I am writing this from my perspective as a nurse and understand that it will conflict with the viewpoint of a family who has a loved one in an intensive care unit and possibly many others, even (gasp) some healthcare workers.
From my experience in ICU, patients are generally not able to “visit” with family and friends. A majority of our patients are either intubated and sedated or completely exhausted and weak from illness. We also frequently care for patients that are what we call “no info” patients which can be anything from gunshot wounds to someone who has been beaten or abused and needs to be protected. I feel that set visiting times only add stress to the day in the ICU for all involved. In the unit where I work we have visiting times four times a day, each lasting an hour. Three of these occur on the day shift…which is when I work. We do have the authority to call visitors out at any point if there are procedures to be done or if one of the patient’s conditions suddenly worsens. This is helpful, but not always practical.
During the set visiting times it is not unusual for doctors and nurses to avoid family contact. I do go visit with family initially and give updates when I have them, but I am not a nurse who will hang out in a room with family there. I once overheard another nurse tell family “the more you are in there, the less I will be.” I thought that an interesting statement. It is true. If the family wants us to do our jobs and take care of the patients, we need to be in the room and doing what we are there to do.
Now I am not against all family contact in the ICU, I think it can be decided on an individual basis and for limited times. Of course all pediatric patients would have a parent present at all times. I do not believe family should be kept from a dying family member or that they should be kept away at all times. I understand a family’s wish to be there to care for and show their support for a loved one in critical condition, but it is not always advantageous to the patient. These patients are attached to monitors, have multiple wires, tubes, lines coming from their bodies.. ..they are not dressed, and typically look a mess despite our effort to make them otherwise.
As a side note…
In the 1800’s visiting times were instituted for those that could not pay their hospital bills in an attempt to encourage families to pay. Those that were paying customers had unrestricted visiting times. This still happens today in a way…we have those patients that the hospital recognizes as “VIP” patients. These patients get whatever they want, including family at the bedside if so requested….this is in my opinion completely unethical. How do you explain to the terminal man’s wife next door that she can’t stay but it is ok for the patient in the next room to have his mom, dad and sister at his side at all times, you can’t because it doesn’t make sense!
It should be up to the patient to some degree, some find it comforting; but I personally prefer to be left alone when I’m sick. When my appenix burst I had to wait 3 1/2 days for a surgeon. Had tubes pumping stuff in & out of me and a steady flow of morphine. The last thing I wanted when I woke up was to have to talk to someone – fortunately my family knew that about me.
I agree that patients should have choices, but in the ICU there are many reasons we have to do things a little differently. There are invasive procedures performed on patients in the room that do not need an audience of nearby visitors. Many of our patients are sedated and on the ventilator. They could not speak even if they wanted to. I understand the need for family to see their loved ones and make sure they are ok, but feel there is no reason for them to gawk at someone for an hour that is unable to respond. It was considerate of your family to respect your wishes when you were not feeling well. Some families are just not that thoughtful. Thank you for your comment!
As I nurse, I completely agree. One thing you didn’t even mention, is the fact that healthcare workers and physicians are held to a very high standard with the HIPAA law. It is very easy for a visitor in ICU to hear something they shouldn’t just because the nurse needs to discuss the issue with a rounding physician or other team member. Family members just don’t understand.
And as far as patient dignity is concerned. If I were the patient, I wouldn’t want people to see my urine in my Foley, my stomach contents in the suction canister, or my secretions in my ET tube.
I think that it is sad that nurses don’t want families at the bedside so they can spend time with a critically ill patient. What are nurses afraid of? Most of the time families are so afraid that they need emotional support from the nurse. Anyone can write down vital signs, hang drips and do physical care for patients – that is called being a good technocrat. Nursing encompasses the skill and knowledge to care for the patient and family while coordinating and collaborating care with the health care team. Some of my best experiences in nursing have been when I have bonded with a family and they have leaned on me for support. You should give it a try …… it may change your mind.
