Running head: PERCEPTION OF VISITATION POLICY PRACTICES 1

Perception of Visitation Policy Practices by ICU Patients and Their Families

Jessica Acker, Kenna Majors, Jessica Moore, and Megan Schleigh

King University
PERCEPTION OF VISITATION POLICY PRACTICE 2
Perception of Visitation Policy Practices by Intensive Care Unit Patients and Their Families

Topic and Reason for Concern

An intensive care unit (ICU) admission is a stressful event for the patient and the patient’s

family. Several studies demonstrate symptoms of anxiety, depression, and post-traumatic stress

disorder in family members of patients admitted to ICU (da Silva Ramos, Fumis, Azevedo, &

Schettino, 2013). The role of families in improving ill patients’ conditions is important

(Khaleghparast et al., 2015).

A restrictive policy allows family to visit during certain periods of the day and restricts

the number of visitors per period. An open visitation policy always allows access to family (24

hours), with or without restriction on the number of family members during any given period

(da Silva Ramos et al., 2013).

Some studies recognize that the open visitation policy is related to a reduction in symptoms

of anxiety and depression for the patient and an improvement in family satisfaction. However,

some issues have been presented as barriers for the adoption of that strategy (da Silva Ramos et

al., 2013). There has been significant resistance among nurses to encourage open visitation due to

concern of increased physiologic stress for the patient, interference with the provision of care, and

physical and mental exhaustion of family and friends. These perceptions, though, may not be

always be accurate (Whitton & Pittiglio, 2011). This study will investigate how open visitation

compared to limited visitation hours affects patient outcomes and overall satisfaction and will be

valuable for determining best practice.

Type of Study

This study proposal will be a mixed method that integrates both quantitative and

qualitative data as we believe the problem and purpose of our study will be best addressed by

using both methods (Grove, Burns, & Gray, 2017). A questionnaire was developed to assess
PERCEPTION OF VISITATION POLICY PRACTICE 3
patient and family preferences for visiting hours in the intensive care unit. The instrument that

will be used is a 11-item questionnaire that will ask for specific demographic data, questions

regarding visitation and the last question includes an open-ended question asking the participant

to comment on what could be done, if anything, to improve the visitation policy (Hardin et al.,

2011).

What would be an appropriate research question, problem, and hypothesis?

Research Question: In intensive care unit patients, how does open visitation

compared to limited visitation affect patient outcomes and satisfaction?

be different in each ICU, even in the same facility. The definition of immediate family may not

clear and may not be the patients customized preferences. Patient-centered care is the goal in

most healthcare facilities today; however, regulatory visitation practices still remain in place in

most intensive care units. While a large amount of research has been dedicated to the effects and

outcomes of patient-centered care, there is less known about the effects of limited visitation

hours on patient outcomes and patient satisfaction. Patient families whom may have not

experienced restricted visitation hours in the past may not be fully aware of process

improvements with implementation of open visitation policies (Smith, Medves, Harrison,

Tranmer, & Waytuck, 2009). There is a need for further studies on the impact of open ICU

programs on patient length of stay, infection risk, patient mortality, and mental health of both

visitors and patients.

Hypothesis: Open visitation policies implemented in intensive care units improve both

patient satisfaction and clinical outcomes, while reducing stress. Admission to an intensive care

unit (ICU) is stressful and potentially disrupts the emotional and physical function of the patient

and patient's family. Research studies demonstrate patients admitted to ICU and their family

members often reported symptoms of anxiety, depression, and post-traumatic stress

(Khaleghparst, Joolaee, Ghanbari, Maleki, Peyrovi, & Bahrani, 2016). Some studies recognize

that flexible family visitation hours are related to an unanimous reduction in symptoms of

anxiety and depression. Currently, there is no research available to support negative

physiological impacts of family visits on patients. To the contrary, researchers suggest that open

visiting reduces stress and leads to tranquility and patient rest (Khaleghparst, et al, 2016).

Influencing factors can be due to local factors, lack of hospital policies, and cultural differences.
PERCEPTION OF VISITATION POLICY PRACTICE 5
This mixed-method study is designed to evaluate perceptions of patients and their family

pertaining to ICU flexible family visitation hours.

Some resistance from perceived barriers that exist among healthcare providers in regard

to open ICU visitation policies include: Perceived patient care provisions, increased

physiological stress from patients, hand washing concerns, increase patient care interferences,

physical and mental exhaustion of visitors, as well as patients (Cappellini, Bambi, Lucchini,

Milanesio, 2014), (Hart, Townsend, Ramsey & Mahrle-Henson, 2013). Implementation of

clearly presented visitation guidelines, equal enforcement, and education for discretionary

restriction are essential to decrease staff resistance while improving all parties’ satisfaction. Clear

communication of expectations, and what open visitation policy means, equally important is

educating families about what it doesn’t mean. Increasing flexibility in visiting hour times allows

decreased stress in meeting restricted policy visit times (Venkataraman, Ranganathan, Rajnibala,

Abraham, Rajagopalan, & Ramakrishnan, 2015). One study found that open visitation had a

beneficial effect on 88% of families and decreased anxiety in 65% of families. Flexible visiting

provides areas to improve critically ill patient care and recognizes its importance to families and

patients in their illness recovery (Mitchell & Aitken, 2017).

