NR 307A Week 7 Visitor Policy Revision Proposal Example

Replacing "Immediate Family" With "People the Patient Names": A Proposal to Revise One Sentence of an ICU Visitor Policy

Student Name

College of Nursing, Chamberlain University

NR 307A: Advancing Equity, Inclusion, and Diversity in Healthcare

Instructor Name

Month Day, Year

Replacing "Immediate Family" With "People the Patient Names": A Proposal to Revise One Sentence of an ICU Visitor Policy

Addressed To

This proposal is addressed to the nurse manager of the 16-bed medical-surgical intensive care unit at a 300-bed community teaching hospital, who owns the unit's visitor policy and can take a revision to the hospital's policy committee for approval. It asks for one sentence to be replaced.

The Current and Proposed Wording

Current wording, Section 3.1 of the ICU Visitor Policy, last revised in 2019: "Visitation in the ICU is limited to immediate family members, defined as spouse, parent, adult child or sibling. Other visitors may be approved by the charge nurse."

Proposed wording: "Visitation in the ICU is open to the people the patient identifies as family or support persons. If the patient cannot say, the patient's designated representative or the people who usually support the patient may identify them. The limits on the number of visitors at one time and on clinical restrictions in Sections 3.2 to 3.5 are unchanged."

Four things move: "limited to immediate family members, defined as" becomes "open to the people the patient identifies"; the list of relationships is removed; a route is added for patients who cannot speak for themselves; and the discretionary approval by the charge nurse is removed because it is no longer needed. Nothing else in the policy changes, including visiting hours, the number of visitors, or infection control rules.

Who the Current Wording Serves and Who It Costs

The current sentence works well for a married patient with living parents and adult children who live nearby. It assumes that the people closest to a patient are related by blood or marriage. On our unit, that assumption fails regularly. In the past six months, the unit's charge nurse log records 23 requests for approval of "other visitors." Most were approved. The log includes an unmarried partner of 20 years, a patient's best friend who held her health care power of attorney, a foster son, a niece who was the patient's only caregiver, and the partner of a gay man admitted after a cardiac arrest. Three requests were denied, and the log records the reason for each as "not immediate family."

The cost of the current wording falls unevenly. It is lowest for patients whose families match the list and highest for patients who are unmarried, divorced, estranged from their birth families, living in chosen families, LGBTQ patients whose partners are not legally recognized as spouses, and older adults whose closest support is a neighbor or friend. Because approval depends on the charge nurse on duty, two patients in identical situations can receive different answers on different shifts. That inconsistency is itself an equity problem: it makes access depend on who happens to be working and how the request is phrased.

Why the Change Is Supported

The first reason is federal. Under the Medicare conditions of participation, a hospital must tell each patient of the right to receive the visitors they designate, including a spouse, a domestic partner, including a same-sex domestic partner, another family member or a friend, and prohibit restricting visitation on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation or disability (Condition of Participation: Patient's Rights, 2024). The current sentence, which names only four relationships and requires approval for everyone else, sits uneasily with that requirement even if every request were approved.

The second reason is professional. The Society of Critical Care Medicine's guideline on family-centered care in the intensive care unit defines family by the patient's relationships rather than by biology or law, and recommends that families be given the chance to be present at the bedside and to take part in care (Davidson et al., 2017). The American Nurses Association (2015) Code of Ethics opens with a provision on each person's dignity and individuality, and the choice of who stands at the bedside is part of that individuality.

The third reason is local fairness. The CLAS standards ask organizations to provide services that are responsive to patients' diverse cultural health beliefs and practices (U.S. Department of Health and Human Services, Office of Minority Health, 2013). In many families on our unit, including extended families and chosen families, the people who make decisions and provide daily care are not on the current list.

The Case Against, Stated Fairly

Three objections are likely, and each deserves a real answer.

The first is that open definitions will bring more people to the bedside and strain nurses. This is a fair concern. Nassar Junior et al. (2018) pooled studies comparing flexible and restrictive ICU visiting policies and found that flexible policies were associated with less delirium and anxiety in patients and greater family satisfaction, but also with higher burnout among ICU professionals. However, the proposal does not change visiting hours or the number of visitors allowed at one time. It changes who counts. The number of people at the bedside is still governed by Section 3.2, which allows two visitors at a time.

