J Nurs Care Qual

Vol. 20, No. 2, pp. 182-189

© 2005 Uppincott Williams & Wilkins, Inc.

Nurses' Perceptions of Open

Visiting Hours in Neuroscience
Intensive Care Unit
Sarah Livesay, BSN, RN; Alicia Gilliam, BSN, RN;
Marilyn Mokracek, MSN, RN, CCRN, CNA;
Sherly Sebastian, BSN, RN, CCRN, CNRN;
Joanne V. Hickey, PhD, RN, ACNP,BC, FAAN, FCCM
A quality improvement project was undertaken by Neuro-ICU nurses to determine possible effects
from open visitation. From a quality improvement perspective, nurses' concerns were investigated
along with their perceptions about open visitation to determine a need for visitation policy revi-
sion. Vast variability in nurses' interpretation and implementation of individualized open visitation
policy suggested a need for the following: staff education about the policy and its implementation,
a review of the literature to determine the validity of concerns about deleterious physiologic ef-
fects on neuroscience patients from visitation, and improved communication among nurses about
visitation. Key words: limited visiting hours, open visiting hours, visitation

S the current healthcare system moves to-

A ward a cotisumer-driven paradigm, visit-
ing hours for family and friends of the hospi-
talized patient have become a topic of interest
and discussion. Disappearing are the intensive
care units (ICUs) that allow family visits for a
15-minute period twice a day. With a shift in
philosophy to include the patient and family
in decision making, a concurrent change in
nursing practices has occurred. Many nurses
have questioned the wisdom of open visita-
tion fearing potential harm to vulnerable neu-
roscience patients. Differences in caregiver in-
terpretations of open visitation can lead to
confusion for visitors and eventually to the
family's mistrust of the nurse. It is important
From the Neuroscience ICU, St Luke's Episcopal
Hospital (Mss Livesay, Gilliam, Mokracek, and
Sebastian), and School of Nursing, University of
Texas Health Science Center at Houston (Dr Hickey),
Houston, Tex.
Corresponding author: Marilyn Mokracek, MSN, RN,
REVIEW OF UTERATURE
CCRN, CNA, Neuroscience ICU, St Luke's Episcopal Hos-
pital, Houston, TX 77030 (e-mail: mmokracek@sleh.
com).
Accepted for publication: May 4, 2004
182
to clarify the role of the nurse at the bedside in
facilitating open visitation. Issues that compli-
cate open visiting hours could be resolved if
the perceptions and needs of the nurse about
individualized open visitation were better
understood.
This survey was undertaken because staff
nurses within a 10-bed neurological ICU
(NICU) believed that nurses' perceptions of
open visiting hours affected family and patient
satisfaction. The posted visiting hours for the
NICU are open except for 6 AM to 8 AM and
from 6 PM to 8 PM when the unit is closed for
change of shift report. However, open visita-
tion holds different meanings among nurses.
The interpretation and application of open
visitation may vary from nurse to nurse and
create inconsistencies and frustration for the
patient, visitors, and nurses themselves. The
nurse-visitor relationship may become adver-
sarial as a result of perceived inconsistencies
in visiting hours.
The structure and effects of visitation in
ICUs have been reported in the literature
 Nurses' Perceptions of Open Visiting Hours in Neuroscience ICU
since the late 1970s. A review of the nurs-
ing and medical literature was undertaken
to examine visitation from the perspectives
of the patient, family, and nurse particularly
in relationship to neuroscience patients. Few
research-based studies w^ere found.
Hendrickson' investigated the association
betw^een family visits and fluctuation in
intracranial pressure GCP), using a quasi-
experimental design. Of the 24 subjects, 18
(75%) patients had a decrease in ICR Although
6 patients had a rise in ICP, the rise w^as not
statistically significant. Bay and colleagues'^
studied the relationship between family vis-
itation and change in mental status. Of the
25 subjects in the study, 19 patients (78%)
had improved scores w^hereas the scores of
6 (22%) patients decreased. There was no
consistent association between the patient's
mental status and family visitation. In a de-
scriptive study of 15 patients designed to de-
termine the relationships between family vis-
itation and ICP, no statistical relationship was
found.' Although these studies are few and
include small samples, there is no conclu-
sive evidence to support a deleterious physio-
logic effect of family visitation on neurological
patients.
