New visiting policy: A step toward nursing ethics

Abstract

Background:

Patients’ rights arise from their expectations of the healthcare system, which are rooted in their needs. Visitation is seen as a necessary need for patients and families in intensive care units.

Objectives:

The authors attempted to design, implement, and evaluate a new visiting policy in the intensive care units.

Research design:

This study was an action research, including two qualitative and quantitative approaches.

Participants and research context:

The viewpoints of 51 participants (patients, families, doctors, nurses, and guards) on how to change the limited visiting policy were explained through semi-structured interviews and focus groups. The new visiting policy (contractual visitation) was designed, implemented, and evaluated with the involvement of participants.

Ethical considerations:

The hospital ethics committee approval was gained and the informed consent was obtained from all the participants.

Findings:

The content of interviews was analyzed and classified into four categories: advantages and disadvantages of visiting policies, and barriers and facilitators of changing the limited visiting policy. After implementation of the new policy (contractual visitation), a significant difference observed in satisfaction status before and after the changes (p value < 0.001).

Discussion:

Nowadays, many countries’ clinical guidelines recommend flexible visiting policy, which is consistent with the results of this study.

Conclusion:

Changing the limited visiting policy was a necessary need for patients and families that established with the involvement of them and staff.

Keywords

Ethics flexible visiting intensive care unit patient right visiting policy

Introduction

Patients’ rights arise from their expectations of the healthcare system, are rooted in their needs. The medical team personnel, especially nurses, are responsible for securing these rights and meeting such needs and expectations.¹ Individual and societal rights are closely related to ethics. Professional ethics aims to improve the quality of patient care by identifying, analyzing, and solving ethical problems and issues in practice.² Visitation is one of the problems that has challenged patients and their families for many years.³ On the one hand, illness and hospitalization in intensive care units (ICUs) is a critical situation for the patients and their family members,⁴ which is usually associated with physiological and emotional dysfunction of patients.⁵ Thus, the role of families in improving the critically ill patients is so important, and the focus of the healthcare team is based on the patient-centered and family-centered system.⁶ Many studies have also emphasized the importance of considering the needs of families of admitted patients. “Being with the patient” has been seen as one of the important needs of families.^7,8 In this regard, visiting the patient has been emphasized as a positive and effective measure for better adapting and coping with stress and crisis.⁹ Hence, today’s environment of care involves patients and families. Thus, to achieve an optimum environment, active participation of families should be considered, and with the implementation of holistic care measures, in addition to considering the needs of patients, the families’ needs should be considered seriously.¹⁰ Despite the attention to this matter in the world, it is for years that limitations of visiting in ICUs of Iran are seen as a routine practice. Although ethical principles do not offer a useful measure in a certain situation, these can be used as a practical framework to overcome the conflicts.¹¹ Norms and values of the medical community (i.e. the hospital and its staff) are often in conflict with values of each patient and relevant families.¹² Ethical principles help to understand and overcome these conflicts. For example, families tend to visit and accompany their patients more often than allowed time. Clinical staff disagree with this issue and do not prefer long visits by the families. With regard to the issue of professional ethics as a principle in the care of patients, humanistic approach to the nursing profession, as well as Iran’s cultural contexts as an Eastern country with special behavioral and emotional features, the importance and necessity of research and contemplation in this context, are provided. Since, visitation, in fact, is a kind of respect for the dignity and rights of patients about their therapeutic decisions and health.

Objective

In this study, the authors attempted to design, implement, and evaluate a new visiting policy in the ICUs with the involvement of patients, families, and staff in order to overcome visitation conflict between families and staff.

Research design

The study had an action research design involving the combined use of qualitative and quantitative approaches. Action research is one of the best ways to make changes in clinical situations with an iterative and spiral cycle.

The quantitative part of the study, which was a descriptive cross-sectional study, was done to determine the level of satisfaction of patients and families of the current limited and new visiting policies. In the qualitative study, some interviews and focus groups were made with patients, families, and staff to explain the viewpoints of the participants regarding the visiting policies and identify the barriers and facilitators of changing the limited visiting policy.

