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.