I disagree Laura. Not just anyone can hang drips, do physical care or as you call it “be a good technocrat”. Nursing involves seeing the big picture in an ICU and oh yea, intensive care. This means that there are times nurses need to take care of patients and not have to worry about the emotional needs of families. I do agree families’ emotional needs should be addressed but this is best done during visiting hours. Sometimes what nursing encompasses is more than a definition straight out of a book. I agree with restricted visiting times and possibly individual basis because some families cannot handle the stress of an ICU or understand that maybe saving dads life is more important than repositioning him because “he just looks uncomfortable.” I don’t mean to be unsympathetic but the patient is the top priority not bonding with their family members.
Bob – thanks for your comment but try not to be too frustrated with families when they are requesting you help make their loved one comfortable. They recognize that the patient is uncomfortable because they know the pt better than you do – They are stressed and feel helpless in the face of what is going on with their family member. I don’t think the family is aware of how hard you have worked because they have been in the waiting room. If they were present in the room they could have witnessed all the great nursing care you have done. Have some confidence in what you do and don’t take their anxiety as an attack on your nursing abilities by them telling you the patient doesn’t look comfortable.
Sorry Bob but you make the statement. We should deal with the families emotional needs during visiting hours. I can promise you that the family is an emotional wreck during the hours that they can’t visit as well. To bad if we don’t want to deal with it, it is not about the nurse. You can still take care of the patient and if you need them to step out because you need to save dad’s life then have them step out. But don’t fall back on visiting hours as a crutch. I can tell you that families often know when someone looks uncomfortable and usually they are right. So you reposition the patient and if is not a good time to do so because it will not be good for the patient you tell them so. I am sure they can understand when you explain it to them.
Laura, thank you for your comment. I would be interested to know what type of nursing it is you do? There are certain areas of nursing where bonding with families would be appropriate, and maybe even necessary such as hospice nursing or pediatrics. Intensive care is just not always the place to form relationships with family members of critically ill patients. I do believe I even recall from nursing school some teaching on not becoming too emotionally involved in the lives of those you care for. And as far as your statement that “anybody can write down vital signs, hang drips and do physical care for patients,” this is just not true. There is so much more to caring for a critically ill patient than what you have listed. Patients in ICU can often become unstable very quickly, and we are responsible for these patients living (at least until we get off work) so if we are a bit short with family at times and ask them to leave so that we can better care for their loved one or someone else’s than I would hope that they would understand why we couldnt be there to comfort them instead of doing compressions or giving drugs to save someone’s life.
That being said, I am not so cold as not to have some feelings at times for those I care for or the situation their family is in, but I would not treat that family any differently than the patient’s family next door that maybe I didn’t like as much.
I have worked in a level 1 trauma center for 21 years. My specialty is critical
care in a medical respiratory ICU which cares for everything from GI
bleeds,septic shock,overdoses,rabies,cancer,over flow from the 5 other adult
ICU’s . We takest the sickest patient’s in the state.
I believe the more a family member participates in the care of the patient and
are aware of the interventions done at the bedside ,the easier it is for them to
comprehend quality of life issues,pain and suffering and when to switch the care
focus from curative to palliative. Often it is the the family member who shows
up at the end of the efforts made to save the patients life demanding that we
continue while the family member that has been at the bedside is advocating to
stop.
