In an attempt to provide patient-centred care, Derby Hospitals NHS Foundation Trust implemented an open visiting policy.
- This article has been double-blind peer reviewed
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VOL: 101, ISSUE: 27, PAGE NO: 38
Judith Tanner, PhD, MPhil, BN, is lead for nursing, research, Derby Hospitals NHS Foundation Trust
Aim: To obtain the views of patients, visitors and nursing staff regarding visiting hours.
Method: Questionnaires, collecting qualitative and quantitative data, were distributed on each of the trust’s 35 inpatient adult wards. A total of 863 completed questionnaires were returned - 432 from nursing staff, 227 from patients and 204 from visitors.
- None of the three groups of respondents preferred completely open visiting;
- Patients and visitors preferred open visiting with a quiet hour;
- Nursing staff preferred set visiting hours;
- One-third of patients were embarrassed about receiving nursing care in front of visitors;
- One-third of patients, visitors and staff did not like visitors to be present at mealtimes.
Conclusion: Nurses, patients and visitors did not prefer open visiting as first choice, preferring to have a rest period. This highlights the need to consult with service users.
Open visiting is considered to be a positive intervention (Clarke, 2000) that improves the quality of care by allowing visitors access to wards at any time. In an attempt to provide patient-centred care, Derby Hospitals NHS Foundation Trust implemented an open visiting policy.
However, informal feedback, predominantly from nurses, raised some concerns about open visiting. A study was therefore commissioned to obtain the views of patients, visitors and nursing staff regarding visiting.
More accessible patterns of visiting have been introduced to hospitals over the past 30 years. The impetus for this change was the move towards a patient-centred philosophy of care (Hoban, 2004; Bradley, 2001). Open visiting is considered to improve the quality of care for patients and the experience of visitors by allowing visitors access to wards at any time.
A considerable amount of literature discusses visiting policies. Much of this consists of anecdotal and personal opinion (Bates, 2002; McMillan, 1999) but a number of studies have evaluated hospital visiting. Many of these focus on visiting within specialised units, predominantly intensive care units (ICUs) (Carlson et al, 1998; Gonzalez et al, 2004) and on issues involving children (Clarke and Harrison, 2001; Bradley, 2001; Franck and Spencer, 2003).
A small number of studies have evaluated visiting within entire hospital trusts (Hoban, 2004; Anonymous, 2001). However, the findings of this research are conflicting. Hoban (2004) refers to a trust-wide survey of nursing staff and patients carried out at West Suffolk Hospitals NHS Trust in 1997. Nurses were found to want open visiting as they assumed that this was what patients wanted, while the patients surveyed were found to want rest periods. As a result, the trust implemented restricted visiting.
Conversely, 83 per cent of staff surveyed after a move to open visiting at Essex Rivers Healthcare NHS Trust believed it brought benefits and 93 per cent of patients felt open visiting had played a part in their recovery (Anonymous, 2001).
In some trusts, although visiting policies are in place, their implementation can be subject to the discretion of nursing staff. Indeed, surveys of units claiming to operate open visiting policies revealed numerous restrictions in practice (Biley et al, 1993; Plowright, 1996).
There appears to be some resistance among nurses towards open visiting. Some nurses have negative views about visitors, believing they are an intrusion to both themselves and patients (Coughlin, 2002) and one from which patients need to be protected (Plowright, 1998).
Visitors are perceived to cause patients stress and to hamper nursing activities (Bates, 2002). These beliefs have been used to restrict visiting (Chow, 1999), but Johnson (1994) states that these assumptions are based on fears and are not research-based.
Contradicting the assumption that visitors are stressful, a study of patients in an ICU setting found that visiting was not reported to be stressful (Gonzalez et al, 2004). There is some physiological evidence to support this from another study, in which patients’ heart rates were monitored during open visiting and restricted visiting. Heart rates remained lower during open visiting compared with restricted visiting, where there were fluctuations (Schulte et al, 1993).
An interesting theory opposing open visiting in palliative care settings is that control over visiting times gives patients a more general sense of control that helps them to cope with their situation (Thomas, 2001).
The purpose of this study was to obtain information from nursing staff (including health care assistants), patients and visitors on their preferences for visiting times. It was deemed that questionnaires would be the most effective method of generating information from this potentially large group. All 35 adult wards in the trust’s two city-centre acute hospitals were included in the study. Paediatric wards were excluded as there is already a considerable amount of literature exploring visiting in paediatric settings.
Ethical approval was obtained from the local research ethics committee and written approval was given by the trust.
