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Discussion

The benefits and drawbacks of open and restricted visiting hours

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Should all hospitals adopt open visiting hours? This article discusses some of the arguments for and against unrestricted hospital visiting, considering the evidence and the ethical aspects

Abstract

Hospital visiting hours are a contentious issue. The arguments for strictly limiting visits are based mainly on outmoded views of care, while those in favour of open visiting are more in line with the principles of person-centred care. This article discusses some of the arguments for and against unrestricted hospital visiting, considering the evidence and the ethical aspects. It concludes that blanket restrictions on visiting are incompatible with person-centred care, but also that there is a case for applying some restrictions so patients’ interests are protected.

Citation: Ellis P (2018) The benefits and drawbacks of open and restricted visiting hours. Nursing Times [online]; 114: 12, 18-20.

Author: Peter Ellis is registered manager, Whitepost Healthcare, Redhill, and independent nursing consultant, educator and writer.

Introduction

One of the principles of the NHS Constitution is that “NHS services must reflect, and should be coordinated around and tailored to, the needs and preferences of patients, their families and their carers” (Department of Health, 2015). This suggests a system that aspires to deliver care that is person centred rather than provider centred.

Visiting hours remains a contentious issue. Some care facilities (including most hospices, as well as many care and nursing homes) allow visitors at any time. Others – particularly hospitals – have policies that restrict not only visiting times, but also who is allowed to visit and the number of visitors a patient can have at any one time.

There are arguments on both sides. Some claim patients have the right to decide who they see and when, while others defend a clinical prerogative to restrict visits to ensure they do not interfere with clinical activity. Whatever the rights and wrongs of ‘open’ and ‘controlled’ visiting times, it is worth considering why care facilities differ in their approaches, how different practices have developed and what they mean for staff, visitors and, most importantly, patients.

Why restricted visiting?

Historically, visits to patients in hospital were controlled for a variety of reasons, including:

  • Reducing the risk to patients from epidemic diseases, infections and unnecessary stress;
  • Allowing the ward to run smoothly;
  • Protecting patient confidentiality (Ismail and Mulley, 2007).

Such was the power of the matron that she alone would decide what was good for the patients in her care; she could decide to restrict visiting times to one hour a day or even less. Much of this was based on the belief that patients only needed to interact with clinical staff – and that this interaction was, in itself, therapeutic. Today, as there are potential difficulties with unrestricted visiting, many care facilities continue the tradition and restrict visiting times.

A common belief among caregivers is that patients need time in the day to rest. This was reinforced by the well-intentioned and widely adopted practice of protected meal and rest times adopted by many NHS hospitals, although a recent systematic review of the evidence says there is “insufficient evidence for widespread implementation of protected mealtimes in hospitals” (Porter et al, 2017).

Of course, in the hospital setting, especially in wards with bays, the needs of the many might trump the needs of the individual. In these environments, open visiting might mean other patients could be disturbed by noisy visitors or overhear things about other people that they should not. Some visitors might come at unsocial hours and disturb patients who are resting. Some studies of ward ‘quiet times’, which presuppose visiting restrictions, have shown them to be beneficial for some patients (Dennis et al, 2010) and to matter to the vast majority (Maidl et al, 2014). There are also instances when some patients may feel they have to entertain their visitors when, in fact, they are tired or in pain and want to be left in peace (Cooper et al, 2008). This creates a conundrum for nurses wanting to advocate for patients while not wishing to appear rude.

Having visitors at the bedside may mean staff feel they cannot disturb the patient and, therefore, cannot attend to tasks such as washing or changing dressings. This may cause anxiety among staff, and some may actively discourage relatives and friends from participating in the delivery of care, which they consider their job.

Visitors are also regarded as a potential source of infection (Birnbach et al, 2015) and cross-infection in the hospital setting. One study shows that external visitors account for almost a quarter of all visits to the bedside (Cohen et al, 2012), while others have shown that the objects visitors carry, such as mobiles phones, are a potential source of infection (Tekerekoglu et al, 2011). These observations add weight to the argument that visiting times to hospital wards should be restricted.

Why open visiting?

It has been apparent for some time that the idea that patients only need to interact with clinical staff to recover is unfounded. There are good reasons to support the notion that friends and family play a huge role in patients’ emotional wellbeing (Dokken et al, 2015) and therefore in their recovery. As we live in a 24-hour economy, potential visitors may work shifts; visiting restrictions – which usually only allow visitors in the afternoon and early part of the evening – will prohibit them from coming. This equates to putting a system’s needs before the needs of patients and relatives. Policies that support open visiting recognise the importance of relationships for patient recovery and are, therefore, arguably, more person centred.

Experience in many settings suggests patients prefer their relatives, or perhaps their close friends, to be involved in washing them, feeding them and helping them mobilise. Family involvement in care has, for many years, been the norm in paediatrics, where open visiting for parents is universal. It is increasingly encouraged in other settings, including intensive care units (Ciufo et al, 2011).

Boltz (2013) suggested many relatives could be involved in guiding professional carers, especially for patients with conditions such as dementia. However, the times of day during which visitors can be the most useful as care providers – in the morning and around mealtimes – are often the times where visits are restricted. There is evidence that open visiting benefits patients when family members are involved in their care. For example, family members present during ward rounds offer new information in almost half of cases (Aronson et al, 2009) and act as a second pair of eyes with respect to the consistency and accuracy of care, as well as patient safety (Maurer et al, 2012). If the majority of care in the UK is delivered in the home by informal carers, why still have rules that preclude this during a hospital stay?