What would be the intended benefit of conducting such a study (the purpose?)

The purpose of this mixed method study it to explore the effects of open visitation hours

on patients in adult intensive care units globally. The general data supports open visitation and

many hospitals have embraced patient centers care theories that involve families as a partner in

healing (Hart, Townsend, Ramsey & Mahrle-Henson, 2013). The intended benefit for conducting

this study is for improved satisfaction with a successful balance of open visitation, exploring

potential barriers, and to evaluate patient outcomes. Although liberalizing visiting hours many

not be good for every patient, goals should not be universal implementation but patient control to
PERCEPTION OF VISITATION POLICY PRACTICE 6
customize their circumstances in their care. Not all patients wish to have visitors in their

condition or desire to limit specific visitors. An additional intended benefit is for patients to

determine their own visiting hours and clear communication of their wishes should be shared

with families and visitors. This may entail clear presentation of guidelines, equal enforcement of

rules, and staff consideration. Tracking measurable negative effects with individuals can assist

with development of customized patient visiting plans without mitigating or compromising the

open policy plans for the entire unit.

Some alternate potential benefits of this study can evaluate a possible decrease flow of

traffic from the rush of family members who visit the ICU patient during the visitation times in

restricted units. This may decrease visitor anxiety, staff demands, and stress on everyone. Open

visitation should not indicate an automatic contractual obligation to be present all the times.

However, flexibility in open visitation may increase time at the patient’s bedside to better

facilitate communication. This in turn may increase confidence and trust from family members

about the care of their loved one. Reassurance of immediate contact about a patient change in

condition may provide an opportunity and permission for family to leave (Khaleghparst, Joolaee,

Ghanbari, Maleki, Peyrovi, & Bahrani, 2016). Policies guidelines implemented with open

visitation may also decrease interruptions by clearly outlining times when staff are not available

and approximate timelines when providers will be available to answer family questions. These

guidelines may also encourage having a family spokesperson that is present which may decrease

the amount of phone calls made, as well as received throughout the shift.

What theoretical framework would be appropriate for this study?

The Synergy Model for Patient Care of the American Association of Critical-Care Nurses

provided the framework for this study. The model recognizes that patients have specific needs

and possess characteristics that when matched with nurse competencies result in optimal patient
PERCEPTION OF VISITATION POLICY PRACTICE 7
outcomes. This includes understanding the level of resources available, the ability of the family

to participate in care and help with decision making. Meeting the needs of the patient, along with

the family, is needed to restore a patient to an optimal level of wellness (Hardin, Bernhardt-

Tindal, Hart, Stepp, & Henson, 2011).

Our research framework conceptual map, found below, reflects our philosophy that

admission to an intensive care unit is stressful and potentially disrupts the emotional and physical

function of the patient and patient's family. Research studies demonstrate patients admitted to

ICU and their family members often reported symptoms of anxiety, depression, and post-

traumatic stress. Some studies recognize that flexible family visitation hours are related to a

unanimous reduction in symptoms of anxiety and depression (da Silva Ramos et al., 2013).

Literature Review and Knowledge Gap

A review of the literature was done through MEDLINE, CINAHL, PUBMED, and

Wolters Kluwer databases. The following keywords were searched: “visiting,” “visitation,”

“hours,” “ICU,” “policy,” and “intensive care unit.” Inclusion criteria for the review were

original research paper or abstract, articles published in the last 10 years, and English language.
PERCEPTION OF VISITATION POLICY PRACTICE 8
The knowledge gap that we found during research was that most of the data was from a nurses’

perspective, rather than a patient or family member.

Survey Sample

Our convenience sample will include our target population of intensive care unit patients

or their family member at a local hospital. The data will be collected over a 12-month period

from June 2019 to June 2020 or until a minimum of 300 or a maximum of 600 questionnaires

have been completed. A convenience sample of patients will be based on their admittance to any

of the four intensive care units at the hospital. Inclusion criteria will include anyone ≥ 18 years

old and without intellectual disability (Hardin et al., 2011).

Collection of Data and Data Analysis

Upon discharge from intensive care, patients or their family, will be asked by nursing staff

to consent to the study and then complete the short questionnaire based on their experiences with

the current visitation policy. The questionnaire will take approximately 5 minutes to answer. All

shifts will have a questionnaire available to distribute (Hardin et al., 2011).

The data will be entered to a spreadsheet and analyzed with Statistical Package Analysis

Software (Bates, n. d.). Analysis of quantitative data will identify frequencies, percentages,

means, and medians. Correlational statistics will be analyzed to identify relationships between

variables. Qualitative comments will be analyzed utilizing content analysis to identify

categories of responses (Hardin et al., 2011).

