, and I do not go the bathroom until after 3 or 4......I am SURE you the families we love. And we thank you for being sweet and understanding.....:)

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    7. Dear Shirley,
      Because I do not support completely unrestricted open visitation I do not care? I simply collect a paycheck? I am a Cameo of Caring winner, certified experienced nurse. I have a STACK of cards from patients and families I have cared for over the years. HOW DARE YOU decide that because some of us are starting to burn out from these issues we do not care about our patients and families? I educate ALL my families, all my patients. I offer emotional support to ALL of them. And I love my job caring for people.
      I know mistakes happen, and I would NEVER want a patient or family member to fail to ask a question regarding a possible mistake that could cost someone their LIFE. This is not all or nothing. All things in moderation. BALANCE. And as mentioned above, compromise. Compromise which can allow for quality care, and quality caring. Education and emotional support. Open communication and building of trust.
      Putting your MSN is fine and well, I am working on mine now, however, it is less likely to cause any of us to suspect that you continue to work on the front lines of this issue, decreasing your credibility to many of us still work this environment day in and day out. And quite frankly those are the opinions that hold weight in this conversation- the real bedside caregivers, not the biased researcher, and not the management.
      Cece, I believe you and your family definitely have input, weight, and a say in care that affects you and that costs so very much. And I applaud your paying attention in order to be an active healthcare participant- lets all have a real conversation about these issues and find compromises that WORK

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  26. Yes. The staring is NERVE WRACKING. What other profession has to put up with this nonsense? I leave my shift emotionally wrecked because the life is hounded out of me!!! When are these administrators going to get a clue???

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  27. What steps has the ACCN taken to address the toxicity (if that's what it is) of RNs as expressed in these comments? Are there other causes and open visitation is just the straw that broke the camel's back? I await a reference to a credible study that shows that nursing attitudes about OVPs in ICUs have been adequately studied. I wish to scrutinize the survey instrument to see if it passes the sniff test. I'm going to guess that if such research exists, it was conducted in such a way as that the frustrations in the comments above were not captured. Perhaps a motivated nurse and I could team up and study this by surveying membership of one of the nursing professional societies. The goal would be to capture sources of nursing frustrations regarding OVP and family presence in the ICU.

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    1. Dr. Aberegg, I applaud you for bringing this problem into the open. I too, would be very interested to see a valid study free of bias. I speak from experience, and it's my opinion this free for all type of visitation policy is the worst thing that has occurred in ICUs. I think the family should be with the patient. Absolutely. Within reason. We seem to have lost all sense of reason. And nursing staff be damned.

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    2. I also applaud you bringing this out.... And agree with your questioning the thoroughness of the nursing perspective. Nearly every ICU nurse I know is facing frustration and feels like they are at their limit with this. An academic who is not in the real battlefield of care, who shows up and hangs out a few weeks and then writes a paper is not getting the real story. Add to that that most of us KNOW that speaking in opposition on the record regarding these issues is the same as making yourself unhirable and putting your job at risk for not having the right "customer service" attitude. I give these studies little weight, because I know too many critical care nurses and do NOT see the support for them-anywhere. This is not real life, its what the ANA, the government, and other entities want in their feel good care, vs actual good care.

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    3. AACN--American Association of Critical Care Nurses.

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  28. As a PICU and NICU nurse, open visitation is something I've always worked with. I get the inconveniences it can cause, but don't y'all try to communicate with the families a little bit if they're being a problem? I've rarely had an issue with an overly-interfering family member if I respectfully explain that their child is extremely critically ill and unstable, and every ounce of my concentration needs to go towards saving their life right now, and I simply don't have time to answer all their questions right now because I need to focus on the patient. If you've built a mutually respectful relationship with the family, most will understand where you're coming from. I've never had a family member complain about it (the key is to put it in the context of "leaving me alone right now helps your loved one" and not "leaving me alone right now helps me"). A little bit of respectful boundary setting goes a long way.