Participants and setting

The inclusion criteria for patients to enroll in the study were as follows:

At least 18 years old;

Not being intubated;

Having acceptable general health to answer the questionnaire questions.

The inclusion criteria for family members to enroll in the study were as follows:

At least 18 years old;

Willingness to participate in the study;

Having immediate family relation with the patient.

The doctors and nurses had to have at least 1 year of experience working with patients in ICUs; and guards had to have at least one year work experience too, as well as their willingness to participate in the research. The exclusion criteria were decreased level of consciousness of patients and the unwillingness to continue to participating in the study. In the quantitative part of the study, the sample size was calculated as 297 subjects based on Cochran’s sample size formula. The qualitative part sampling came to an end by achieving the saturation in collaboration with 51 participants (including 14 patients, 16 immediate family members of patients, 10 nurses, 6 doctors, and 5 guards).

The research environment in this study included all ICUs of Rajaie Cardiovascular, Medical and Research Center. This hospital is a specialized center in the field of diagnosis, treatment, and rehabilitation of cardiovascular diseases and has five adult ICUs. In this study, two ICUs A and B were chosen to implement the visiting policy change. The current visiting policy in ICUs of this hospital was limited. The routine rules allowed the visiting of patients in all days a week for 60 min, from 3 o’clock until 4 in the afternoon, for family, friends, and acquaintances individually.

The ICU A has 12 beds, while ICU B has 21 beds, where patients with a medical or surgical diagnosis requiring special care would be hospitalized. A total of 66 nurses are employed in these two units. On average, each is responsible for taking care of one or two patients during their work shift. Nurses work on rotating shifts in these wards. They work from 190 to 250 h/month. The number of patients hospitalized in these two section accounted for 1325 people within 1 year before the study.

Instruments

Although a comprehensive literature review was made on visitation status and schedule in Iran and the world, no standard questionnaires were found in order to measure the level of satisfaction with the visitation schedule. Therefore, a questionnaire was developed by the author in order to measure the satisfaction of patients and their families with the visitation schedule. The author reviewed all the books, texts, and translated materials relevant to visitation schedule and policy in order to develop a questionnaire with the help of supervisors and advisers in the research.

Content validity of the tool was confirmed through content validity approach (opinions of experts). For this purpose, the questionnaire was offered to 10 faculty members of School of Nursing and Midwifery and Rajaie Cardiovascular, Medical and Research Center too. Their opinions were considered in revising the questions in terms of relevance, appropriateness, and competency for measuring the desired items. Reliability of the questionnaire was confirmed through internal consistency approach using Cronbach’s alpha (α = 0.78). For this purpose, the questionnaire was distributed among 20 patients and first-degree relatives. Internal consistency of the items was determined using Cronbach’s alpha. The mentioned individuals were excluded from the study. The first part of the questionnaire included the demographic information of patients and families. The second part consisted of 20 questions that were set based on a 3-item Likert scale of agreement from “Yes” (score 1) to “No” (score 3). In scoring the questions to describe the overall satisfaction status with the current visiting policy in ICUs of the hospital, the scores 20–33, 34–46, and 47–60 showed the situations of satisfied, somewhat satisfied, and unsatisfied, respectively. In scoring the questions to describe the state of patients’ satisfaction with the current visiting policy in ICUs of the hospital, the scores 15–24, 25–35, and 36–45 showed the situations of satisfied, somewhat satisfied, and unsatisfied, respectively. Also, in scoring the questions to describe the families satisfaction status with the current visiting policy in ICUs of the hospital, the scores 5–8, 9–11, and 12–15 showed the situations of satisfied, somewhat satisfied, and unsatisfied, respectively.

Data collection method in the qualitative part of the study included observation and semi-structured interviews that the question guide directed the process. The qualitative sampling was done in a targeted manner. Thus, after analyzing the first interview, some results were obtained that led the other samples. The interview duration lasted from 30 to 45 min depending on the response rate of participants and according to the study general questions coverage. Interviews with all the participants initially started with two general questions: How do you evaluate the status and schedule of visitation in this ICU? What was the reaction when the families demanded to visit their patients in non-visiting hours? Further questions were asked based on responses of the participants. The participants were allowed to answer some other open questions too. The content of formal interviews was recorded with the consent of the participants. The author also took notes during the interviews.