Recently in our unit, the newer nurses have become intolerant of families and
are attempting to change the unit’s open door policy. I have witnessed many new
nurses struggling with their practice and feel uncomfortable with their
knowledge base when answering the questions from families. We are going to have
a training workshop to improve communication with families and help alleviate
the stress nurses are feeling. AACN has advocated for many years now for
families to be more present at the bedside. This is researched based. You
wouldn’t do something contrary to research just because you didn’t think it
was valid…. like head of bed elevation doesn’t prevent pneumonia -research says it does ! – you just
don’t value that research…. You practice based on research. Having families
at the bedside has been researched and the data supports it. I am not
suggesting that families camp out until the patient is transferred out of the
ICU or dies but they need to be present to fully understand what is happening
and to make informed decisions. —- Until you have had a loved one in an ICU
and have been at the mercy of a nurse who doesn’t believe her job is to care for
you as well as the patient you will hold fast to your belief. But I will tell
you that in a crisis you need the nurse who can manage it all. It is possible to
be that type of nurse but the trend is to be more focused on machines and
numbers -not what is under all that technology. There is a person under there
who is attached to the family outside in the waiting room -waiting for you to
let them in for 15 minutes …….
Laura- I’m curious based on your comments (and your experience in a level 1 trauma center) what you think about family members in the shock room? Not just during “low level” shocks, but during hard core, chest-tube placing, chest-cracking shocks as well?
I think that depends on the family member – in most cases I think that it would
be traumatic to see invasive bloody procedures done however we have let family
in during codes along with a nusre to stay at their side to explain what is
going on. Most families don’t want to be present but some are up for the
experience and just want to be present when the patient dies. Of the families
that have been in the room – none have said they wish they hadn’t have been
present but instead saw that we did all we could to save the pts life.
That experience may help them make decisions for the next family member in the
ICU when code status is discussed.
I agree with you that actually seeing a family member undergo a trauma shock might keep them from pursuing aggressive therapy for other ICU bound loved ones in the future, and that in and of itself would be a valuable outcome for society as a whole. I guess one of the reasons I agree with NurseWendy about limiting visiting hours is due to the nature of what I do in an ICU: chest tubes, central lines, paracentesis, pleural taps. None of these procedures are things I feel comfortable performing in front of family members. For the most part, they don’t understand what they’re seeing, they don’t understand that some or all of those can produce a lot of blood or fluids (on the sheets, on the patient, on the nurses….) and that this doesn’t mean it was done incorrectly but is just inherent to the nature of the procedure. To schedule a time when there are no family members present and when nurses are available to assist (instead of explaining to or comforting family members) is most easily done with set – and limited – visiting hours in both the ER and the ICU. Liimited, set visiting times also allows the docs to know when family is likely to be available so we can consent for procedures, explain recent developments or arrange for family meetings. Just my perspective having been both a resident and a trauma/critical care fellow at the third largest level I trauma center in the country
I may be new and idealistic, but I think ICUs should be open. I’ve worked in an open ICU for two years. No real limits on number of visitors, relation (i.e. you can visit even if you’re not family, at the patient’s or family’s discretion) or times unless the nurse’s discretion dictates otherwise.
I don’t know how people can say that family presence is not conducive to healing. Why does ICU psychosis occur? Because of constant unfamiliar stimuli during critical illness. Why would you NOT want most of your patients to experience familiar stimuli? And I really hate when nurses try to limit visits for our not-so-critically ill. I hate to say this, but most of the reasons I see for excluding family from ICU are nurse-centric.
Any nurse should feel confident enough to tell family members or visitors to leave the room for any reason at all, from sterile procedures and codes to bed changes and turns. And any nurse should feel confident enough to tell people to scram if they’re disruptive or not facilitating healing. There are times for peace and quiet during illness. But I don’t think there’s really a place for one-size-fits-all prohibitions on visiting.
Chris – you are a great nurse and you will go far in your career. i hope you never give in to other nurses pressure to not allow families to be present at the bedside. The AACN recommends that families become involved with care and JCAHO also supports patients families being active in the care of patients.I believe that many nurses feel uncomfortable with families being in the room because they don’t feel comfortable with their own practice. When you have integrated care of the patient to include care of the patients family you have gone from novice to expert. I applaud your thinking!!
I recall reading that the average hospitalized patient experiences at least one medication error during the period of hospitalization. Additionally, I find the rate of hospital-acquired infections alarming.