Three different one-page questionnaires were designed, using a combination of tick boxes and free text boxes. The questionnaires were designed for each of the three sample groups (staff, patients and visitors), and were colour-coded in order to make analysis easier.
The questionnaires were piloted among staff, patients and visitors on two wards. Following some amendments, 20 copies of each questionnaire were distributed to each of the 35 wards. The nursing staff were responsible for distributing the questionnaires to patients and visitors. A sealed box was provided for completed questionnaires and these were collected after one week.
The tick-box data was collated using a formic scanning system and the free text was transcribed onto a database. Quantitative data was analysed using descriptive statistics, while qualitative data was grouped into themes.
From the 2,100 distributed, a total of 863 completed questionnaires were returned. Of these, 432 were from nurses and health care assistants - this constituted 65 per cent of the 660 questionnaires distributed to this group. Of the remaining completed questionnaires returned, 227 came from patients and 204 from visitors. It was not possible to determine the response rates for these two groups as it was not known how many questionnaires the nursing staff had been able to distribute.
Preferred visiting policy
Patients and visitors held different views from nursing staff on preferred visiting policy (Table 1, p39). While the largest group of both patients (45 per cent) and visitors (56 per cent) preferred open visiting with a quiet time, nursing staff’s preference was for set visiting hours. This was the option least favoured by patients and visitors.
Visiting during nursing care interventions
A total of 35 per cent of patients reported feeling embarrassed if they had to receive nursing care while visitors were present. In comparison, only 13 per cent of visitors said they found this situation embarrassing. This may put patients in the awkward position of having to ask visitors to leave while they receive nursing care because they do not do so of their own accord. Most nursing staff (84 per cent) found it difficult to give nursing care when visitors were present.
Visiting during mealtimes
This was the only point on which all three groups held similar views. Almost one-third of each did not like having visitors present during mealtimes (patients 45 per cent, visitors 33 per cent and nurses 34 per cent).
Do patients find visitors tiring?
This point was raised frequently in responses from nursing staff. While 95 per cent of nursing staff thought visitors stayed too long, only 35 per cent of patients found their visitors tiring and 30 per cent thought visitors stayed too long.
Maximum visitor numbers at one time
Patients and visitors were in agreement that the maximum number of visitors per patient at one time should be four (39 per cent patients, 38 per cent visitors). Surprisingly, 18 per cent of patients and 18 per cent of visitors thought that there should be no limit. This suggests that patients and visitors may not understand the reasons for limiting numbers of visitors. Perhaps educating visitors and patients may increase compliance.
Nurses were more conservative and felt that two was a more appropriate maximum number of visitors (48 per cent). Table 2, p39, shows the number of visitors preferred by each group.
Visiting start and finishing times
Table 3 shows the preferred starting times for visiting hours. Most patients and visitors (40 per cent patients, 39 per cent visitors) thought 10am appropriate. Nursing staff preferred visiting to start slightly later at 11am (39 per cent).
Table 4 shows the preferred times to end visiting. Nursing staff thought visiting should finish early in the evening, with 69 per cent stating 8pm. (The questionnaire did not give earlier time options, and perhaps some staff may have chosen these if available.) Most visitors and patients felt visiting should end at 8pm or 9pm.
Reasons nurses ask visitors to leave
A total of 67 per cent of nursing staff (280 out of 432) had asked visitors to leave their wards at some time. The most common reasons for asking visitors to leave are shown in Table 5, p41.
Qualitative data: staff attitudes towards visitors and visiting
A large number of nursing staff completed the open-ended section of the questionnaire. This is unusual for a questionnaire and perhaps reflects the strength of feeling on this topic. The following issues emerged from this data and relate to staff attitudes towards visitors and visiting:
- Some nurses felt visitors could be helpful in assisting with patient care;
- If a patient is not settling, having relatives close may help;
- It can be useful to have relatives around when taking a history if the patient is confused.
Conversely, a number of nurses held what appeared to be negative views about visitors. Their main complaints were that visitors ‘get in the way’, ‘are demanding’, ‘do their own thing regardless of the rules’ and ‘treat the wards like a hotel’. Comments included:
- ‘Visitors put ideas into patients’ heads like ‘do you want a bed pan?”;
- ‘We are unable to do our jobs properly with visitors around - they can be very demanding’;
- ‘When you tell visitors there is no visiting between 2pm and 4pm they just come up with some excuse’;
- ‘Visitors do not put chairs away and treat the ward as a hotel’;
- ‘Nurses are treated as waitresses and expected to provide food and drink and clear up after visitors’.
Some valid points about quiet times and visiting during ward rounds were raised. Quiet times were considered beneficial for patients who do not sleep well at night and were also felt to benefit some visitors as they were able to rest and did not feel obliged to remain on the ward. It was also felt that having a quiet time protected patients from a constant stream of visitors.