The observations environment was an environment where the patients and families are in direct contact with doctors and nurses. Therefore, before implementing the new visiting policy, the majority of the researcher’s observations took place in ICUs at public visiting hours (from 15:00 to 16:00) with the aim of studying the interactions as well as estimating the patients and families satisfaction with the limited visitation policy in the ICUs. However, after running the new visiting policy, the researcher’s observations occurred during the hours of new visiting policy (from 9:00 till 21:00) in ICUs to investigate the interactions and satisfaction of patients and families with the new visiting policy, explain challenges, and monitor the new program. In addition, the families’ interactions with personnel in the security and information stations were observed to monitor coordination processes and providing special visiting cards.

Various methods were used to enrich and strengthen the qualitative part of the study. Long-term interaction and continuous observation, careful and active listening during the interviews, accurate data collection to obtain comprehensive and rich data, the trust of the participants, a combination of data collection methods, dynamic and comprehensive data record were mentioned as all the strategies used in this study to improve the quality of qualitative data.¹³

Procedure

First cycle

Since the group needs to reach an agreement for changing policies, the results of initial quantitative section (dissatisfaction with the current limited visiting policy) and the results of the qualitative section (barriers and facilitators of changing the limited visiting policy) were discussed in a focus group (composed of nurses, doctors, family members, as well as guards) so that the group members plan to solve this problem. Thus, the design of new visiting policy was made with the cooperation of participants. This new policy, which was a kind of contractual visiting policy, allowed the immediate family members to visit their patients between 9:00 and 21:00 by getting a special card. Instead, they were subject to comply with laws and regulations so that their presence and actions would not interfere with of nursing care, doctor’s visits, and management of ICUs. After designing, the new visiting policy was implemented. Attended in the scene, the researchers regularly collected information and discussed and evaluated the intervention results constantly and progressively in an ongoing changing situation. They solved the problems with the help of participants continued the program again. For final evaluation and assessment of the new visiting approach, the satisfaction rates of patients and families with the new visiting policy were again determined and compared with their satisfaction rates before making the changes.

Second cycle

One of the problems we faced after the implementation of the first cycle of action research was to how to use the special visiting cards. Despite that the guard staff had been justified only in ICUs A and B to implement new visiting policy with the special card, the visitors sometimes used the card to enter into other wards by passing through the guard stations entrances. After detecting the new problem, there was a need for planning, implementation, monitoring, and feedback to correct the program problems and improve and upgrade the new program. Again, a focused group with associated members (members of the guards, officials and members of the hospital information station, as well as the head nurses of two ICUs as nurses’ representatives) was formed to be programmed to solve this problem. After receiving comments, it was decided to insert the stamp names of the intended ICUs on the back of the cards, and then the cards would be pressed. It was also passed that the head nurses would provide verbal instructions regarding compliance with relevant laws and regulations to families receiving special visiting cards (see Appendix 1) and then obtained a written commitment from them to abide by those laws and regulations. This suggestion provided the exclusive use of the special visiting cards merely for the mentioned units. After implementation, observation and monitoring process was again continued, and given that the above problem was not repeated, the new visiting policy continued meanwhile providing feedback to the participants.