    I'm not sure what is meant by open visitation anyway; some comments on here speak as if they think open visitation means visitation with no limits whatsoever. In my hospital only three people are allowed in the unit at a time, and they're educated about our need to be able to physically reach the patient at all times. At night visitation is limited to two people in the entire hospital per patient (i.e. no switching out with people all night long). The only time these restrictions are relaxed is for actively dying patients, as they should be.

    As someone who's never worked without open visitation, it doesn't seem that bad to me, but maybe I'm just used to it. Open and honest communication usually keeps things under control for me. And sometimes--like when you have a delirious patient or whatever--those family members can be your greatest ally. Put em to work!

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    1. Hi. Maybe PICU/NICU is different?

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    2. Open visiting hours were I am employed entails family coming and going anytime day and night. We give out pamphlets with rules that state 2 in the room @ a time but this rule is not inforced. Part of the problem is the staff is not consistent, then when I ask the family to have 2 in the room, I'm the bad guy. The same thing happens with families spending the night it is suppose to be only under special circumstances but then if the family insists or another RN lets them they r there every night. They don't expect to leave the room either. It is truely becoming out of control. I want to quit and its because of the families. I love caring for people and I am often complemented by family for being a attentive good nurse but there is no boundaries.

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    3. Dear PICU/NICU RN.... for the facility I am employed by, open means ope... no restrictions on the numbers of, ages of, relations to the patient, no restrictions on privacy for complete care, recovery from anesthesia, admission, discharge, transporting for scans. I have had patients demand to breastfeed their infant after receiving toxic medications and be told I cant stop it, I have had visitors storm down a hall punching doors windows and walls with no way to stop them, I have had visitors sleeping on the floor of the room and have tripped over them at 0300, all of this to be told by my administration that we are a family focused facility. I have had families tell me their feet hurt and they want slippers when I suggested they not go bare foot. I have had patients tell me the pot of coffee I made them was too strong.....they are out of control, and I cant even get to my patient to provide the care I want to give....

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  29. Lets all be respectful and sensible. As an RN with more than 15 years of experience a person who has been the ICU nurse and has been the nervous family member in the waiting room during critical times.
    Healthcare is now being guided by politicians does Anyone else see this as a problem? A board of Nursing is made of nurses, a politician, and a community member. Why is this not the model for those groups making these decisions? Many MDs and RNs who actually work, not research, in the battlefield of care, a few politicians, and some normal citizen reps (NOT lobby folks) FACT- if your patient doesn't mark a 9 or 10 on their survey the result is counted the same as a zero-THE SAME. Customer service and common decency are important in healthcare, but lets have common sense. I CANNOT take care of your family member with 30 people in the room, CANNOT safely keep down the level of sedating medication for your family member while you continue to shake them, they will not simply be FINE if you wake them up. I am happy to explain things to you, but cannot explain the same things to thirty people thirty times. I CANNOT care for your family member when you have given 30 people the password and they are all calling. Do you want me with your dad, or on the phone with your third cousin?

    The fact is not everyone can behave-society tells us we are unlimited, there are no rules, and no one can tell us what to do. Just because you or I would behave and act decently doesn't mean the other people in ICU do-they don't. If they did maybe I would like open visitation.
    The fact is, regardless of if they will tell you or not-your family member regardless of their level on cons. needs rest. I need time to care for them, I need time to work with the MD on them, and I need time to do report in a thorough, complete uninterrupted manner. I think you should come more than 30 min twice a day, I DO NOT think you should camp out. Its not appropriate to have a family reunion when Im trying to save your loved ones life, or the life of their neighbor.

    Since we cannot all be decent and have sense-we must have rules. It is easy for an academic, to talk to the people who give them the answers they want to hear, hang out in ICU for a while and go publish an article. Most nurses wont give you a statement anyways, IT MAKES US UNHIRABLE and we WORRY ABOUT OUR JOBS. Shouldn't we want the bedside nurses real opinion on these matters? When did getting cousin Joe a cup of coffee become more important than good patient care because someone might mark their customer service survey out poorly? We want to do a good job, we want to take good care of you. Is it so much to ask for a little space to do so?