A large number of nurses felt that visitors should not be present during morning ward rounds as this compromised patient confidentiality. The nurses also said they were busiest in the morning and, if visitors were present, they usually wanted to ask questions that prevented them from carrying out direct patient care activities.
A large number of nurses appreciated that many visitors had other commitments and that they may have travelled long distances to the hospital. Therefore, they felt that they should be flexible about visiting hours. Patients and visitors also cited the need for flexibility.
Many nurses who felt that children accompanying visitors should be restricted, raising the issue of ‘uncontrolled’ children. Perhaps the most extreme example of poorly supervised children was when visiting parents left the ward and patients were expected to take responsibility for them.
It would appear that visiting is an important topic to nursing staff, on which they hold strong views. This is evident from the high response rate to the questionnaire and the unusually large number of free text comments.
Nursing staff in general held different, almost opposing, views about visiting hours from the patients and their visitors. This finding was similar to that of Hoban (2004), who also describes nurses’ views differing from those of staff and visitors.
In this study, the nursing staff favoured restricted visiting and were conservative in their views about visitors and visiting times. They appeared to want visitors to spend as little time on the ward as possible, arriving late in the morning and leaving early in the evening. They did not want visitors present during mealtimes or during nursing care interventions, and wanted the smallest number of visitors per patient.
The patients and visitors had more relaxed views on visiting. They would have allowed visitors onto the ward earlier and allowed them to stay later in the evening than the nurses. They also would have allowed a larger number of visitors per patient on the ward at one time.
However, it must be pointed out that there was a slight difference in the views held by the patients and their visitors on two aspects of visitors’ presence on the ward. Over one-third (35 per cent) of patients reported feeling embarrassed if they had to receive nursing care while visitors were present, compared with only 13 per cent of visitors. Similarly, 45 per cent of patients did not like having visitors present during mealtimes compared with 33 per cent of visitors.
Nursing staff may have been advocating a more restricted visiting policy to protect either their patients or themselves. Indeed, their comments suggest that both these reasons may be valid.
For example, some nurses felt that visitors ‘got in the way’ while some believed that patients needed a quiet environment to be able to rest properly. As in other studies (Plowright, 1998; Chow, 1999), nurses assumed that patients found visitors more tiring than patients actually reported.
The findings reveal that nurses in the trust would wish to be more restrictive about visitors and visiting hours than patients would want. However, they also show that nurses still need to protect patients from any stress in relation to visitors, especially during mealtimes and on occasions when nursing care is being given.
Nurses are often accused of having negative opinions of visitors. This study shows that there is some truth in this within our trust but also suggests that this attitude may not be entirely unjustified. While the nurses in this study did not cite security issues specifically as a concern, a number had been faced with drunk and abusive visitors. This sort of experience is increasingly common and nurses have reported being concerned about their own security when visiting access is more open (Coughlin, 2002).
Perhaps the most surprising finding was that neither patients nor visitors preferred the open visiting option. It had been assumed that this was what they would want, and was the reason why this system had been implemented by the trust.
This finding highlights the need to consult with service users regarding hospital policies that directly affect them. The recent move towards patient councils and patient advice and liaison services (PALS) should help facilitate a forum for discussion, as should conducting research, audits and service evaluations.
At the same time as this study was being conducted a similar questionnaire was distributed at the trust’s maternity unit. Though this was a much smaller study, with only 80 returned questionnaires and an average response rate of 30 per cent, it showed that maternity patients preferred an open visiting policy for their partners and open visiting with a quiet time for other visitors. This suggests that the recommendations based on the findings of this study may only be applicable to adult inpatient wards.
The following recommendations have been generated by taking account of the responses of all three groups included in the study:
- A policy of open visiting with a quiet time should be implemented;
- Visiting during ward rounds or early mornings, when the majority of nursing interventions are carried out, should be discouraged;
- Visiting should be discouraged at mealtimes;
- Patients and visitors should be educated regarding the need to restrict numbers of visitors. Notices should be displayed in appropriate languages;
- Staff should be flexible about visiting times to take account of practical difficulties some visitors may experience in adhering to set times.
It would appear that both users and providers of health care should be consulted to prevent decisions being made on the basis of incorrect assumptions. This study found that nursing staff held different opinions on visiting policies from patients and visitors. Contrary to widely held opinion, nurses, patients and visitors did not prefer open visiting but appreciated a rest period.
- This article has been double-blind peer-reviewed.
For related articles on this subject and links to relevant websites see www.nursingtimes.net