In 2001, the Institute of Medicine’s Crossing the Quality Chasm became the seminal paper recognizing patient-centered care as a crucial component of overall health care quality. Since then, patient and family centered care (PFCC) has been increasingly recognized as a valuable model for improving patient outcomes, facilitating communication, and increasing satisfaction with care. Open and flexible visitation policies are a major component of many PFCC programs and have been widely embraced by hospitals throughout the US  However, the impact of family presence on patients and hospital staff is complex, with varying impacts on patients, family members, and hospital staff.
A substantial body of research has identified positive patient outcomes related to open visitation policies, including rapid recovery times and decreased length of stay. [4,5] Hospital visitors can boost morale, provide comfort and relief for patients in the otherwise cold and sterile environment of the hospital, and supplement the day-to-day care provided by hospital staff. [3,6] Visitors can reduce patient anxiety and delirium in ICU settings.  They can follow up on lab work and imaging that might otherwise go unnoticed. Family advocates can also provide detailed information about the patient and ensure smooth transitions between care teams and hospital units, potentially reducing medical errors. [7,8] Visitors who are engaged in the care of sick loved ones are also better equipped to take over that care once the patient is discharged. Given these findings, it is unsurprising that surveys of patients and family members about open visitation policies and PFCC have received almost universally positive feedback. [4,5]
But visitors also bring potential risks. A friend dropping off a get-well card may serve as an equally effective conduit for the latest flu strain, just as a patient’s visiting daughter may be at a heightened risk for contracting an illness from the hospital milieu (although recent studies suggest that the fear of spreading infection outweighs the reality). [2,9] Patient information may also be transmitted in unwanted ways. In a survey of emergency department patients, while 42% of patients arrived with a relative, less than half desired their health information to be shared with their family members.10 In the post-HIPAA era, noncompliant visitation practices remain a major concern, as many staff members fail to obtain consent prior to sharing health information in the presence of visitors.  The threat to patient privacy is further compounded by the ubiquity of shared rooms.
Equally concerning is the potential negative impact of open visitation policies on hospital staff. A 2011 survey found that many nurses believe flexible visitation policies increase their workload and impede their ability to practice.  As family members demand greater accountability from health care providers, staff members may feel threatened or targeted, challenging nurse and physician wellbeing. Overcrowded rooms can also lead to heightened stress and a decreased ability for staff members to perform necessary procedures.  However, studies suggest that while PFCC policy changes may cause an initial increase in stress for health care providers, these stress levels normalize over time as the new policies become familiar.
Finally, the effect of family presence on physician behavior and clinical decision-making is an unanswered but fascinating question due to the Hawthorne effect, the phenomenon whereby study participants perform better at executing simple tasks when there are other people in the room. In the presence of an observer, one study found an increase in physician compliance with hand hygiene protocols from 29% to 45%.13 A 2017 JAMA Internal Medicine study similarly found a significant decrease in patient mortality during weeks in which the Joint Commission performed unannounced inspections, suggesting that physicians more closely adhere to best practices when they believe they are being observed.  While there are no studies specifically examining the impact of visitors on physician behavior, there is reason to believe that some version of this phenomenon may occur in the presence of hospital visitors. A physician performing a lumbar puncture under the watchful gaze of a patient’s spouse or parent will undoubtedly have heightened focus and attention to detail, consciously or not. Whether any behavior changes would result in positive outcomes, however, remains to be determined.
Open and flexible hospital visitation policies have improved many aspects of patient care in hospitals, including improved clinical outcomes and patient satisfaction with care. However, challenges remain in ensuring that PFCC policies are enacted in judicious and responsible ways. As research continues to accumulate, hospitals and staff will undoubtedly continue to refine the role of hospital visitors in order to best address the needs of patients, family members, physicians, and nurses in providing the best possible care.
Brit Trogen is a 3rd year medical student at NYU School of Medicine
Reviewed by Michael Tanner, MD, Associate Editor, Clinical Correlations
Image courtesy of Wikimedia Commons
1. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press (US); 2001. https://www.ncbi.nlm.nih.gov/pubmed/25057539
2. Smith L, Medves J, Harrison MB, Tranmer J, Waytuck B. The impact of hospital visiting hour policies on pediatric and adult patients and their visitors. JBI Libr Syst Rev. 2009;7(2):38-79. https://www.ncbi.nlm.nih.gov/pubmed/27820226
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