I have long been a champion of working in partnership with the carers and families of our patients, and have implemented ‘open visiting’ in my current and previous organisation to enable all of the well-published benefits. Cummings (2018) reflected that a flexible approach to embracing the presence of carers led to improving the overall experience of care, changing the atmosphere in wards and services, and helping to make best use of resources. Open visiting was also thought to lead to better communication, fewer complaints, a reduction in falls, violence, delirium and length of stay, an improvement in hydration and nutrition, acceptance of therapy and medication, generally improved wellbeing and maintenance of function.
Nursing through the current pandemic has had a profound impact on us all in so many ways. We have had to make such significant changes to enabling visiting, and this has been difficult for many patients and those of us nursing them.
One of the early issues of this pandemic for me as a Chief Nurse was a lack of national guidance in respect of visiting. Reflecting back, this was before the term ‘social distancing’ had even been heard of let alone the common phrase or practice that it is today. However, reducing the foot fall to our hospitals was common sense and there were calls to reduce visitors from our clinical teams. Balancing the benefits of enabling visiting with infection prevention and control practice meant that as a first step, the majority of us placed restrictions to visiting times and limited visitors to one per patient.
Following my organisation's implementation of visiting restrictions, there was clear national guidance stating that patients who had been diagnosed with COVID-19 were not permitted to have visitors. Over the course of the following days, as knowledge about COVID-19 developed, national advice changed, to protect ourselves and care for all patients as if they were suffering with COVID-19. Again, despite the promise of national guidance, it was not forthcoming; however, across the country all patient visits—with the exception of one birthing partner during labour—was prohibited across the NHS.
This change was significant, and the decision was made at pace to implement these restrictions, with a key driver of the decision being based on patient and staff safety. The impact on families was significant, and although the initial fear of COVID-19 appeared to force an element of understanding for the decisions that we had all made, the high profile death of a child alone without his parents prompted the charity Marie Curie to write in The Guardian calling upon the NHS to enable visiting to be allowed in the end-of-life situation (Booth, 2020). It asked the NHS to: ‘make efforts to allow close family to be with loved ones,’ saying it was an ‘important part of their duty of care’.
Marie Curie (Booth, 2020) urged us to consider the wishes of the dying when considering whether visits are possible and to ‘take a moment to think about what is achievable—is it achievable to isolate the individual in a room? Is it possible to give a small group of people close to them the full personal protective equipment they need to be with them in their last hours?’
Marie Curie does recognise we have to weigh the decision to not permit visiting with limiting the spread of the virus and adding that, in many cases, the dying person may not be aware of what is going on around them (Booth, 2020).
National guidance around palliative care in hospital during the coronavirus pandemic was published by NHS England (2020). Although an earlier version of the guidance was more explicit around the balance of risk of visitors, this version was silent on advising if visitors were permitted to COVID-19-positive patients.
This prompted professional debate in my organisation and an appraisal of the Association of Palliative Medicine guidance reviewed by Lawrie and Murphy (2020) whereby, with advice form infection prevention specialists, my organisation has moved to a standard approach across all settings that enables a balance of risk based on the patient's clinical condition, and a risk assessment for the healthcare staff and visitor to ensure that safety is maintained. This has made a tremendous difference for our staff to enable end-of-life care to be delivered with families and carers—this is not yet common practice across the NHS, with many areas still prohibiting visitors. I am very pleased that my colleagues and I were able to have some space to review our practice, and that there was guidance to support us to enable end-of-life care to meet individual needs. Of all of the many areas of practice that we have had to develop, review and refine, this for me is the most important one.