Third cycle

During the implementation of the new visiting policy, the researchers continued their active participation in the field and followed the process of observing, discussing, and negotiating with patients and families for continual and correcting possible problems of the new visiting policy. With the implementation of this program in ICU “B” and increased number of visitors in this unit, which had more beds than the unit “A” (21 beds vs 12 beds), the researchers faced with the problem of increased resistance of some staff against implementing the new policy and their inappropriate behavior by visitors. During the negotiations, some families mentioned that some personnel do not behave well with them due to their presence as a visitor at the patient bedside. Due to the fact that the problem was limited to a handful of people from the entire personnel, the group agreed to use incentive methods to reduce the people resistance. Therefore, in addition to maintaining a close relationship, doing individual negotiations and convincing these people, the researchers tried to reduce the resistances with the encouragement and appreciation of the efforts of staff to successfully implement the project and accelerate the recovery process of patients. Hence, a report was provided on the patients’ conditions and the positive impact of the family presence in facilitating the healing process of patients and increased families satisfaction and was put on the hospital site with the help of the audio-visual ward. Reading the patients’ reports and seeing their group photos along with the patients and families, the personnel cooperated more motivated in implementing the new visiting policy, and their resistance was reduced. Gradually, with providing similar examples by the staff and putting the new news on the site, the resistance of the very few opposed personnel also came to an end. In addition, through increasing his working relationship with the staff and dealing sincerely dealing with them, doing individual negotiations and convincing them, the researchers solved this problem and the program continued.

In fact, in every phase of the study, periodic evaluation of the new policy, performing modifications and continuity of the modified policy were done, and the cycle of action research was continued spirally. Finally, with frequent implementation, evaluation, feedback, and ongoing reforms in three spiral cycles, the visiting policy improved in two ICUs of this hospital.

Statistical analysis

The quantitative data were analyzed using descriptive and inferential statistical methods using the SPSS Ver. 22 software. The mean and standard deviation were used to describe quantitative variables, while frequency and percentage were employed to describe the qualitative variables. Also, the chi-square test was used to compare the level of satisfaction among patients and families (satisfied, somewhat satisfied, and dissatisfied) regarding the situation of visiting program before and after the changes.

The qualitative data analysis method was the qualitative content analysis approach by a conventional method with thematic technique. The analyses of qualitative data were initially done manually so that the process of classifications formation would appear. Thus, data analyses began by listening to recorded verbal descriptions of participants and data analysis by the frequent study of hand-written notes until the researcher reaches to the immersion stage and get a general sense of the subject. Then, the data were read word by word and marked to achieve the codes. Depending on the linkage between codes, the classes were generated. These emerging classes were used for organizing and grouping codes to meaningful groups. Understanding the main connections between sentences and preparing a comprehensive description of the topic was the final step of data analysis. The Max QDA10 software was used for better data management and organizing.

Ethical considerations

After obtaining permission from the ethics committee of Rajaie Cardiovascular, Medical and Research Center (RHC.AC.REC. 92/37), explaining the research goals and methodology, and obtaining informed consent from participants, they were assured that the information will be confidential with no name, and whenever they wish, they could leave the study. The recorded interviews were securely archived, which would be destroyed after 5 years.

Findings

The quantitative approach: before changing routine visiting policy

The results of initial satisfaction survey of 303 patient with a member of their families about the limited visiting policy in ICUs showed that in total, 43 (14.2%) people were satisfied, 94 (31%) were somewhat satisfied, and 166 people (54.8%) were dissatisfied with the current limited visiting policy in ICUs of the hospital.

The qualitative approach

In the qualitative part of the study, the results of 54 interviews with 51 participants were classified into four general categories. The categories related to the visiting policies are shown in Table 1, and the categories of barriers and facilitators of changing the limited visiting policy are given in Table 2.

Table 1.

Participants’ views about visiting policies in intensive care units.

Categories	Sub- categories	Secondary sub-categories
Limited visiting policy	Advantages	Respecting the law and preventing chaos
		Respecting the patient’s will in case of unwillingness to have visitors
		Better infection control
		Coherence and continuity in the work of staff
	Disadvantages	Non-meeting of emotional and spiritual needs of patients and families
		Lack of families’ information on the clinical status of the patients
		Presence of large numbers of visitors at the patient bedside in a limited time (1 h)
Unlimited visiting policy	Advantages	Calmness and improved mental status of patient and family (reduced anxiety, enhanced safety)
		Family’s help to the patient’s primary care
		Respecting the will and rights of the patient and family
		Better interaction with patients and their families with medical personnel
		Providing education to patients and families at the same time about the condition of patients
	Disadvantages	Invasion of patients’ privacy
	Disadvantages	Interference with staff task and challenging the staff

Table 2.