In a seminal study, Molter'* developed the
Critical Care FamUy Needs Inventory to iden-
tify and rank needs of relatives of critically ill
patients. The top 5 needs were to (1) have
hope, (2) feel that the hospital staff cares for
the patient, (3) be near the patient, (4) be in-
formed of any change in patient status, and
(5) know the staff. Molter's work has been
replicated by other researchers.^'^ Giuliano
and colleagues^ reported that families •wanted
assurance, proximity to their loved ones, and
information. There was no evidence to sup-
port detrimental effects of liberal visitation on
the patient in the 24-bed ICU. Although there
was initial staff resistance for a liberal visita-
tion policy, the staff worked together to de-
velop a video and brochure designed to teach
visitors how to optimize visitation. Staff even
initiated a pet visitation program. Family satis-
faction increased significantly with the liber-
alization of the visitation policy.
183
In another study, seeing the patient fre-
quently and having the ability to visit as de-
sired were most important to family members
(A'^ = 30).^ In a study of 145 family members
in a medical ICU, Hanneman and colleagues^
found that implementation of open visitation
along w^ith information booklet met the fam-
ily's needs and increased the likelihood of
recall of information related to the patient's
care.
Simpson'" studied verbal behaviors during
visitation of 24 patients in a community ICU.
She reported that visitation fostered a link be-
tween the patient and the outside environ-
ment. Visitation also facilitated cognitive pro-
cessing of concerns related to the patient's
health, provided physical assistance or ver-
bal encouragement, and fostered positive re-
lationships betw^een visitors and patients. She
concluded that liberal ICU visitation should be
encouraged. In a review of the research liter-
ature, Titler'' noted 3 factors responsible for
moving from a restricted to more liberal visi-
tation in the ICU: know^ledge, beliefs, and at-
titudes of nurses; administrative policies; and
structural barriers.
Brannon et al'^ found that both nursing
staff and visitors benefited from a visitation
contract that identified the times and length
of visits that worked for that particular patient
and family thus addressing individualization
of visitation. In addition, nurses were encour-
aged to appreciate the added stressors placed
on family members and to support the fam-
ily when a loved one w^as critically Ul." Puz
and Tracy identified reasons nurses give to
limit visitation as well as reasons for less re-
strictive visitation.'^ Finally, in an editorial ad-
dressing visitation,'^ a trend from closed to
open visitation and then back to closed visi-
tation has been noted. The editor encouraged
maintaining liberal visitation hours. She also
challenged nurses to become involved with
visitation concerns on their units and exam-
ine current policies to determine the need for
modifications.
In summary, there is limited research on vis-
itation, and few studies have focused on visita-
tion with neuroscience ICU patients. Of those
184 JOURNAL OF NURSING CARE QUAUTY/APRIL-^JUNE 2005

studies reviewed, no researcher reported dren under the age of 10 are allowed. A sec-
any sigtiificant negative effects on ICP or ond sheet provides information to guide fami-
neurological function associated w^ith visita- lies in the ICU environment. The policy states
tion. Therefore, if open visitation is to be that visiting hours are flexible depending on
maintained, nurses need to examine their un- the needs of the patient and fatniiy.
derlying beliefs about a liberal visitation pol- The research team w^as ctirious about how
icy with the goal of optimizing the therapeu- visiting hours were interpreted and imple-
tic outcomes of visitation for the patient and mented by staff members. The team also
family. In this way, modifications in structur- wanted to explore the impact of visitation on
ing visitation can be made with the best pos- the specific population of neurological and
sible staff support. neurosurgical ICU patients. For example, the
standard of care for our population of cerebral
PURPOSE aneurysm patients includes decreased stimu-
lation, which is often perceived as an impor-
The purposes of this survey were to im- tant aspect of preoperative and postoperative
prove quality of care and patient/family satis- care. Decreased stimulation includes control-
faction by examining (1) nurses' perceptions ling light in the room, closing doors to de-
of the current open visitation policy, (2) their crease ambient noise, avoiding television, and
perceived need for policy and unit practices limiting numbers of visitors and the amount of
changes, and (3) their perceptions of the im- time that they stay. A handout entitled "Guide-
pact of the current visitation policy on the pa- lines for Neurological Patients and Their
tients' health status. Families" is posted on the patient's door and
details the need for visitors to maintain a
Current visitation policy peaceful and quiet environment. More spe-
cific visitation guidelines might be useful for
The current visitation policy is general and the nurse providing care at the bedside in
thus open to different interpretations. The
these specific cases.
policy states.
