Wong Yin Yin Adv Dip (Med Surg), BHSc, Chow Wei Ven Adv
Dip (Med Surg),1 Lee Yean Adv Dip (Med Surg), BHSc 2
Infection Control Unit, SGH
1 Ward 45 (Respiratory and Critical Care Medicine), SGH
2 Ward 74 (Neurology), SGH
ABSTRACT
Background. Patients and nurses have different preferences regarding
visitation policy in a hospital. Family and patients seemed more dissatisfied
with the current visitation policy i.e. restricted visitation in the local
hospital while more nurses actually favoured the current visitation policy.
Traditionally, nurses believe that open visitation is actually harmful to
critically ill patients. Although literature reviews support open visitation,
few studies have been done on how to implement and measure changes in
visitation policy.
Methods. A quantitative descriptive study was conducted to explore the
views of both nurses and patients on visitation policies in the Singapore
General Hospital. It was a convenience sample where 145 registered nurses and
145 patients were selected from the hospital’s medical-surgical wards. A
32-item questionnaire was administered to the patients while a 33-item
questionnaire was administered to the nurses.
Results. Nurses and patients had different perceptions and preferences
regarding visitation policy. While 83% of nurses indicated preference for
restricted visitation policy, 66% of patients preferred open visitation.
Workload was found to be an important factor influencing nurses’ perception of
open visitation.
Conclusion. A flexible visitation that addresses both nurses’ and
patients’ concerns is needed to benefit both parties.
Keywords: nurses’ views, patients’ views, visitation policy
INTRODUCTION
Currently, most public hospitals in Singapore have a restricted
visitation policy under which visitors have to abide by designated visiting
hours i.e. 12 to 2pm and 5 to 8pm.
Restricted visitation, which refers to limiting the number of
visitors and visiting hours, often makes a patient vulnerable to anxiety due to
the reduced level of emotional support from family members.
Studies have shown that medical-surgical patients with
psychological problems have longer stays. Altering visiting hours to meet the
needs of these patients and their families not only enhances their
psychological well-being, but also helps to reduce healthcare costs.1
However, open visitation is still not widely practiced in local hospitals.
Open visitation and constant enquiries from relatives on the
patients’ condition raises nurses’ concern about disruption to their work.2
In addition, inadequate staffing often leads to nurses’ having to take on
multiple roles at work.3
Research on open visitation has however shown the beneficial
effect of family involvement in the care of patients.1,4,5 Hence a
descriptive study was conducted in a local hospital over 2 weeks to identify
patients’ and nurses’ perceptions of open versus restricted visitation in the
medical-surgical wards. The findings of the study could provide useful
information should the hospital review its visitation policy and help improve
patient satisfaction.
METHODS
Research Questions
-
What are the nurses’ and patients’ perceptions and preferences
on restricted and open visitation in medical-surgical wards?
-
What are the factors contributing to patients’ and nurses’
preference?
Research Design
A quantative descriptive study was conducted between 12 April to
20 June 2004 in medical-surgical wards of the Singapore General Hospital (SGH)
to explore the views of patients and nurses on visitation policy. There were
multiple variables, which were each distinctively described to enhance the
participant’s understanding.
Sampling
Registered Nurses (RNs) with more than one year of working
experience in medical-surgical wards were included. Seven to eight registered
nurses were conveniently sampled from the 20 wards based on 10% of the RN
population in SGH. RNs on the permanent night shift or working on part-time
basis at the time of study were excluded.
All English literate patients above 18 years of age who did not
have underlying mental conditions and who were admitted to either a B2 or C
class ward for at least 3 days were included. Patients who were confused,
demented, in pain or clinically unstable were excluded.
The Finite Population Multiplier formula was used to calculate
the sample size based on 5% of the nurse and patient population. This formula
was chosen as it gave a confidence level of 95%, accepted 5% margin of error
and attrition rate of 5 to 10%.
Instruments
A 32-item structured questionnaire and a 33-item questionnaire
were administered to patients and nurses respectively (Appendices 1 and 2).
Open visitation was defined as no restriction to the number of visitors and
visiting hours. Restricted visitation was defined as limiting the number of
visitors and visiting hours per hospital. Prior to the actual study, a pilot
study was conducted on 5 RNs to test the content validity of the questionnaire.
A validity test was not run using SPSS as 5 RNs were chosen to test for content
validity. Ambiguous or unclear questions were dealt with through feedback from
the 5 RNs.