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  30. (cont)A trained educated liason is the best solution. I worked in a PACU with one for the first time a few years ago and thought I was in heaven. They are educated enough to understand a lot of what is going on, can keep family members informed and act as a bridge, and can really help with some of these issues both in the PACU and the ICU. Shame no one wants to pay for them, because they really help patient/family and staff satisfaction.

    My husband watched a panic inducing CNN report on medical mistakes LAST week that was totally outdated. Mistakes which have been addressed, and had protective measure put into place already, flaunted as front page new things. Don't let the nurse give you blood that doesn't match your blood type, they will kill you. Does it mention that a number of blood types can accept different blood? No, it simply tells you to panic and not trust your caregiver when they come to give a type AB some O blood. Incomplete information or wrong information is as damaging as no information.

    Several years ago nurses were voted in Readers digest as most trusted after firefighters.... its a shame no one really wants to allow us to safely express our opinions without retaliation or be a REAL voice in what is going on in healthcare in this country. This is about the fifth time in the last few years I have seen a MD speak out in this manner, thank goodness someone can do it, I sure don't feel like I can, which is why you wont see my name on this post....

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  31. ~*NOTHING and no one is more important than the excellent care of the patient. Take your place, caregivers. Stand and be counted as you let your heart lead you to be the BEST you can be for us. ~"
    God Bless our Hero's. Every one. ~ <3 ~

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  32. I've been an ICU nurse for 16 years. I have also been the mother of a PICU patient, as well as the family member of several ICU patients. Open visting hours have their place in the ICU with reasonableness. An ICU stay is extremely stressful for all concerned parties and can be draining. The main point is that the critical care team needs to remain effective. When the family poses a threat to the effectiveness of the team, care becomes compromised. The ICU is a controlled environment and its team members are the gatekeepers. Poor control of the environment could lead to medical errors due to multiple interuptions. I'm all for compassion, friendly, and cuddly care, but let's not forget that our priority is SAFE care.

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  33. My nursing contract job was cancelled because of my response on this blog; therefore, this is written anonymously. Just thought you and your viewers would like to know.

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  34. Whoa! I smell a conspiracy to silence these views!

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  35. Julia Weinberg RN, BSN Raleigh, NCFebruary 19, 2014 at 6:00 PM

    Thanks Scott for this article. Our hospital recently went to open visitation however there are still restrictions. In the CTICU there may be one visitor or patient representative in the room at all times but this is still under the discretion of the RN taking care of the patient. If BP or heart rate increases and family does not respond to requests to limit patient stimulation the nurse may ask them to give the patient a break and we explain the reasons why. Other family members may visit for 20 min. every two hours with a limit of 2 visitors including the patient representative so if there are a lot of family members they will need to switch out. The nurse also may increase visitation for a patient if it is deemed to help the patient (ie: the dementia patient who calms better with familiar family present, or a dying patient). Our rooms are very small and are only separated by a curtain, family members who tend to roam or spy on other patients are asked to return to patient's room or waiting room. The patient rep is included in report when present. Our unit is the only one with these restrictions the other ICUs have open visitation, again with nurse discretion. All ICUs do have quiet time from 1-3:30 AM and PM where we limit disturbances to the patient and ask family, if in the room, to allow the patient to sleep.
    No matter what the visitation policy of a particular hospital, it should not override the needs of the patient. The person that should determine visitation is the nurse or physician. Any visitation policy that does not allow flexibility, does not take into account all the dynamics of family members, the patient and the current status of the patient and this is best determined by the people at the bedside.

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    1. Julia,
      You must be the nurse who terminated the other RN for complaining above?