Barriers and facilitators of changing the limited visiting policy in intensive care units.

Categories	Sub-categories	Secondary sub-categories
Obstacles of changing the limited visiting policy	Factors related to system of providing health services	Center policies
		Physical structure of ICUs and hospital
		Human resources (number of manpower, manpower attitude)
	Factors related to visitors	Families’ over-expectation from staff
		Lack of awareness of families regarding visiting policy
		Visitors’ inappropriate culture about the commitment to regulations
Facilitators of changing the limited visiting policy	Factors related to the management system	Modifying and establishment of a private structure for ICU patients
		Providing facilities for families
		Presence of consultant at the hospital for informing the families a bout the patient’s status
	Factors related to personnel	Passing certain domestic laws for unlimited visiting of immediate family members of the patient
		Designing and providing solitaire visiting presentation sheets and cards with certain rules
		Education to families
		Increased frequency of visiting times of first-degree people to 2 or 3 times a day
		Nursing as a humanitarian and moral profession

ICU: intensive care units.

The limited visiting policy was originally used in the ICUs of the hospital according to opinions of patients, families, and staff. According to these viewpoints, one advantage of this policy was respecting rules and preventing chaos so that the staff can easily and professionally do their job. A female doctor believed that visiting hours should be restricted; otherwise, the ICU could not be controlled efficiently. This would lead to chaos and disorder. Staff frequently mentioned that infection control, patient care, and continuous patient care were more manageable in case of limited visiting policy. A nurse stated that one advantage of limited visitation was the contribution made to infection control. Hospital facilities cannot afford masks and gowns for visitors so that they can be at the bedside of the patients.

In contrast, unlimited visiting policy ensures tranquility and improvement in the mental status of the patient and family members. The participants also discussed that this policy violates the privacy of other patients. A married patient stated that other female patients would be uncomfortable if one spouse wants to frequently visit his partner. Thereby, the ICUs should be designed more privately so that a visitor would not disturb the rest of the patients.

The participants believed that limited visiting policy can be replaced with a new policy based on mutual agreement between the families and staff. They suggested that individual visitation card or sheet should be designed and offered to the families in order to prevent disturbed nursing care. Implementation of this policy requires certain rules and training programs for the families. A hospital guard stated that the first-degree visitors could be offered a specific visitation sheet or card. This card or sheet should be given to the father, mother, sister, brother, children of the patients so that they would be prioritized over other relatives and could visit their patients unrestrictedly.

The participants also believed that nursing is a humanitarian and ethical profession. Therefore, nurses are the most effective group in changing limited visiting policy.

A nurse stated that nursing is an ethical and humanitarian profession because nurses always strive to meet needs of the patients. If the nurse believes that a patient would be calmer and better if relatives were at his/her bedside, the nurse would not restrict visitors because this contradicts nursing profession. Categories of interviews with the participants were discussed in a focus group in the first study cycle. As a result, a new policy (contractual visitation) was designed for first-degree relatives in order to establish a mutual agreement between families and the staff. In the second study cycle, the results of the second focus group showed that new rules should be formulated on how to use new visiting cards. Finally, visitation conflict between families and staff was resolved.

The quantitative approach: after changing routine visiting policy

After the design, implementation, evaluation, improvement, and continuity of the new visiting policy in ICUs, the satisfaction rates of patients and their family members improved. Thus, 153 people (51.5%) were satisfied with the new visiting policy and only 82 people (27.6%) were dissatisfied.

Table 3 indicates the overall satisfaction status (patients and families) before and after the changes in the visiting policy. As seen in Table 3, due to the conducted test, a significant difference is observed in terms of overall satisfaction status before and after the changes (p < 0.001, χ² = 96.700). Figure 1 shows the satisfaction status of patients and families before and after making the changes in separation.

Table 3.

Comparing the overall satisfaction status regarding visiting policy in ICUs before and after the changes.

Group	Before the changes		After the changes
Satisfaction status	Number	Percentage	Number	Percentage	χ² statistic	p value
Satisfied	43	14.2	153	51.5	96.700	<0.001
Somewhat satisfied	94	31	62	20.9
Dissatisfied	166	54.8	82	27.6
Total	303	100	297	100

Figure 1.

