Fair is Fair: Preventing the Misuse of Visiting Hours to Reduce Inequities

The experience of healthcare as a social activity feels very different when viewed from the perspectives of the patient, their relatives, or the healthcare staff. The patient is the centre of attention, but profoundly dependent; the relatives are independent, but unempowered and on foreign ground; and the staff are on home territory and authoritative. These unequal relationships come into sharp focus in the emotionally charged context of critical illness and the Intensive Care Unit. Which of us would not want our family to be near to us and supported by the staff in such a situation? And yet surveys repeatedly show that there is wide variation between countries in national policies, that restrictive visiting is common in practice, and that there is wide variation between ICUs in how those policies are applied.[1-3] Why should this be so?

When patients are asked, they express a strong preference to be visited by their relatives.[4] Involvement of relatives in their loved one’s care has been linked to improved outcomes in a number of conditions, including stroke.[5] [6] However, nursing staff attitudes to visiting [7] reveal concerns about the additional workload involved in caring for and communicating with relatives, and that their presence by the bedside might impede delivery of care, adversely affect infection control, or result in exhaustion of family members. Deeper enquiry might well reveal a lack of empathy and professional confidence: anxiety about being constantly observed by family members, or that lapses in care might result in criticism.

Netzer and Iwashyna take a social justice perspective to argue that this is wrong, and that ICUs should implement current national best practice guidance by making open visiting for families the default,[8] thereby avoiding selection bias in permitting or restricting access. The authors argue that excluding families from their relative’s care can impact negatively on both the patient and relative. The visiting hours offered to relatives may be misaligned with their working hours, creating a further obstacle for those with less flexibility and support from their employer, especially in a society where zero hour contracts are more common.

Moreover, staff discretion to vary these restrictions creates opportunities for conscious or unconscious selection bias. The authors describe a personal experience in which visiting hours reinforced the racial inequalities seen in US healthcare. Such biases might also affect other minorities such as same-sex couples, or transgender communities. Training in equality and diversity organised by NHS Trusts might minimise conscious bias, but the fact remains that while restricted visiting is the default, discretion increases the opportunity for social discrimination.

In considering an open visiting policy, attention must be paid to the potential negatives this may pose. Organisations will be conscious of staff limitations and resources, and the potential for abusive/disruptive family members. Ethnic minority or migrant families bring with them different cultural norms and behaviours which may impact adversely on the family members of indigenous patients. Implementation of open visiting would need to include contingencies to cope with such events as they occur, an example being training staff to have the necessary skills and behaviours to deal with such situations. We are working on this as part of the HS&DR-funded PEARL Project (Patient Experience And Reflective Learning), which also includes interventions designed to maximise empathy.[9] Ultimately, the level of involvement of relatives in their family members’ care should be a decision made by the patient and the family and supported by professionally confident and compassionate staff.

— Olivia Brookes, PEARL Project Manager;
— Prof Julian Bion, PEARL Chief Investigator, Professor of Intensive Care Medicine

References:

  1. Liu V, Read JL, Scruth E, Cheng E. Visitation policies and practices in US ICUs. Crit Care. 2013; 17(2):R71.
  2. Giannini A, Miccinesi G, Leoncino S. Visiting policies in Italian intensive care units: a nationwide survey. Intensive Care Med. 2008; 34(7):1256-62.
  3. Greisen G, Mirante N, Haumont D, Pierrat V, Pallás-Alonso CR, Warren I, Smit BJ, Westrup B, Sizun J, Maraschini A, Cuttini M; ESF Network. Parents, siblings and grandparents in the Neonatal Intensive Care Unit. A survey of policies in eight European countries. Acta Paediatr. 2009 Nov;98(11):1744-50.
  4. Wu C, Melnikow J, Dinh T, Holmes JF, Gaona SD, Bottyan T, Paterniti D, Nishijima DK. Patient Admission Preferences and Perceptions. West J Emerg Med. 2015; 16(5):707-14.
  5. Inouye SK, Bogardus ST, Jr., Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. New Engl J Med. 1999; 340(9):669-76.
  6. Tsouna-Hadjis E, Vemmos KN, Zakopoulos N, Stamatelopoulos S. First-stroke recovery process: the role of family social support. Arch Phys Med Rehabil. 2000; 81(7): 881-7.
  7. Berti D, Ferdinande P, Moons P. Beliefs and attitudes of intensive care nurses toward visits and open visiting policy. Intensive Care Med. 2007; 33(6): 1060-5.
  8. Netzer G, Iwashyna TJ. Fair is Fair: Preventing the Misuse of Visiting Hours to Reduce Inequities. Ann Am Thorac Soc. 2017.
  9. Teding van Berkhout E, Malouff JM. The efficacy of empathy training: A meta-analysis of randomized controlled trials. J Couns Psychol. 2016; 63(1):32-41.
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One thought on “Fair is Fair: Preventing the Misuse of Visiting Hours to Reduce Inequities”

  1. I was shocked by the comment in your otherwise excellent piece on ITU visiting that “Ethnic minority or migrant families bring with them different cultural norms and behaviours which may impact adversely on the family members of indigenous patients.”

    Isn’t this an example of the very thing you commented on earlier – i.e. bias (or even ‘institutional’ racism)?

    Why did you not say “Dominant culture families (whether by class/ education/ race) bring with them cultural norms and behaviours that may impact adversely on the family members of ethnic minority or migrant patients” – maybe we need to think about mechanisms that explain the inverse care law?

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