Appendix
1. Patient’s questionnaire.
Appendix
2. Nurse’s questionnaire.
Data Collection Methods
Questionnaires were administered to the nurses in a designated
room in the ward. The principal investigator and collaborators were present to
answer any queries from the nurses and collect the questionnaires at the end of
session. Alternatively, the researchers approached the ward managers to assist
in distributing the questionnaires to the nurses. Questionnaires were then
collected from the ward managers one week later.
Patients were selected from the ward census list and those who
met the inclusion criteria were invited to participate in the study. After
written consent was obtained, they were briefed and the questionnaires were
collected by the end of the day. The principal investigator and the
collaborators were available to assist patients in completing the questionnaire
if needed.
Ethical Considerations
Prior to commencement of the study, approval had been obtained
from the SGH IRB/Ethics Committee. Subjects’ participation was strictly
voluntary. There was no personal risk or benefit in participation and subjects
could withdraw at any time without any penalty or compromised care to them.
Written consent was obtained from the subjects. Confidentiality and anonymity
were maintained since names of the subjects were not necessary as no follow-up
was required.
Data Analysis
Findings were reported as group data. All statistical analyses
were carried out using SPSS Version 11.0. Analysis was done using descriptive
statistics, frequency distribution and chi-square. Statistical significance was
set as p<0.05.
RESULTS
Questionnaires were given to 145 nurses and 145 patients in
medical-surgical wards. A total to 120 (response rate=83%) and 140 (response
rate=97%) questionnaires were collected from nurses and patients, respectively.
Questionnaires, which were either incomplete or not returned to the
researchers, were not included in the study.
Table 1 presents the demographic profile of the subjects.
Table
1. Demographic data of respondents.
There was a significant difference in the perceptions on
restricted visitation (p< 0.05). These could be seen in statements 1, 2, 4,
5, 6 and 9 of Table 2.
Table
2. Respondents’ perceptions of restricted visitation.
No significant differences were found in most of the statements
between the 2 groups (p>0.05) (Table 3). However, there was a significant
difference seen in statement 5 (p <0.05). There were vast differences in
patients’ and nurses’ preferences in the type of visitation (Table 4). There
were no significant differences between the 2 groups.
Table
3. Respondents’ perceptions of open visitation.
Table
4. Respondents’ preference on the type of visitation.
Among nurses who preferred restricted visitation, 30% (n=30)
ranked "Restricted visitation aids nurses in providing quality care to patient"
as the most important reason for their preference, while 24% ranked "Restricted
visitation helps nurses to organise work better" as the most important reason
(Table 5).
Table
5. Statements of importance to nurses on open and restricted visitation.
Among nurses who preferred open visitation, 20% (n =4) ranked
"Open visitation reduces nurses’ workload if family members participate in the
care of patients" as the most important reason for their preference, while 15%
(n=3) ranked "Open visitation enhances nurses’ interpersonal skills" as the
most important reason.
DISCUSSION
Visiting privileges in hospitals have tended to be rigid as
administrators and nurses believe that open visitation affects patients
adversely and disrupts the delivery of care.6 Despite evidence
showing the benefits of open visitation, nurses still impose restricted
visitation at their own discretion.7 From the nurses’ point
of view, open visitation often takes up more of their time, leading to
difficulty in providing nursing care.5
The time spent by nurses attending to enquiries from patients’
families often makes them feel that visitors disrupt their delivery of patient
care.8 Lack of time and limited ability in handling some family
situations whilst maintaining control over visitors as well as patients causes
stress among nurses.4 Taylor et al found that nurses felt
stressed by the constant interruption by patients’ relatives and telephone and
working in a noisy environment.3 Therefore, restricting visitation
gives nurses a break from the constant presence of visitors.7 Nurses
who have been working in the traditional setting are initially reluctant to
accept the change in restricted visitation. In addition, nurses have to
repeatedly answer the same questions as visitors often call throughout the day
to ask about their loved one’s condition.9
Hospital visitation rules are often designed for the staff’s
convenience rather than with the patients’ needs in mind.6 A study
by Whitis showed that 54% of nurses determined the visiting rules and
regulations.10 Nursing managers cited reasons, such as the patients’
need to rest or patients showing physiological changes, for restricting
visiting hours to between 10 to 14 hours. Regulating visiting hours eventfully
helps to protect the rights of the patients and ensure privacy for their
roommates.6
Studies have shown that family members play an important role in
patient care.1,4 Daniels cites a case of a stroke patient whose
garbled words could only be understood by his wife.9 She was able to
help keep her husband calm and provide the information on what her husband
needed when the nurses could not comprehend him with ease.