The second is infection risk. In a cluster-crossover trial across 36 Brazilian ICUs, Rosa et al. (2019) found that flexible visitation of up to 12 hours a day did not significantly increase ICU-acquired infections compared with restricted visitation, and family members in the flexible arm reported fewer symptoms of anxiety and depression. That trial tested longer hours, not a broader definition of family, so it cannot prove that this change is safe, but it gives no reason to expect harm from a change that does not increase hours or numbers.

The third is that staff may not know who is legitimate when a patient cannot speak. The proposed sentence addresses this by naming the patient's designated representative, or the people who usually support the patient, as those who may identify visitors. Where there is a dispute, the existing escalation route to the house supervisor and social work remains in place.

Cost

The cost is small. The policy revision requires one committee review. Staff education would take about 15 minutes at two unit meetings and one page in the unit's weekly newsletter. The signs at the ICU entrance and the patient admission packet must be reprinted; the print shop estimates about $140 for both. The charge nurse log of approval requests would no longer be needed, saving an estimated 10 to 15 minutes of charge nurse time a week.

Implementation

Week 1: nurse manager reviews the proposal and the current log with the unit's practice council.

Week 3: revised sentence submitted to the hospital policy committee, which meets monthly.

Week 7: if approved, education at two unit meetings; reprint signs and admission packet.

Week 8: revised policy in effect.

Week 20: review of three measures: the number of visitor-related complaints or incident reports, charge nurse time spent on visitor approvals, and family satisfaction scores on the unit's existing survey, each set against the same three measures from the quarter before the revision.

Conclusion

The change is one sentence. It removes a list that fits some families and not others, replaces a charge nurse's discretion with the patient's own choice, and brings the unit's wording into line with federal requirements and critical care guidance. It leaves visiting hours, numbers and clinical limits untouched. I am asking the nurse manager to take the revised sentence to the practice council and then to the policy committee.

References

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements.

Condition of Participation: Patient's Rights, 42 C.F.R. § 482.13 (2024).

Davidson, J. E., Aslakson, R. A., Long, A. C., Puntillo, K. A., Kross, E. K., Hart, J., Cox, C. E., Wunsch, H., Wickline, M. A., Nunnally, M. E., Netzer, G., Kentish-Barnes, N., Sprung, C. L., Hartog, C. S., Coombs, M., Gerritsen, R. T., Hopkins, R. O., Franck, L. S., Skrobik, Y., . . . Curtis, J. R. (2017). Guidelines for family-centered care in the neonatal, pediatric, and adult ICU. Critical Care Medicine, 45(1), 103-128. https://doi.org/10.1097/CCM.0000000000002169

Nassar Junior, A. P., Besen, B. A. M. P., Robinson, C. C., Falavigna, M., Teixeira, C., & Rosa, R. G. (2018). Flexible versus restrictive visiting policies in ICUs: A systematic review and meta-analysis. Critical Care Medicine, 46(7), 1175-1180. https://doi.org/10.1097/CCM.0000000000003155

Rosa, R. G., Falavigna, M., da Silva, D. B., Sganzerla, D., Santos, M. M. S., Kochhann, R., de Moura, R. M., Eugênio, C. S., Haack, T. D. S. R., Barbosa, M. G., Robinson, C. C., Schneider, D., de Oliveira, D. M., Jeffman, R. W., Cavalcanti, A. B., Machado, F. R., Azevedo, L. C. P., Salluh, J. I. F., Pellegrini, J. A. S., . . . Teixeira, C. (2019). Effect of flexible family visitation on delirium among patients in the intensive care unit: The ICU Visits randomized clinical trial. JAMA, 322(3), 216-228. https://doi.org/10.1001/jama.2019.8766

U.S. Department of Health and Human Services, Office of Minority Health. (2013). National standards for culturally and linguistically appropriate services in health and health care: A blueprint for advancing and sustaining CLAS policy and practice.