Reporting on their experience of introducing 24-hour visiting at a tertiary acute and rehabilitation hospital, Shulkin et al (2014) noted improvements in the patient and the family experience, as well as the absence of an increase in complaints or security incidents. A fringe benefit of the change was that employees received fewer phone calls from family members asking for updates about their relative – this improved the experience of staff. These findings are replicated in other settings including intensive care (Chapman et al, 2016).

The increased prevalence of single rooms in hospitals can lead to patients becoming isolated, but it also reduces the risk of visitors disturbing other patients (Persson et al, 2015). If all patients have single rooms, open visiting may need to be considered more widely.

Ethical arguments

Health professionals often say their actions are in the patient’s best interests. Benjamin and Curtis (2010) defined two forms of medical decisions: those made in a technical sense and those made in a contextual sense. In the technical sense, patients might benefit from long periods of rest and sleep, as this is most likely to aid their recovery. In the contextual sense (which is concerned with personal preference and exercising autonomy), patients might prefer to have friends and family visit whenever they choose – and this might also be better for them emotionally. In a situation where restricted visiting policies are in place, patients have the chance to rest but miss out on visits. Which interpretation of their best interests should be applied?

Hospitals and care facilities are, by their very nature, social institutions. This means there has to be give and take, with the needs of the many being taken into account – mostly, over and above – the needs of the few. From a utilitarian perspective (as described by Ellis [2017]), when seeking outcomes that benefit as many people as possible, it may seem reasonable to restrict visiting so everyone benefits from peace and quiet. But – and this is an important but – the outcome of such a policy is an unknown. We do not know that restricted visiting does not negatively affect more people than it benefits; we do not know that the joy of being visited does not outweigh a little lost quiet; we do not know that less restrictive visiting does not increase care quality and patient safety.

The notion of open visiting does, at first glance, look to be something of a ‘free for all’, with families and friends coming and going all day and all night, disturbing patients. This may well happen but is likely to be limited to a few cases. Visitors have lives too and most will need to go home to eat and sleep. The majority of visitors are, in fact, sensible about their own needs as well as those of the person they are visiting and other patients.

Some studies, such as that by Cooper et al (2008), suggested that open visiting needs to be tempered with caveats allowing patients to rest as and when they need. This means there is a role for nursing staff to play in advocating for patients who need their visitors to sit quietly – or even to leave.

Conclusion

Restricted visiting is a relic of a bygone era. Hospitals are not prisons, patients are not inmates. Visiting restrictions are anathema to the principles of person-centred care and, where still in place, they need to be reconsidered. The scenarios in Box 1 illustrate why person-centred care goes hand in hand with open visiting. The failure of care staff to understand the important role family members can play in the care of a loved one in a care setting and their active negativity toward visitors is the antithesis of person-centred care. In both cases highlighted in Box 1, asking what the patient wanted would have been the person-centred thing to do, would have increased patient and visitor happiness and, arguably, would also benefit the staff member.

Box 1. Visiting scenarios lacking person-centred care*

Scenario 1
Ann Jenkins had driven for several hours to visit her father, Ray, who was terminally ill, in hospital. Just after she arrived, Steve, a care assistant, approached Mr Jenkins’ bed and asked her to leave, as he was about to wash Ray. Ms Jenkins refused, saying “Come back later please. I’ve just arrived and it is visiting time”. Steve mumbled something and left. Mr Jenkins was not washed that day.

Scenario 2
June Wilson slipped on ice while out walking. She was taken to hospital in an ambulance and found to have a complicated fracture of the ankle. She was rushed to the operating room at 2pm. Her husband Paul, who was with her when she fell, did not manage to get to the hospital before she was taken into theatre. The surgery took several hours and, at 10pm, Mrs Wilson was admitted to the ward directly from the recovery room. Her husband wanted to visit her, but was denied access by the staff nurse, who indicated that visiting hours finished at 8pm. Mr Wilson came the next morning within visiting hours and Mrs Wilson asked him if he would help her wash. He asked a nurse for a bowl, having brought everything else he needed with him from home. The nurse replied that he could not wash Mrs Wilson because that was “the nurses’ job”.

* All names have been changed

The arguments against open visiting, for the most part, relate to things modern care providers also need to consign to history: the supremacy of professional carers and a disregard for visitors and family life in general. The risk of infection to the patient from a visitor, except one who is actively unwell, is minimal and, in all likelihood, considerably less than the risk posed by staff failing to wash their hands properly between patient contacts. Open visiting and engagement with visitors to support and lead patient care is the future. It is time for nurses to abandon the notion that they are the providers of care.

If one of the key purposes of nursing is to rehabilitate people so they can go back to their homes and families, it is better that we do not deny them access to their loved ones when they most need them. We need to embrace a new era of family-centred care in which family carers are treated as equals in the delivery of care.

Talking points

  • Many hospitals still restrict visiting hours and the subject remains contentious
  • Both restricted and open visiting policies have benefits and drawbacks
  • Receiving visits improves patients’ emotional wellbeing and helps with their recovery
  • Open visiting enables relatives and friends to play a role as informal carers
  • Open visiting policies may need to be modulated to protect the interests of patients
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