Study Approval

Under FDA regulations, an Intuitional Review Board (IRB) is an appropriately constituted

group that has been formally designated to review and monitor biomedical research involving

human subjects. In accordance with FDA regulations, an IRB has the authority to approve,

require modifications in (to secure approval), or disapprove research (HHS, 2018). The IRB
PERCEPTION OF VISITATION POLICY PRACTICE 9
proposal for this study has been submitted and we have received IRB approval or IRB

submission is being prepared or IRB protocol has already been submitted and is pending at the

time of grant application.

Ethical Concerns

Subjects will be allowed to freely participate in this study if they choose. Consent for study

participation is made clear and participants will be informed that their decision to participate in

the study will not influence patient care.

There will be minimal risk for patients included in this study. The participants will not

receive any benefits or incentives to participate. All participants will be assured of their

confidentiality (Hardin et al., 2011). We will maintain the patients’ names, contact information

and all protected health information (PHI) in an encrypted computer database or all PHI

identifiers will be removed in the database during data analysis. Patient identifiers will not be

used. None of the samples will be linked to the patient’ names or contact information directly.

The identifiers that link to PHI will be secured in a locked file cabinet. The computer laptops

containing patient data will be encrypted. The database will be in Redcap or other data storage

medium (Burns, n. d.).

Where would this study be conducted?

The hospital where the data will be collected is a 609-bed Level-1 Trauma center in East

Tennessee that serves Knox County and 21 surrounding counties. The units that will be surveyed

include Trauma-Surgical ICU (23 bed), Neuro Critical Care (16 bed), Medical Critical Care (20

bed), and Cardiovascular ICU (24 bed) (The University of Tennessee Medical Center, n. d.).

Who should be involved in the study (from a nursing standpoint?)

Many nurses have discussed frustrations with open visitation policies due to increased

time demands, frequency of interruptions, family demands, and time requirements. Yet many

nurses also appreciated the holistic nature of open visitation that improved family

communication. Nurses transition to family-centered care recognize benefits for families but also

can experience how changes create new challenges for the delivery of nursing care in intensive

care units (Coats, et al, 2018).

The study will seek participants who have experienced and are knowledgeable about the
PERCEPTION OF VISITATION POLICY PRACTICE 11
culture of intensive care units visiting hour polices, effects on patient outcomes and satisfaction.

Participants include employees, patients, and families of intensive care units. Employees should

also include the entire team that participates in caring for ICU patients, such as: providers,

nurses, nursing assistants, physical therapists, speech therapists, occupation therapists, and

respiratory therapists (ASAHP, 2018). The selection of participants is nonrandom but not totally

specified in terms of characteristics (Shantikumar, 2018).

Elimination of even minimal restrictions on visitation hours improved family satisfaction

and improved nurses’ perceptions of family satisfaction with the visitation policy. However,

nurses’ satisfaction did not change. These findings support open and patient-centered visitation

guidelines in critical care settings but require additional measures to include improvement of

nurses’ satisfaction (Chapman, Collingride, Mitchell, Wright, Hopkins, 2016). Approximately

92% of nurses believe that effects of the visit are dependent on both patients and their relatives

(Athanasiou, Papathanassoglou, Patiraki, McCarthy, & Giannakopoulou, 2014). Additional

involvement in this study should include inquires to nursing staff about existing guidelines and

equal enforcement for appropriate evaluation of successful balance of open visitation policies.

What resources would be needed to conduct such a study?

Resources will include a questionnaire for intensive care unit patients, families, and staff

addressing how open visitation compared to limited visitation affects patient outcomes and

satisfaction. Use of informed consent for participation of the purpose of the research study will

be used to ethically inform participants about disclosures and study approval from the IRB. A

disclosure would be needed to inform participants that findings will be used for influence of best

practice and protocol changes to benefit patients and families. The disclosure will also need to

state that confidential results may be posted in academic journals.

Funding and Expenses

Charles Center serves as a primary resource for funding undergraduate and graduate student

research throughout the academic year (Charles Center, n. d.). A grant would help assist us with

expenses directly related to the conduct of research and any other unexpected expenses. We

expect to spend the following:

Laptop: $1099.00 (Dell, 2019)

JMP Statistical Software: $1,785.00 (JMP Statistical Discovery, n. d.)

Printer: $279.98 (Sam’s Club, 2019)

Paper: $32.98 (Sam’s Club)

Ink: $111.96 (Sam’s Club, 2019)

Pens: $21.13 (Sam’s Club, 2019)

Filing Cabinet: $139.98 (Sam’s Club, 2019)

Shredder: $79.98 (Sam’s Club, 2019)

Microsoft Office 2019: $49.99 (Software Pro World, 2018)

Our total expected expenses are $3,550.01. The total budget for the entire completed study should not

exceed $5,500.00.
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