Hospitals are parting with visiting hours as they move toward more patient-centred care

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When Chuck Davis was rushed to Kingston General Hospital in May 2013, the nurses in the intensive-care unit offered his wife something she did not expect – a cot.

Phyllis Davis was surprised because the last time Davis's Type 2 diabetes, low hemoglobin and other health troubles landed him in at KGH, back in 2008, she was not allowed to bed down in his ICU room. When visiting hours ended at 8 p.m., she had to drive an hour to the couple's home in Prince Edward County, where she would fret until her husband's inevitable call.

"He would phone me, totally upset, then I would try to sneak in to see him and see what I could do," she recalled.

"There was angst on his part, on my part. It was not a very nice situation at all."

All that changed in 2010, when KGH followed an increasingly widespread trend in the United States and became one of the first hospitals in Canada to do away with visiting hours, a move at least 20 other hospitals and health-care facilities across the country have since followed and which others are considering.

The open-door approach is one element of a larger move toward putting patients and their families – as opposed to doctors and nurses – at the centre of hospital culture, a shift that "patient engagement" proponents say helps the ill get better faster.

At KGH, signs advertising visiting times and loudspeaker announcements hustling family and friends out the door at 8 p.m. were eliminated and replaced with a "family presence" policy – which, translated from health-care speak, means letting in as many visitors as a patient wants, 24 hours a day, seven days a week.

That idea is as appealing to some as it is repellent to others. Supporters see it as a way to involve families more intimately in their loved ones' healing, while opponents worry that an around-the-clock parade of visitors could spread infectious disease, disrupt other patients and put unnecessary pressure on nurses and security staff.

The Institute for Patient- and Family-Centered Care (IPFCC), the major U.S. organization advocating the end of visiting hours, says those fears have not come to pass in the American hospitals that welcome family and friends day and night.

The Bethesda, Md.-based organization is hosting its first international conference outside the United States, in Vancouver Aug. 6-8, and the group's campaign to end visiting hours is one of the bolder pitches on the agenda.

"Families are less angry when we get rid of these locked doors," said Beverley Johnson, president and CEO of the IPFCC, a non-profit that helps health-care facilities implement pro-patient practices.

Johnson said hospital bosses in the U.S. are warming to the idea of around-the-clock visiting. In 2008 and 2009, about three-quarters of all hospitals and 90 per cent of ICUs in the United States restricted visitors in some fashion, according to a study of 606 hospitals published last year in the journal Critical Care.

A survey conducted this year by the research and education arm of the American Hospital Association found 42 per cent of hospitals in the U.S. reported restrictive-visiting-hour policies, which suggests the open-hours trend has spread over the last six years. (It should be noted, however, that the 2014 survey was not a straight replication of the 2008-2009 study, making it difficult to draw firm conclusions.)

In Canada's fractured provincial health system, nobody is keeping track of the number of hospitals that have done away with visiting hours. But, at least anecdotally, it appears that more are giving it a try. Island Health, the health authority on Vancouver Island, made the change a few years ago; Quinte Health Care, a network of four hospitals in and around Belleville, Ont., announced the end of visiting hours last October; and Providence Health Care, a network of 16 facilities in Vancouver, officially followed suit in December.

Before Providence Health Care's facilities moved to a family-presence policy, the network approached visiting hours in the same ad hoc way that a lot of hospitals do. There was no blanket visiting hours regime, just a patchwork of rules that varied from unit to unit and even shift to shift, depending on the staff on duty.

"You'd get one nurse who worked a night shift who would say, 'Yeah, absolutely, come by whenever you feel like it,' and literally at the next shift, you'd get, 'No, no, no, you have to go home, it's 4 p.m,'" said Shannon Parsons, a nurse who is leading Providence Health's patient-engagement efforts. "It was seen as our – meaning our health-care providers' – space, which you were being invited into."

Shifting that mentality can be challenging, especially for nurses and other frontline workers who are already overburdened.

Linda Haslam-Stroud, the president of the Ontario Nurses' Association, said welcoming visitors all day and night has advantages for patient well-being, but can pose minor headaches for workers, particularly in older hospitals with cramped rooms that hold up to four patients, and in the rare cases when visitors turn violent.

That is nothing her members can't handle, she added – they are already handling crowd control during designated visiting hours.

Leaving it to nurses to exercise their judgment is a cornerstone of the family-presence approach. Common sense is supposed to prevail. All such policies include provisos allowing staff to ask visitors to quiet down or leave if they are bothering other patients in shared rooms, or if neighbouring patients need privacy during sponge baths or when hearing about test results.

The policies also advise sick visitors to stay away, which has helped keep the open-door approach from opening the way for more infectious disease outbreaks linked to guests.

"The data [linking visitors and infectious disease] is simply not there," Johnson, the IPFCC head, said. "That's not where we're getting all these infections in hospitals. We're getting them mainly from staff not washing their hands."

The upside, meanwhile, is that family support can be as practical as it is comforting. Relatives and friends help patients to the bathroom, track their medications and watch how wounds are dressed so they can repeat the procedure when patients are sent home.

For Phyllis Davis, the benefits of around-the-clock visiting hours at KGH could not have been more clear. After Chuck's stint in the critical-care unit, he was transferred to a general medicine floor where he stayed until his death in October 2013 at the age of 66. Phyllis, 65, stayed, too.

"The only time I ever went home was on the weekends, when I would just buzz home quickly, have a shower, do a wash, get clothes for the week and go back again. I wouldn't be away for more than about three or four hours," she said.

When Chuck, her husband of 25 years, died, Phyllis was at his bedside.

"Oh, what a relief to have spent that time with him, to have been there," she recalled, weeping openly. "He kept saying to me, 'Thank you so much for staying. Thank you so much for doing this.' He was such a sweetheart. I said, 'Where else would I be? Where else would I be?'"

Culture has suited doctors and nurses

Eliminating visiting hours is just one part of the push for patient- and family-centred care at North American hospitals. On its face, the campaign might seem unnecessary – who else would be at the centre of a hospital's mission? – but hospital culture has historically suited doctors and nurses more than their patients. Some of the other changes that hospitals are making include:

• Creating patient-and-family advisory councils, whose members weigh in on nearly every decision a hospital makes.
• Asking former patients to help design learning materials and signage for the hospital.
• Inviting patients to sit on hiring panels for hospital staff.
• Hosting town hall-style meetings at which patients and their families can raise concerns about the hospital.