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  36. I am guessing that you have not been one to sit at the bedside of a loved during their ICU stay (113 days) or you might have a different take on things. I was the only constant. Even the surgeon left the hospital staff after the first 39 days and a whole new team brought in. I was there to catch the mistakes, and there were errors: wrong meds, no trach at bedside during an emergency which I then supplied, etc. There is no" one size fits all" policy and if there is, it isn't t working!

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    1. You rock Debbie Bohn!!! Thank you for the testimony that has been something I have observed over the last 18 years of bedside nursing! You as other family/loved one are the only true CONSTANT in the patients life. You have the biggest vested interest in your family getting better. ICU nurses as a general "rule" like to control their environment. This blog is a composite of feelings and fears of nurses who see family members being a threat to caring for people in ICU. When in reality the family is your best most reliable resource and only in RARE/unusual situations are the relationships so dysfunctional that it is actually threaten care of the patient. In 18 years of full time bedside care I have seen that about 5 times and it is easily resolved with designed limits for the patient, not the nurse. The current culture has not grasped the importance and value of making the center of care the patient and family. Healthcare has come a long way but this blog demonstrates some of the barriers in the way.

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  37. My mother was murdered when I was nine. When my father was diagnosed with Lymphoma, I was in my late 20s (and not prepared to lose my last family member). I was attending college and working full time, so I was visiting my father whenever I could. I cannot imagine someone sedating him - not for pain management, but so that my visitation would mean less, or someone actively discouraging my presence.

    This article is tone-deaf, pandering only to hurried nurses who haven't got time available to provide personal comfort to patients - and you are suggesting taking away virtually ALL human interaction from an ICU patient, by blocking family members from visitation because they ask the nurse questions? If the nurse hasn't got time to sit and hold a sick loved one's hand, it only makes sense to make family wait in the waiting room*.

    *sarcasm

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    1. have you really read with such inattention that you have not recognized that this is not a debate about "Free-for-all" visitation versus "No-visitation" rather than a debate about proper and reasonable limits to visitation? Really? If so, you may be one of the family members about which so much frustration is being expressed here....

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    2. Patient's aren't sedated to make visitations mean less, they are sedated to keep them in a calm state, often times with they are on breathing machines with numerous tubes and drains coming from every orifice. The article does NOT suggest ending visitation, but merely controlling the times when families can come in because in an intensive care unit, there are going to be times when visitation is NOT conducive with the healing process. In your position as a visitor and not a medical professional, I can see your point of view to some extent, but my MAIN job as an ICU nurse is to care for my patient, who in most circumstances is in critical need of my attention. It's THEN when I don't have the time or the patience for the family member across the hall who's asking me for a glass of ice water...

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    3. Can you not be direct and caring and ask the family member to get their own ice water? Or respectfully tell them as soon as you can you will grab them the ice water? It is the biggest Myth that every minute in ICU is critical. And the biggest myth that medical personal do not have the time to fulfill obligation to respect and teach and care for who they are designed to care for. All the examples of "problems caused by open visitation" wouldn't happen at all if the nurse had created the rapport and education in the first place. I wish the man who originated this blog and all the complainers would have to take a dump on a bedpan in front of 4 strangers with the door open to 30 more while keeping their leg straight due to an arterial line, because it would have a profound effect on what you really think you are capable of.

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  38. I resent this entire blog! Clearly the writer forgot why they got into medicine in the first place - to help people get better. That also includes family members. Working in an ICU is a privilege that should not be taken with such a sarcastic pompous attitude. Yes, your job is to take care of the patient first and foremost, however, you also have a responsibility to the family. Perhaps you didn't get that memo in school. To say that family should have limited time with their loved one, clearly indicates to me that you are a heartless jerk! It's clear that you only come to the ICU to collect a paycheck. It's also clear that you are a follower NOT a leader and have conformed to the strict standards that have been implemented by hospital policy makers who have nothing better to do than to make up ridiculous rules that have no right being in a hospital. In all the years I have worked in the ICU as a RN first and then a physician, I have never come across such stupidity. It's a good thing you don't work for me or the hospital I represent - I would have fired you ass a long time ago. Let it be known that human contact with familiar people is the strongest form of healing in any patient regardless of their condition or prognosis. Unfortunately its people with your line of thinking that make more work for the rest of the ICU team. I scoff at people like you because clearly you have no idea what it is like to be a family member suffering the pain of not knowing what is going to happen with their loved ones. If sitting in the room holding their loved ones hand makes them feel better, than so be it!!!! I think the take home message here is if you want to be in this business, you better get use to serving people.