As a result, if I were unfortunate enough to be hospitalized, my significant other and close friends (almost all of whom are either physicians or veterinarians) would be frequent visitors. They wouldn’t be looking to the nursing staff for support. They won’t be asking for information beyond: “what is that you’ve giving now?” And they will not be shy about saying when appropriate, politely: “Could you please wash your hands before you touch her? Thank you.”
Their job is to advocate for me. And I’ll do the same for them. The grandmother of one of my close friends died of a heparin overdose while hospitalized, and she blames herself to this day for not catching the error. My own horse nearly died from a medication error while hospitalized post-surgery; it was only because I was in the stall with him and summoned help (he nearly fell on top of me) that he is still alive. He was at an excellent hospital where care is equal to that provided at any human hospital, by the way. The fact is, however, that errors occur in every hospital, and the loved ones of a hospitalized patient sometimes can be a second pair of eyes for the busy nursing staff.
I would love to say that you’re wrong about medical errors, but sadly I think you’re spot on- there are an enormous number of medical errors every year that contribute to bad outcomes in the hospital. The unfortunate by-product of medicine performed by human beings and not computers.
But having said that, I think non-medically trained family members would be hard-pressed to help eliminate many of these errors. My analogy would be flying in a plane: my life is certainly in the hands of the pilots, but I don’t expect the right to be able to hang out in the cockpit, watching monitors I don’t understand and questioning every decision they make.
But agree 100% with everybody washing their hands more! The easiest, cheapest and truly most effective method of infection prevention around
>>I think non-medically trained family members would be hard-pressed to help eliminate many of these errors.>>
I agree in general, however…
Family members are certainly capable of saying: “Before you administer that dose of drug A, could you please check his medical record? His physician should have noted that he had an allergic reaction to drug A last time it was given. Thanks.”
My non-medically trained husband knows that I am allergic to amoxicillin, for example.
As I mentioned in my first comment, I and most of my closest friends are all veterinarians and physicians. We are indeed capable of catching more errors than the average visitor. Not all errors – but some. Since medication errors can result in death or lasting harm, I think it’s worthwhile to welcome attentive visitors who can act as healthcare advocates for the incapacitated person.
I think we can all agree that visiting hours are good practice but that none of us want them during his/her shift
I’ve worked in many ICUs with all types of visiting policies and I have to say, gulp, that I’m in favor of an open door policy because it actually makes my job easier. Setting specific times is so limiting. They get out of work, “rush” through traffic to get to the ICU before change of shift, wanting a full day’s update in the 3 minutes you have to offer before change of shift and when you don’t have the time to tell them what they want to know, they get angry, complain and ask to speak to “the person in charge” who may have even less time. I’ve found that by having an open door policy takes the defensive “I have a right to be here” attitude out of their hands. They’re much more likely to step out of the room when you ask because they know that they have the freedom to visit whenever it best fits into their schedule. The old “kille em with kindness” routine.
Lipodoc, I’m all for for families being present during certain bedside procedures, PROVIDED that what they are about to witness has been explained AND that a staff member is with them to provide reassurance, explain what they are seeing and (occassionally) pick them off the floor. I am not in favor of family members being present for invasive procedures like chest tube insertion, central lines, chest cracking or any other “hard core” resus. I have allowed family members to be present for intubations, extubations, CPR and terminal vent D/C. Of course, I always give them the choice first (patient condition permitting) after explaining what’s involved.
Having recently been on the other side of the bed while someone I loved was dying, I finally get why so many family and friends never leave the hospital, choosing instead to come in for 5 minutes every hour, staring at the patient as if s/he is an exhibit of some kind. It’s because they don’t know where else to be that feels comfortable or what to do with the energy they have. Since watching my friend die, I have become much more sensitive to this perspective and a little more tolerant of the exhibit watching. It’s impossible, and impractical, to make yourself available to every visitor and I don’t even try. I do, however, identify those closest to the patient and make myself available to them, with limits of course. I’ve also begun arming them with a website, http://www.caringbridge.org, a place where someone can create a profile page for the patient on which they can post medical updates, progress, pictures and have others leave messages. It’s a great place to put some of their energy. Basically I try and innundate the family with as much information up front so they won’t notice that I’m rarely in the room when they are.