Comparing the overall satisfaction status regarding visiting policy in ICUs before and after the changes.

Discussion

Quantitative approach: measurement of satisfaction with visiting policies

The results of this study showed that more than half of the families were dissatisfied with restrictive policy in the hospital ICU. The results of this study are consistent with the results of the studies conducted by Soumagne et al. (2011) who investigated family satisfaction in ICUs in France.¹⁴ Interference with working shifts of nurses and perseverance of privacy of the patients motivated some hospitals to select restrictive visitation policy. However, liberal visitation policy reduces stress in patients and families and leads to significant improvement in patients.¹⁵

This policy is the first step to a patient/family-centered care in the ICUs. Findings of several studies suggested that treatment and hospitalization in the ICUs are stressful both for the patient and their families.^5,6,16
–18 Therefore, any intervention that reduces the effects of stress on families will directly help the patients because reducing stress in families can improve patient care and provide emotional support for the patients.⁴ The findings of this study showed that stress is reduced in families by implementing unrestrictive visitation policy and patients and families feel more relaxed and satisfied in presence of each other. Berwick and Kotagal (2004) showed that open visiting hours gain the trust of the families.¹⁶ This contradicts the results of this study where the families participating in the study believed that they trust nurses in ICU regardless of restrictive visiting hours. It seems that this difference in opinions may be due to geographical environment and location of the hospital and governing socio-cultural differences. It seems that families entrust their patients in the critical state with nurses in ICU.¹⁹

The qualitative approach

Advantages and disadvantages of visiting policies

The participants believed that restrictive visitation policy governs the ICUs in the studied hospital for respecting rules, preventing chaos, and providing intensive patient care more easily. Haghbin et al. (2011) also wrote that restrictive visitation policy is traditionally more in favor of the hospital and medical staff and not much in favor of patients and families. Restrictive visitation policy is still implemented in many ICUs. This is bound to public traditional beliefs and people rationalize that this policy helps the patient to rest or sleep more comfortably, prevent chaos, and restrict rude and irritating visitors. This also helps the nurses to control their patients more easily. The reports would not be manipulated by false data too.²⁰

The staff also mentioned that infection is more controlled in case of limited visiting policy in this study. However, Fumagalli et al. (2006) reported less bacterial contamination in room environment in case of restrictive visitation policy. Nevertheless, the same rate of infection (pneumonia, urinary tract infections, and general infections) was reported in both liberal and restrictive visitation policy.²¹ Malacarne et al. (2011) wrote that the type of infections reported in the case of liberal visitation policy significantly differed from the type of infection reported in the case of restrictive visitation policy in terms of both infective microorganisms and infection zone.²² These confounding results may be due to the issue that the studies performed in other countries account for clinical evidence while infection rate was not investigated in Iran. Only opinions of the hospital staff were referred to report infection rate in the studied hospitals.

The patients and their families believed that presence of families at patients’ bedsides in unrestrictive visitation policy help the patients to be more relaxed, improve mental and physical states of the patients, and inform families about progress in disease. A study was conducted in 2010 in Athens in Greece where the participants believed that liberal visitation is emotionally in favor of the patients.²³

Cappellini et al. (2014) also showed that patients believed that presence of families provide emotional support and help the patients to more easily understand the information given by the nurses. In contrast, families deliver important information about medical history and needs of the patients to the staff.²⁴

Participants believed that violation of patient privacy should be considered in unrestrictive visitation policy regardless of its many advantages. Livesay et al. (2005) also emphasized this issue. In the former study, all respondents allowed the visitors to freely visit their patients but they were not allowed to sleep in the patients’ rooms. The nurses also demanded the visitors to leave the room in case of patient care and treatment, particularly during collecting blood samples and tracheal suctioning.²⁵

The staff believed that visitors disturb them and do not let them do their job efficiently and on time. The visitors interfere with treatment and challenge the staff. The presence of visitors leads to chaos and mismanagement in the ICU. These items were mentioned as disadvantages of open visitation policy in many studies.^23,24,26,27