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    1. have you really read with such inattention that you have not recognized that this is not a debate about "Free-for-all" visitation versus "No-visitation" but rather a debate about proper and reasonable limits to visitation? Really? If so, you may be one of the family members about which so much frustration is being expressed here....

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    2. For some reason, I HIGHLY doubt your credentials...

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    3. Please list YOUR credentials....

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    4. The problem isn't the family visitor who sits and holds their loved ones hand, I venture (based on personal experience) that if you aren't in the way and are respectful of the nursing staff and what they are attempting to accomplish, you'll be allowed to sit there as long as you want (even against visiting policy). The problems
      are the families that don't get it and feel that the ICU pt's room is the place to hold their family reunion and reconnect with people they haven't seen in 20 years.

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  39. I currently work in a Medical ICU with a "open door" policy. I can tell you that ALL of the nursing staff feels this is a mistake. Family members just walk in as the please, during rounds, during codes, during procedures. Most have NO clue which room their family member is in, and instead of proceeding to the nurses station to inquire, they peek their heads into other patient's rooms, invading their privacy. I think having the family present is important to the healing process, but I agree, if they are allowed to just "hang out", they begin asking questions just for the sake of asking questions. I think if there were set times for visitors, it would not only enhance patient care (since nurses/drs/staff would be able to concentrate on the task at hand), but it would better communication between the staff and families, while improving the privacy of all the patients on the unit. That's all I got :)

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  40. ICU RN for 13 years.....I've read through the entire thread of replies on this article. I've noticed a common theme with many, and that is a general rancor for the healthcare facilities. EVERYONE should be angry with the government, not the hospitals. This customer satisfaction push is a direct result of reimbursement. If patients don't mark a 9 or 10, the hospitals don't get paid. So regardless of the illness that was treated successfully or the elective surgery that was done well, if the patient has a nurse or two who "seemed curt" or "didn't answer a call light" fast enough, they score an 8.....which counts as a big fat zero. It's a vicious cycle....those nurses who are "curt" or didn't respond fast enough are the same ones pushed by all the new policies and mandates that are constantly pushed upon them because "administration said so." Newsflash! It's not administration, it's the government. Give the employers a break......what's really sad is that these big hospitals will be pushed to the breaking point because of lack of reimbursement and indigent care and they will shut down. Where will we be then?

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    1. Lack of reimbursement? "the hospitals don't get paid" That is 1% percent of Medicare’s regular reimbursements not private insurance reimbursement. Do you know how much your hospital CEO is getting paid? The average compensation was approximately $600,000 per year, though this varied widely. CEOs of small rural hospitals earned salaries and bonuses of just $118,000 a year, while those at the largest urban teaching hospitals earned on average nearly $1.7 million per year. And some CEOs earn considerably more than that. Now compare that to 1% of medicare reimbursement or the whopping 2% for 2016. Wow, you have the right perspective at least you think you know where the money is. No problem as long as you get your check, let me guess you are one of those "I just work here" nurses.

      Also for your information the questionnaire is not based on the call light but are the questions: Did the doctors and nurses communicate well? Was pain well controlled? Was the room clean and the hospital quiet at night? The surveys go to younger patients as well as Medicare beneficiaries. The surveys also ask patients to rank their stays on a 10-point scale, and Medicare will credit only hospitals that receive a 9 or 10.

      Just so you know, so when your CEO has that hospital wide announcement that your salary is being decreased because of poor customer service you will know what that rich guy is talking about!