If patients were robots then I would agree with you. Since they are human beings I feel visitng hours are very necessary. Many people visit to help their loved ones feel more comfortable and not alone.
When my 78yo Grandmother was in the ICU my grandfather stayed by her side all day, unless I was there to cover for him. They would not let my grandfather or anyone stay overnight with her, which is their policy. I can see why they wouldn’t allow that. The first night she was alone in the room and in the middle of the night she woke up confused and scared and ripped out her IV’s and tried to leave. They ended up using mechanical and chemical restraints on her. The 2nd night she was in the ICU we again asked if myself or my grandfather could stay over night. This time we just quietly spoke with the charge nurse, who agreed that she might have a more peaceful night if she woke up to someone she knows. I stayed the night with her. I didn’t sleep, I just sat with her, held her hand, and smoothed her hair as she did to me when I was a child. She did wake up throughout the night, and each time she did, I told her I was there, and she was safe. That night there was no need for restraint and she slept peacefully. The 3rd night they allowed my grandfather to stay, and he did the same. The 4th night I stayed with her again, and she slept peacefully each night, then the 5th day she left ICU. I can tell you I am so grateful to the nurses who allowed us to stay with her, we did everything we could to stay out of their way and not cause them any more work.
Without a comforting presence I am sure my Grandmother would have had more restraints, or the hospital might have had to provide her a 1:1. It was a good solution for my Grandmother, the nurses (as they hated having to restrain her) and our family.
Please let’s not forget that family members can be an encouraging presence who provide love and comfort for a sick person.
Sarah, I can understand your wish to stay with your grandmother, and there are times when exceptions are made…but it is just not something we can do for every patient. This is why I see it as unfair to allow some family members of patients to stay and not others. The ICU is just not a place where it is feasible to have that many extra people in rooms when critical care is being performed daily. During shift report and really at any other time there could be confidential patient information being discussed by the nurses. We do try to protect this information and is one reason we do not allow any visitors in any rooms during report.
nursewendy
I am a social worker so I understand HIPPA, but having worked on an inpatient psych unit I can say that there are ways to protect HIPPA while being flexible and allowing for visitors. I know the ICU is a different animal altogether, but there are unique challenges in both settings. We had guidelines about visits, but we made exceptions when it was indicated for the health of our patients. Visitors made our jobs much harder, having visitors and trying to protect HIPPA meant we had to change the way we did some things. Still on the psych unit we understood that visits were important for the well being of our patients, so we worked harder.
That’s the part we must disagree upon I suppose. Loved ones being by their side helps people heal. I know that to be true, from my experience in my work, as well as my personal life. It was not for my own well-being that I stayed nights at the ICU, it was for my grandmother. Luckily they have single rooms at that ICU, and report is never given in the rooms, so really, violating HIPPA was never a concern.
I hope that one day you see the sense of flexibility, I know it makes things more complicated, and makes your job harder, and I know nurses work awfully hard already. However, if it’s in the best interest of the patient, then I would think it’s worth it.
Great discussion. I am always sad to hear any ICU nurse believing that our jobs are so busy that we can’t step outside and realize that we will probably forget this patient a year from now but the family will sadly remember this forever, especially when the person dies. Wendy you are correct in stating that we can’t let everyone stay the night but we can and should always do it for the ones who need it period. You are also right, what we do is critical and those families know what is at stake as well and need us too. However, it appears that you have an overinflated idea or ego about Critical nursing with respect to the task portion of our job. Setting limits is fine if a family needs that but most just want to be near the person they love. It has been my exerience that nurses who want to keep famililies at a distance either have not acquired the skills to help ICU families because they have only been an ICU nurse for a few years. Trust me you will need those skills whatever advanced degree you get. Yes, it usually take more than five to be able to take care of any ICU patient and the family at the same time for 12 hours. So having said that I will place it out ther now. I have been and ICU nurse at a level 1 trauma center for 15 years and I will complete my Masters in Nursing Administration in 3 weeks. I am interested to hear how long it is that you have been a nurse? It is an interesting discussion and one that I have had with many nurses during my career. If you are ever on the other side of the ICU bed and are watching someone you love so much getting worse you really want to be there as much as you can because those may be the last days you get to hold their hand. Until you have lived that you can’t imagine how wonderful it is getting an ICU nurse who wants you there and can still get their job done.