Holl studied the psychological importance of well-being of
patients and family members who had been assigned to either a restricted
visitation group or a Role-Modeled group.1 The restricted visitation
group was entitled to 20 minutes of visiting time 4 times a day while the
Role-Modeled group had the same visiting hours plus extra time which was
acceptable to both patients and their family members. The results of this study
showed that Role-Modeled visiting increased patients’ perception of family
social support and helped to control and decrease their anxiety.
A study by Hupcey suggests that family integration is equally
important to both nurses and patients.4 An interview with 11
relatives, 10 intensive care unit (ICU) nurses and 30 ICU patients revealed
that nurses often felt the need to protect the patients first, while family
members often thought that patients were in stressful situations when many
processes were occurring simultaneously. Although this study was more in-depth,
no data analysis or reports on the results have been published.
Open visitation can have different meanings among nurses and
this creates inconsistencies. A study by Livesay found that "open visiting
hours" was understood to mean different things, from "open to visit with the
patient at any and all times" to "flexible and patient-specific".11 Some
had indicated allowing only 2 visitors at a time; length of visits at the
nurse’s discretion and so on. This leads to frustration among patients,
visitors and nurses themselves, causing the relationship between nurse and
visitor to become adversarial.
These studies appear to show that open visitation is more
advantageous than restricted visitation. However, these studies were conducted
in either smaller hospitals or ICUs. The small sample size therefore limits
generalisation of the findings to all patients and nurses.
The results of our study support those of the study by Taylor
that nurses prefer restricted visitation.3 In the Taylor study,
nurse satisfaction mean score remained consistent throughout restricted
visitation.
Hupcey found that patients preferred to be taken care of by
their family members when they were sick.4 However, our study found
that family members were less likely to participate in patient care (P value
<0.001).
In our study, patients stated that they felt less anxious when
family members were present (P value <0.03). This supports the findings of
the Hupcey study, which showed that patients felt protected and safe when their
families were present.4
Workload was found to be the most important factor influencing
nurses’ perception towards open visitation. This is supported by the Whitis
study, which found that workload was the determining factor in influencing
nurses’ planning of patient care.10
An initial study by Roland et al on restricted visitation
showed that 65% of patients felt that more open visitation was desirable.12
These
results are congruent with those of our study. A pilot
study by Roland In our study, the majority of nurses (83%) appeared to prefer
restricted visitation. For patients however, family support was an important
factor.
Some of the questionnaires were incomplete and had to be
discarded, which inevitably affected the sample size. Patients also found some
of the words used in the questionnaire to be difficult to understand. This
would have affected the validity of the findings as patients may have
misinterpreted the questions and provided inaccurate responses.
Selecting patients who met the inclusion criteria was difficult,
especially when the ward staff was busy and not able to help the researchers
gain access to the ward census. As a result, some patients may have been missed
out, thus introducing a selection bias. The questionnaire, which was in English
only, also introduced a selection bias as patients who were not English
literate were not included.
This study confirmed that there are some differences in nurses’
and patients’ perceptions and preferences with regard to type of visitation
policy. The results showed that 83% of nurses generally preferred restricted
visitation, while 66% of patients preferred open visitation. This should be
considered when hospitals plan to implement any new policy on visiting hours.
In order to provide a patient-centric care, nurses should
explore different ways to involve family members in the care of patients during
visitation that will benefit both patients and nurses.
A creative visitation policy benefits all parties in the long
run. In difficult situations, flexibility in visitation policies can be
beneficial. Future studies can be conducted using a larger random sample size
over a longer period of time to address the study’s limitations. It will also
be beneficial to involve more hospitals in the study in order to facilitate
generalisation of findings.
We wish to express our deepest appreciation to the following for
their help in this study: Png Hong Hock (Assistant Director, Nursing), Kaldip
Kaur (Assistant Director, Nursing), Tracy Carol Ayre (Assistant Director,
Nursing), Ng Hong Eng (Ward 45), Susan Loh (Ward 74), Ng Kim Sim (Infection
Control Unit), Lee Lai Chee (Infection Control Unit), Goh Sau Mui (Nanyang
Polytechnic), Norwati Bte Hussin (Advanced Diploma in Medical-Surgical 2003),
Tng Bee Lan (Advanced Diploma in Medical-Surgical 2003), Cheong Lai Kam
(Advanced Diploma in Medical-Surgical 2003), Henie Artates Marilla (Advanced
Diploma in Medical-Surgical 2003), and Clara Tai (Quality Management).