It is the policy of St. Luke's Episcopal Hospital to en- METHODS
courage visitation of patients to provide them with
support while maintaining a safe environment for Fach registered nurse (RN) and patient care
patients and visitors. Individualized visiting hours
assistant (PCA) in the NICU was invited to par-
are established to provide and assure continuity of
ticipate in this survey through a personal con-
quality patient care during routinely busy times.tact by a representative of the research team.
Visiting hours may be reexamined for each patient
based on his/her needs and through collaboration
Since this was tindertaken as a quality im-
with the patient's nurse. provement project, institutional review board
approval was not required. Fach staff mem-
The unofficial term for our current policy ber w^as offered a copy of the survey, asked
is "open" visitation. The same policy states to complete it anonymously w^ithin 12 hours
that one visitor at a time is allowed to stay (the typical length of the shift), and return it
overnight with a patient in a private room to a mail slot. Data were analyzed to identify
(the acute care floors have both private and themes, perceptions, and beliefs of the neuro-
semiprivate rooms). science staff.
No specific recommendations are made Of 30 employees invited to participate, 26
about the ICU patient. Two NICU informa- responded although not all participants an-
tion sheets are given to visitors. One sheet ad- swered all questions thus explaining the vari-
dresses visiting hours, which are ongoing ex- ations in responses reported per question.
cept from 6 AM to 8 AM and from 6 PM to 8 PM. Respondents included 22 RNs and 4 PCAs. Fif-
Two visitors may come at a time, and no chil- teen (58%) respondents w^orked the 7 AM to
 Nurses' Perceptions of Open Visiting Hours in Neuroscience ICU
7 PM shift and 11 (42%) the 7 PM to 7 AM shift.
Respondents had been RNs from less than
1 year to more than 20 years; 58% of the RNs
had 11 or more years of experience. The PCAs
had functioned in their roles for a mean of
3 years.
PERCEPTIONS OF NURSES ABOUT
VISITING HOURS
Listed below are the questions posed and
summary of the participants' responses.
1. When a family member asks you
what the visiting hours and policy are,
what do you tell them?
According to the current policy, the unit
closes for change of shift activities between
6 AM to 8 AM and again from 6 PM to 8 PM.
Twenty-two (85%) of 26 respondents said that
the unit is open from 8 AM to 6 PM and again
from 8 PM to approximately 10:30 PM (with
night closing hour varying from 10 PM to 11:30
PM). The notion of "open" visitation was men-
tioned in only 7 of 28 responses. Numerous
factors w^ere identified for amending the visit-
ing hours policy including nurses' discretion,
patient's condition, and procedures. Self-care
behaviors suggested to the family were used
by 3 nurses to explain why the visiting hours
were restricted. For example, family members
should "resf'while the patient is being closely
monitored in the ICU, and overnight stays
should be reserved for when the patient is
transferred to the next acute care setting (eg,
rehabilitation). Responses such as no children
under 10 years of age, no live plants, and 2
visitors at a time w^ere uniform among those
surveyed.
2. If a family member wants to stay
with the patient during the later evening
or during the night, what do you do?
The responses to this question varied
greatly. A few^ nurses (4 of 25) said that they
reiterated the visitation policy and enforced it
although a larger group (10 of 25) indicated
they would amend the visitation rules If the
patient's condition •warranted it. Examples of
such situations were an agitated or a termi-
185
nally ill patient. Other nurses reported that
they were liberal w^ith the policy, allowing vis-
itors to come and go as they wished.
All respondents discouraged family mem-
bers from sleeping in the patient's room and
offered the waiting room as an alternative.
One nurse noted that the effect of the visi-
tor on the patient also was taken into consid-
eration. Five (20%) respondents discouraged
family visitation in the late evening or during
the night. The nurses offered alternatives to
staying at the bedside throughout the night
such as calling from home to check on the pa-
tient's status or staying in the waiting room
and checking on the patient periodically on
an "in and out" basis.
