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The Impact of Hospital Visiting Hour Policies on Pediatric and Adult Patients and their Visitors

Background Policies concerning restricted or open visiting hours are being challenged in health care institutions internationally, with no apparent consensus on the appropriateness of the visiting hour policies for pediatric and adult patients. The rules that govern practice are often based on the institutional precedent and assumptions of staff, and may have little or no evidence to support them. Policy and practice related to visiting hours is of pressing concern in Canada, and in Ontario specifically, following the reaction to the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003 and subsequent changes in visiting policies in most health care settings. A systematic investigation of the impact of hospital visiting hours on visitors (including patients, families, and significant others) would inform decision‐makers who are responsible for hospital policies about the best available evidence. Objectives The objective of this review was to appraise and synthesize the best available evidence on the impact of hospital visiting hours on patients and their visitors. Inclusion Criteria Types of participants This review considered studies that included both pediatric and adult hospital patients and their visitors. Participants were either patients, visitors, or health care providers in the following hospital settings: medical/surgical units, critical care (ICU, CCU, NICU), pediatrics, maternity, or general hospital wards. Articles were excluded if participants came from the following settings: post‐operative and post‐anaesthesia care units (PACU), dementia wards, long‐term care settings or retirement homes, or delivery rooms. PACUs were excluded because there are aspects of the presence of visitors to these units that are very specific, and differ from the general visits to patients who are not in the immediate post‐operative stage. Dementia wards, long‐term care settings and retirement homes were excluded because these were considered to be their "home", so visiting would be quite different from that on acute care hospital wards. Finally, delivery rooms were excluded because this review does not evaluate the impact of the outcomes of presence during "delivery" (or other "procedures"). Types of interventions Studies were considered for inclusion in this review if they evaluated the effect or impact of visiting policies. This included interventions targeted at limiting or expanding patient visiting. We anticipated a paucity of experimental studies regarding this review question, thus included observational studies where the impact of visiting policy on patients and/or visitors was a focus, but testing intervention(s) may not have been the primary aim. We did not consider observational studies that focused only on the presence of visitors during specific procedures, resuscitation, or childbirth. The reason is that this limited aspect of the presence of a significant other was not considered "visiting" per se, and would be best examined in another systematic review. Types of outcome measures For this review, outcome measures related to both patients and visitors as a result of visiting hour policies were considered, including but not limited to: patient and/or visitor satisfaction; attitudes; beliefs; perceptions; mood; or patient physiological outcomes. These also included health care provider beliefs, perceptions, and attitudes about the impact of visiting policies on patients and/or visitors. Studies were excluded if they examined the trend of current visiting hour policies (with no evaluation of their impact), or if they focused on visitor presence only during emergency procedures, resuscitation, or childbirth. Types of studies Randomized controlled trials (RCTs) or quasi‐experimental studies were included. However, given the expected scarcity of these designs relevant to our review question, other quantitative research designs were considered, such as non‐randomized controlled trials, before‐and‐after studies, and descriptive/observational studies. Search Strategy Using a defined search and retrieval method the following databases from 1995‐2007 were accessed: Medline, CINAHL, Embase, PsycINFO, HealthSTAR, Cochrane Database of Systematic Reviews, AMED, and ERIC. Methodological Quality Each paper was assessed by two independent reviewers for methodological quality prior to inclusion in the review using standardized critical appraisal instruments for evidence of effectiveness, from the Joanna Briggs Institute. Disagreements were dealt with by consultations with a third reviewer. Data Collection Information was extracted from each paper independently by two reviewers using the standardized data extraction tool developed by the Joanna Briggs Institute. Disagreements were dealt with by consultations with a third reviewer. Data Synthesis Due to type of designs and quality of available studies, it was not possible to pool quantitative research study results in a statistical meta‐analysis. Since statistical pooling was not possible, the findings are presented in a descriptive narrative form. Results Fifteen studies met the inclusion criteria for this review. The study designs were varied, and included one pilot randomized trial, two quasi‐experimental studies, eight descriptive studies/cross‐sectional surveys, and four pre‐post intervention questionnaires. Findings were inconsistent across studies. Nurses inconsistently enforced visiting policies. In ICU settings, liberalized visiting hours did not increase septic complications. One study reinforced the need for increased patient control over visiting (individual visit contracts, devices). Flexible (open) visitation policies increased patient and visitor satisfaction, and sibling visitation was beneficial to the patient and family. In maternity settings, a 'combination policy' was useful (open visiting for partner, more restricted visiting for others). Conclusion Key recommendations are provided that refer to clinical practice in critical care, maternity, and general ward settings, as well as recommendations for future research. In critical care settings, policy makers/administrators need to be aware of their staff nurses' beliefs and attitudes about visiting policies, educate them about the rationale for these policies and consider program development to assist nurses to work with families. Open visitation, and ways to increase patient control of visiting should be considered. No connection was found between liberal visiting hours and increased infection rates. When facilitating sibling visitation in the NICU, a pre‐visit education process is recommended. Maternity settings may wish to consider a 'combination' policy, where the women's partners and/or significant other would have open visiting (all day), with restricted visiting for others. In other general hospital ward settings, open visiting with a 'quiet hour' is suggested.