Barriers and facilitators of changing the limited visiting policy

Negative attitudes of staff about increased risk of infection were one of the barriers to the limited visiting policy change from the perspective of the participants in this study while many studies did not confirm this issue.^21,22 There is no evidence on increased incidence of infection in ICUs with open visiting policy. Participants believed that unlimited visiting policy is tiresome and does not allow the visitors to meet their own needs. This concern has been raised in other studies.^16,28 In contrast, many studies reported that liberal visitation policy helps relieve anxiety in the families because they are allowed to spend more time with patients and feel more secured and comfortable.^{21,29

–33}

The physical environment of the ICUs violates the privacy of the patients. This is another obstacle mentioned in the study. The results of this study are consistent with the results of the studies conducted by Shojaeimotlagh, (2010) Tayebi et al., (2014) Farrell et al., (2005) Lee (2007) and Khaleghparast et al. (2016). They mentioned the lack of enough space and violation of patient privacy as the most important physical barriers to open visiting policy.^8,34

–37

The staff believed that design of specific visitation card for first-degree relatives facilitates change in limited visiting policy by formulating and observing certain rules. The patients and families believed that the visitors would be allowed one visit per day by receiving special visitation card. The staff also agreed with the patients and families. Therefore, visitation card was mentioned as a useful strategy for changing limited visiting policy. Olsen et al. (2009) reported that patients and families prefer different visiting hours from three to four times per day.¹⁷

Nursing as a humanitarian and ethical profession also facilitates change in limited visiting policy. Staff also confirmed this issue. These results are consistent with the results of the study conducted by Tayebi et al. (2014) who wrote about nurses as supporter and advocate of patients’ rights. They facilitate decision-making, ethical issues, ICU management. These all stem from the important role of nurses in visitation. In addition, humanistic approach to the nursing profession and an emphasis on meeting the needs of patients and their families highlight the importance of visitation in ICUs for nursing department.⁸ According to humanitarian principles and ethical factors governing the nursing profession, visitation is converted from a challenging issue to a tool that helps patients, families, and even staff. It is essential to change existing visitation policy in ICUs by taking into account cultural context, specific behavioral and emotional characteristics and its definitive impact on visitation in Iranian hospitals.

Limitations

Applying changes in current and common practices of doing tasks in an embedded system will always be met with resistance. According to the philosophy of action research, maintaining a close relationship, negotiating and convincing, and bringing all groups together and keeping the ground of study continuously ready for acceptance along with the changes were challenges that the researchers had to face at all stages. They always tried to fix them by establishing proper relationship and continuous clarifying. Some of the limitations of this part of the research come back to the inherent limitations of qualitative content analysis approach, such as the absence of generalizability or presence of restrictions on data reliability and the results. Knowing that the researcher is a nurse, it is possible that some of the doctors and nurses interactions with patients and families during visiting hours would be influenced by the researcher attendance, which was out of the researcher’s control.

Conclusion

Patients and families feel more relaxed and satisfied when they visit each other. Although nurses have understood the importance of unlimited visitation, there are many barriers to implementation of this policy in many ICUs. The visitors attempt to control, disturb, and challenge the nurses, which threaten and dishearten the nurses. Nurses believe in increased risk of transmission of infection by visitors. Violation of patient privacy also motivates the nurse to disagree with the change in limited visiting policy. However, evidence showed that these problems can be estimated and resolved. Formulating certain rules for unlimited visitation of first-degree relatives, designing and offering specific visitation card for first-degree relatives, and commitment of these relatives to observe the above rules facilitate change in limited visiting policy in ICUs. This policy change increases the satisfaction of patients and families, resolve the conflict of patients and families with the staff about visitation schedule. Certainly, changing an old well-established system requires participation, interaction, and collaboration of different teams and groups.

Footnotes

Acknowledgements

We thank the staff, patients, and families that give us valuable experiences shared.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is the result of a PhD thesis in nursing, which has received the research project grant from Iran University of Medical Sciences.

Appendix 1

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