3. Under what circumstances do you
feel the need to ask the family to leave
the bedside?
While individual responses to this question
varied, one underlying theme emerged. Most
nurses ask the family to leave the bedside dur-
ing procedures. Which procedures required
the family to leave the room were nurse spe-
cific. Answers varied from "any procedure in-
volving the patient" to only procedures that
place the patient's privacy at risk such as turn-
ing or bathing. While most nurses agreed that
the family should leave while withdrawing
blood and oral/endotracheal suctioning, sev-
eral nurses believed that the family should be
given information about the procedure and
then allowed to decide if they wished to be
present or not. A few nurses indicated the
family should leave the room during sterile
procedures, code situations, and other emer-
gencies (as identified by the nurse).
Several nurses stated they would ask the
family to leave the bedside w^hen conducting
a neurological assessment particularly if that
assessment required painful stimuli. Another
common reason for asking visitors to leave the
room related to patient agitation or exhaus-
tion caused by visitors. Finally, several com-
ments were made about family members who
stay at the bedside too long (as perceived by
the nurse) and those whose behavior is unruly
and should be asked to leave.
186 JOURNAL OF NURSING CARE QUAUTY/APRIL-JUNE
The varied answers to this question pro-
vide insight into potential mistrust of fam-
ily members toward some nurses. While all
nurses believed there were times when the
family should leave, those instances were
highly nurse specific. Based on the results
of this survey, it is feasible that the inconsis-
tencies among the staff might confuse family
members about standard routines and patient
care expectations. That is, they might observe
"routine" care provided by a nurse on a given
day that is different from the care provided by
other nurses. In addition, information and ex-
planations provided to family members may
vary from nurse to nurse.
Several respondents addressed the diffi-
culty posed by family members who refuse
to leave the bedside when asked and those
who acted unruly. Family members who never
leave the hospital become physically and men-
tally exhausted. Their ability to cope w^ith the
ongoing stress of having a critically ill fam-
ily member becomes further compromised,
which can impede their ability to make deci-
sions on behalf of the patient and participate
in the plan of care. Aggressive and unruly be-
havior may be perceived as threatening the
nurse's safety in the work environment.
The nurses were concerned about con-
ducting a neurological assessment, which in-
cluded providing painful stimuli to illicit a re-
sponse, in the presence of family members.
Neurological assessments are scheduled at
least once every 2 hours. Nurses believed that
the presence of a family member affected the
quality of the neurological assessment. The
assessment might be abbreviated to a form
that the nurse believed would be acceptable
to the family. In other instances, the visitors
were asked to step out of the room to fa-
cilitate a complete assessment. While the in-
consistency among nurses could hinder inter-
personal relations with families, most nurses
agreed that effective patient care is the high-
est priority.
4. What is your understanding of open
visiting hours?
The survey results indicated that the phrase
"open visiting hours" may mean "open to
2005
staff interpretation." Answers from staff var-
ied from "open to visit •with the patient at
any and all times" to "flexible and patient spe-
cific. "Rules applied to open visitation also var-
ied from staff member to staff member. Some
said only 2 visitors may be in the room at a
time; others placed the length of family vis-
its at the nurse's discretion or used the termi-
nology "brief visits. Still others related that
while the visiting hours were "open," family
could be asked to leave if the nurse was to
perform a procedure or an assessment. Inter-
estingly, one respondent stated, "Open visit-
ing to me says that a family member can come
and visit patients any time except for those
stated hours w^hen the unit is closed." It is as-
sumed the closed time is during the morning
and the evening change of shift. Several re-
sponded that the family could visit openly, but
they could not spend the night.
5. Do you think family visits have a neg-
ative or positive effect on patients in the
NICU?
Of 25 responses, 18 (72%) related that fam-
ily visits have both negative and positive ef-
fects on a patient in the NICU. Five of the
respondents indicated that family visitation
had a positive effect on the patient. There
was agreement that the effect of visitors on
NICU patients depended on the patient's men-
tal status and diagnosis. Staff members be-
lieved patients benefit from visitation if family
members w^ere supportive, reassuring, calm-
ing, and comforting to the patient.