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  41. I have been an ICU RN for almost 30 years, ideas come and go all the time...just think of all the hours you used to spend on care plans and all the different charting styles ignorant VPs demanded. But this one takes the cake. How many of the hospitals implementing this actually invested the money into a 24/7 "patient liaison"? How many of them have actually cut staffing because of 'reimbursement decline" so that ratios are no longer 1;1 or 2;1? My hospital is forcing ICU RNs to be 3:1,(not counting the possibility of transferring in or out another one in the course of your 12 hr shift that ALWAYS becomes 14 hrs...they are actually doubling up fresh hearts! Let's do a study on how safe that is! With daily assignments like that, who really thinks we have time to spend "quality time" with families in that environment?...and if its not "quality" time, its worse than no time....THAT'S where the greatest "customer dissatisfaction" comes in...but of course you dare not explain staffing issues to family...that gets you fired....and by the way, yes, this is a "MAGNET" hospital. So I can get written up for being "curt' to a family member, but not a damn thing for saving his life, finding the med error, catching the fluid overload before the pulmonary edema, treating the stemi before the MD is even half awake, etc etc etc ...but god forbid I don't smile enough...I used encourage bright young people to consider nursing as a career, not any more.

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  42. I agree 100% but the hospital lobby is a heck of a lot stronger than the nurses lobby, are they using some of their bucks to fight this?

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  43. Someone should seriously look into whether open visitation units have a higher frequency of aspiration pneumonia caused by families grieving too many water swAbs

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  44. I am a wife and my husband is dying in ICU. I am here a lot and I stay out of the way. I give him water and. put his head up or down and put him on the bed pan so he doesn't have to call the nurse. When i come he finally relaxes and sleeps peacefully because he knows i am there. I can tell him what is beeping and why so he doesn't worry. I can see that too many visitors would be disruptive but why would a nurse not want this help and comfort from a loved one? This ICU is 24/7 and it seems to work.

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    1. Beautifully said. Thank you. At the end of the day, we are all patients.
      H.E. Butler III M.D., F.A.C.S.
      757 377 7775 cell phone

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  45. In some, perhaps even many cases, it appears to work, because visitors are thoughtful, helpful, and mindful. Yours appears to be such a case. Unfortunately, like so many things in life, the thoughtless, disruptive, and mindless in society ruin things for the rest of us. Even in a closed visitation ICU, I'm sure you would be accommodated - unless the administrators and nurses there were thoughtless, dismissive, and mindless. I wish your family the best as you negotiate these trying times.

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  46. Story: Family of 5-8 staying in small Icu room for 3 days have brought in many personal belongings, toiletries, clothes, blankets, books, games, food (including trash from food and drink) and have strewn it all over the floor. I clean it up, and explain the infection risk this poses. They put their stuff all over the floor. I ask them to leave the room for re intubation and I got my butt reamed out. I was very nice and listened, offered understanding of their stress and apologized they they were unhappy. I had to leave the room because the yelling would not stop. This family told me I should be taking temperatures more often, demanded to stay in the room for all procedures, and by their continued interence in care made it impossible to get things done in a timely manner. Don't get me wrong, I am all for patient and family centered care but there is a point where the family becomes a hazard for infection AND for the nurses mental health but when no one says no before you then you become the bad guy. Hospitals, in their quest for better HCAPS, have thrown common sense out the window and cowtow to these horribly behaving families.

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  47. I have it on confidence that at least some of the nurses in the "studies" used to support open visitation do not feel as though they are at liberty to disagree with the avant-garde which is pushing this "agenda". If that is so, then the entire research enterprise may represent one giant Hawthorne Effect demonstration. Agenda yields policy yields "research" to support the former. Junk science.

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  48. Good stuff Scotty! I did not read through all 100 plus comments but I would like to add, pts. need sleep ! Sleep is a great healer. When you have 6 family members standing over their vented pt and petting them saying" breathe mom breathe". Then they say wake up mom, open your eyes and we have them in an induced coma. Just saying.