Shannon I completely agree with your statement. You truly have to be on the other side of the bed to understand what its like. I was an ICU nurse for 10 years before obtaining my masters in nursing. I never minded being there for families and being a patient advocate. Its nice to hear there are still caring ICU nurses practicing. If my scoliosis wasnt so bad I would still like to be there for patients on the weekends. There is usually time to get your work done even with a critically ill patient and be there for patients and families. I think some nurses just aren’t confident in there practice at first and there are many new nurses working in ICU’s.
Shannon, I would first like to say that I have always allowed families to be with patients when they are dying. I am not uncaring or as some of you say, “lacking confidence in my skills.” I have been an ICU nurse for about five years now…but I really dont think there is a correlation between years of experience and nurses acceptance of family presence in the units. I know plenty of nurses that have been nursing for 10-15 years who are much more strict than I am. I have been on the other side of the ICU bed, my grandfather died in an ICU. I went to visit him, he was not at the hospital where I work and their rules for visiting were different. They do not have set visiting times, they have the authority to say yes or no to visitors at any time of the day. I respected their right to do so.
It is nice to hear that you have been an ICU nurse in a level 1 trauma center for 15 years and are very close to obtaining your masters degree, but I would like to know why it is you have decided to leave patient care and go into administration? Seems like a nurse with your experience would serve the patient and their families better at the bedside.
Wendy,
I would say that the ICU nurses that you have experienced who have been a nurse a very long time and are harder than you with flexibility when visiting have suffered the same fate that you have and may have not seen nurses practicing with an open visitation frame of mind. We can get set in our ways if we have never seen practice done differently or stop looking at current research. Remember when all patients were supposed to lay flat in the bed? It is just like a new nurse learning how to read a PA cath, you have to see it done and be surrounded by a team who can show you how to do it, to realize how it works and why. Please dont get stuck in the belief that the ICU is so very different and that gives us reason to need more time to get our work done than other areas of nursing. What Palliative care nurses do, floor nurses, oncology and clinic nurses do is all CRITICAL and a lot of work. They have the family present. I dont think any nurse should be given an award for letting family visit when the person is dying I would love to meet the uncaring nurse who would refuse that. You will not get kudos from anyone for making that statment. It is the other times when a patient is not in the process of dying but still very ill, because as you know with your 5 years of experience, those patients that are doing “OK” can be dead in a few hours and nobody saw it coming. Those families would have missed out on the last hours to be with their family. So to answer your question, my Masters is in Nursing Administration and Leadership. I chose that tract because I want to take care of patients by taking care and leading nurses into making professional sound decisions that help them to not get burned. To make hospital policies that remove obstacles that impede nurses from doing their jobs and thus having impact on patients and families. I absoulutely plan on being at the bedside while a Nurse Manager. You can’t lead by example the nurses you are in charge of from your office. I am pretty sure that by doing this I will be able to impact even more patient and family lives.
Every aspect of our patients’ care is individualized…why not the visiting too? Some patients get dialysis, some don’t. It requires communication, compassion and judgment….hard skills to develop but worth all the work it takes.
Sitting in the waiting room are frightedned people whose fear grows the longer you keep them out. You try leaving the one you love most in the hands of strangers who won’t let you in….wait till it’s your mother or your baby.