Negative effects of visitation stemmed from
family members w^ho agitated or aggravated
the patient. Several nurses suggested that the
negative effects from family visits correlated
with physiologic responses, for example, with
increases in blood pressure, heart rate, and
ICE Two respondents were concerned that
visitation might have a negative effect on both
patients and family, leading to increased anxi-
ety for the patient and family members.
Most of the respondents agreed that vis-
itation effects on the patient depended on
the patient's condition and the family mem-
ber's anxiety level, ability to handle stress, and
ability to calm the patient. When the patient
 Nurses' Perceptions of Open Visiting Hours in Neuroscience ICU
reacted to the visit in a positive manner as ev-
idenced by a decreased blood pressure, heart
rate, and ICP, then the staff member was
positive about the experience. When the pa-
tient reacted negatively, with increased anx-
iety, changes in vital signs, or a decrease in
mentation, the staff held a negative view of
visitation for that specific patient. This may
explain response variation in the survey. The
staff believed that the benefits of visitation
were patient specific. Further research eval-
uating the patient's psychological response to
family visits is needed.
6. If it were your sole responsibility
to determine the fanuly visiting policy,
what would you like that to he and why?
Sixty-eight percent of the staff would mod-
ify the current visitation policy. Specific mod-
ifications included limiting the time of each
visit to 20 to 30 minutes, closing the unit for
change of shift and assessment, and closing
the unit to visitors on the night shift. Seven
respondents wanted to stay with the current
policy aUow^ing flexibility in visitation times
with stricter enforcement of the 6 AM to 8 AM
and 6 PM to 8 PM closure for change of shift
report.
7. What is your personal experience re-
garding limited visiting hours?
Few nurses had experience with limited
visitation, defined as a strict policy that lim-
ited visits to a short period of time a few
times a day. Some mentioned the Cardio-
vascular Surgery Recovery Room visitation
rules, which consisted of 4 half-hour periods
throughout the day. Several nurses preferred
that visitation structure to the NICU's open
visitation structure. Several nurses related that
neuroscience patients specifically need more
rest and less stimulation by virtue of neu-
rological pathophysiology. Patients with un-
stable ICP or who are experiencing cere-
bral vasospasm need less stimulation, and
"open" visitation inherently increases patient
stimulation. Other nurses believed that pa-
tients do not get enough rest when fami-
lies are present with constant talking and
stimulation.
187
Family members calling the unit before vis-
itation was mentioned as desirable because
it enables the nurse to prepare for the visit.
The nurse can then set aside time to spend
with visitors and establish a relationship with
them. Still other respondents acknowledged
that limited visiting hours might make visitors
suspicious and lead to adversarial staff-family
relations.
8. How can visiting hours he improved
on your unit?
The majority of the staff requested a sim-
ple and clear visitation policy. Only w^ith a
clear policy can the staff be consistent in re-
inforcing the rules. Suggestions were made to
have clear signs posting visitation rules on ICU
doors and in ICU rooms as well as in the w^ait-
ing rooms. A majority of respondents believed
family members should not be allowed to stay
overnight in the ICU rooms.
Several staff members suggested having an
announcement through an overhead inter-
com stating visiting hours are over. Again, the
common thread was having a clear visitation
policy and consistency in implementing it. On
admission, family should be notified of the vis-
iting hours, and then staff should consistently
reinforce that information throughout the ICU
stay.
9. What resources are needed to sup-
port you in enforcing visitation policies?
The consensus w^as that clear policies about
visiting hours need to be communicated
to staff, patients, and families. The policies
should be in printed form and framed in a
way that recognizes the needs of the patient,
family, and staff. Most nurses would like re-
sources available for the "difficult families."
Staff intervention and in some instances se-
curity support may be necessary when family
members are unruly. There is a need for uni-
formity in policies, consistency in implemen-
tation of policies, support of the nurse w^ho
is providing the care, and services to support
the fanuly. Education w^as an important
thread, and some specific suggestions were
made for educating and supporting families in-
cluding formats for printed material.