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  49. I was the Nurse for that pt with the very anxious wife and it was exhausting. There is reasoning to your madness. Well written!

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  50. Excellent update. We have been in our new MICU for a year now. And that's a year of open visiting. Most days, it's not as bad as I expected. Other days, I'm hiding in the med room just to chart. Because a sitting nurse, who is actually charting, has plenty of time to fluff up a patient that isn't even hers.
    Having bigger rooms with dedicated space for families helps. Knowing they can come and go as needed also seems to help.
    But we still have to set healthy boundaries. Open visiting doesn't translate to you watching grandma's bronch or EGD. We, at the bedside, need to be empowered to set those boundaries. After over 20 years at the bedside, I have no problem with this but it's a learned skill and it takes practice.
    We also will have 24 hr coverage in the waiting room. So that extra buffer for staff will also alleviate some stress from both sides.
    Families are an important PART of the picture, but the patient is the whole picture. And they need to be the priority. Their needs come first.

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  51. As a passive observer in the ICU and pastoral caregiver for patients and families, I have seen many of these situations and rebuttals, from admission to discharge. I have observed the complex professional relationships between physicians and nurses caring for a given patient while working tirelessly with families navigating the ICU experience. I have observed a few nurses taking unfair advantage of families in the name of medical care leaving families nervously pacing the waiting room with little forthcoming information. This, based on their perception of what is best for the patient. I have also witnessed families rushing the physician for updates before that physician had had a chance to check lab and diagnostic results or even lay eyes upon the patient. Unfortunately, some families have unrealistic opinions of their loved one's lifestyle (which may or may not have led to the admission) or even delusional idea's of treatment needed. Others come with their own diagnosis in mind and attempt to drive the treatment. I believe families in many circumstances enhance the care by providing pertinent information received over many years of treatment by various physicians. There are other cases where families interrupt the care of the patient by pulling staff away from the patient for hours of nonsensical discussion. Families often do not understand the demands on caregivers and lack a respect for their time in many cases. I advocate for families who just need to get into the room to see that their loved one is alive and getting appropriate care. I also advocate for them to get their rest, especially when an LTAC situation is looming and I sense that the family needs permission to leave and care for their own needs. My opinion on this subject rests on the sensitivities of the needs of the family, the care team and the patient. Unreasonable families keep me employed. I save time for the staff addressing the complex needs of families; some which we will never be able to satisfy, even when sending their loved one home when the patient was not expected to survive initially. I read the anonymous comments and realize that irrational and unreasonable families cause a great deal of stress to the professional staff, people that I feel an obligation to be present for as well. I am a realist and although as a pastoral caregiver for a number of years have seen the extremes on both ends of the spectrum. I validate the family and the care team. I also understand that there will always be a population of families and patients whose demands can never be satisfied. Staff respond with tighter restrictions in order to sanely work through their day trying to focus on what is best for the patient. Chaplains come in handy with needy families and can sometimes help them to navigate the admission. There are times that no matter what is offered, a lifetime of survival skills and poor coping strategies cannot be managed with any kind of liberal or managed visitation.

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  52. And this, from the Pastoral Caregiver above, is a reasoned and cogent summary of the issues we all face. Indeed, I did not articulate it in the post, but Pastoral Caregivers, especially great ones like the commenter, can help achieve the holistic goals I'm describing in the post. Dealing with these grief-stricken families is best accomplished with a sincere devotion that is reflected in the assignment of adequate personnel support to deal with the issues.

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  53. "Instead of taking patients' families out of the room for an hour here and there, maybe we need to get the nurses out of the room for an hour here and there, giving them much needed breaks from the chaotic ICU environment."

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    1. Like that would ever happen!!!

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  54. This is anecdotal, granted, but aren't you glad Dad "visited"?
    http://www.nydailynews.com/news/national/texas-man-released-jail-siege-save-son-life-article-1.2474678

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  55. Just to add frosting to this cupcake, has anyone asked administration how they feel about this? Not that many of them would actually care.

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