188 JOURNAL OF NURSING CARE QUAUTY/APRIL-JUNE
DISCUSSION
The philosophy, policy, and procedure for
visiting hours must be clear at the organiza-
tional level before they can be clear at the
unit level. The results of this survey under-
score that nurses need a clear ICU visitation
policy and procedure that will be supported
and reinforced by all staff on the unit. If vis-
iting hours are truly "open," should the hos-
pital then have a responsibility to provide
sleeping areas as an alternative to the ICU
room? Visiting hours may be "open," but an
overwhelming majority of the nursing staff
believed that visitors should not be allowed
to stay overnight at the ICU bedside. This
is particularly important in an NICU where
minimizing stimulation is perceived to be so
important.
Support for staff to deal with problem fam-
ilies should be available. Perhaps a third party
provided from the Patient Relations Depart-
ment could act as a mediator when patients
or families feel their needs are not being met.
Finally, consistent teaching materials can be
used to reinforce that the nursing staff and
family are a team dedicated to the recovery
of the patient.
Recommendations and conclusions
Without an institutional definition of "open
visiting hours,"the phrase is open to interpre-
REFERENCES
1. Hendrickson SL. Intracranial pressure changes and
family presence. / Neurosct Nurs. 1987; 19(1):
14-17.
2. Bay EJ, Kupfererschmidt B, Opperwall B, Speer J. Ef-
fect of the family visiting on the patent's mental sta-
tus. Focus Crit Care. 1988;15(l):10-l6.
3. Prins MM. The effect of family visits on intracranial
pressure. WestJ Nurs Res. 1989;ll:281-297.
4. Molter NC. Needs ofrelativesof critically ill patients:
a descriptive study. Heart Lung. 1979;8:332-339.
5. Bouman CC. Identifying priority concerns of families
of ICU patients. Dimens Crit Care Nurs. 1984;3:313-
319.
6. Lynn-McHale BJ, Bellinger J. Perceived satisfaction
levels of family members of critical care patients
2005
tation. These interpretations may leave both
families and staff feeling unsupported as con-
flict arises. This survey illustrated that atten-
tion to a clear and uniform policy and imple-
mentation procedure could decrease the frus-
tration and dissatisfaction of the nurse at the
bedside as well as patients and their visitors.
Once the policy and procedures are devel-
oped, multilevel education is needed for the
nursing staff to ensure uniform enforcement
of the policy. A clear policy is the basis for
the development of written information for
distribution to visitors. In addition, there is
need for dialogue among unit nurses to clar-
ify and resolve differences related to policy
implementation.
Next step
On the basis of a review of the sur-
vey data, the unit practice committee devel-
oped the foUow^ing action plan: develop a
mandatory educational module to review the
current visitation poUcy and help nurses un-
derstand the flexibility of that policy; spon-
sor an open forum to discuss concerns
and review alternate actions available to the
nurse at the bedside; share the reviewed
literature addressing physiologic effects and
visitation; and monitor visitation practices
as an ongoing quality indicator for the
unit.
and accuracy of nurses' perceptions. Heart Lung.
1988;17:447-453.
7. Giuliano KK, Giuliano AJ, Quirk PA, Wood J. Families
first, liberal visiting hours may be in the patients' best
interest. Nurs Manage. 2OO2;31(5):46-48.
8. Stniwell SB. Importance of visitation needs as per-
ceived by family members of patients in the intensive
care unit. Heart Lung. 1984;13:238-242.
9. Hanneman EA, Mckenzie JB, Dewa CS. An evaluation
of interventions for meeting the information needs
of families of critically ill patients. Am J Crit Care.
1992;l(3):85-93.
10. Simpson T. Visitors' verbal behavior with coronary
care unit patients. West J Nurs Res. 1992;14:482-
497.
 Nurses' Perceptions of Open Visiting Hours in Neuroscience ICU 189

11. Titler MG. Changing visiting practices in criteria care
units. Medsurg Nurs. 1995;4(l):65-68.
12. Brannon P, Brady A, GaileyA. From rules to contracts.
Nurs Manage. 199O;21(2):64M, 64P.
13. Van Horn E, Tesh A. The effect of critical care
hospitalization on family members: stress and re-
sponse. Dimens Crit Care Nurs 2000;19(4):40-
49.
14. Puz C, Tracy MF. Getting to best practice on visiting
time—Yes, hm.AACNNews. 2002;19(5):7.
15. Miracle VA. Critical care visitation. Dimens Crit Care
Nurs. 2003;22(l):48-49.