Introduction

In Europe, most intensive care units (ICUs) have restricted visiting policies [1–4]. Hospitals favor restricted visits, because excessive visits are presumed to be detrimental to the patients (e. g. patients not getting enough rest) and to the organization of care (e. g. interruption of nursing care delivery by visits). However, an open visiting policy, defined as a policy that imposes no restrictions on the time of visits, length of visits, and/or number of visitors, seems to be more suited to patient and family needs [5–11]. An overview of the advantages and disadvantages of an open visiting policy can be found in Table 1 [6, 8, 12–17]. Furthermore, a randomized controlled trial revealed that an unrestricted ICU visiting policy is associated with reduced cardio-circulatory complications, possibly because visits reduce patient anxiety and promote a more favorable hormonal profile [18]. These findings support shifting from restricted visiting policies to those that are more open.

Table 1 Advantages and disadvantages of an open visiting policy
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Since successful adoption and implementation of open visiting policies depends on nurses' beliefs and attitudes about and satisfaction with visitation and visiting policies [16, 19], it is important to explore nurses' views on visitation. The aim of our survey was to study the beliefs and attitudes of ICU nurses toward visitation, visiting hours, and open visiting policies in critical care settings.

Methods

Study population

Nurses and head nurses working in an adult medical, surgical, specialized, or mixed ICU in Flanders (Dutch-speaking Belgium) could be included in this study. Overall, 23 hospitals were asked to participate in this survey. Seventeen hospitals agreed to participate, 16 of which were regional hospitals and 1 university hospital, representing 30 ICUs. A total of 923 nurses were employed at the participating ICUs. Overall, 531 nurses completed the questionnaires anonymously and voluntarily, counting for a response rate of 57.5%.

Variables and measurement

Based on an extensive review of the literature [4, 6, 13, 15, 17, 19], we devised two questionnaires. The first questionnaire investigated the current visitation practices of each participating ICU. The second questionnaire, named the Beliefs and Attitudes toward Visitation in ICU Question naire (BAVIQ), assessed the beliefs and attitudes of the ICU nurses toward visitation and visiting hours. The full questionnaire can be found in Appendix 1. Respondents rated their level of agreement on a five-point scale. Content validity was obtained by submitting the questionnaires to a panel of ten experts (seven ICU head nurses and three Masters-prepared ICU nurses). Subsequently, eight intensive care nurses checked the new questionnaire to assess its face validity, i. e., evaluating clarity and ease of use.

The questionnaires were completed during a 3- or 4-week period before being returned to the head nurse. The questionnaires required 10–15 min to complete. The Institutional Review Board approved the study protocol.

Statistical analysis

Descriptive statistics for nominal data were expressed in proportions. Medians and quartiles were calculated for continuous variables that were not normally distributed. The level of significance was set at p < 0.05.

The questionnaire contained both positively and negatively formulated questions. To calculate an overall score for the nurses' beliefs, we recoded the responses on the negatively formulated questions. Subsequently, we computed the average score over all the belief items. A score of zero corresponded with beliefs that are strongly opposed to open visitation and a score of 4 corresponded with beliefs that are strongly in favor of open visitation.

Results

Visitation policy

All (96.7%) but one of the ICUs used restricted visiting-hour policies, allowing visits during two or three pre-assigned periods. The maximum visiting period was mostly (63.3%) limited to 30–45 min per visit. The majority of the ICUs adapted their policy when the patient was dying (96.7%), when the family had practical problems in complying with the policy (93.3%), and when the patient had emotional needs (76.7%). All of the ICUs had restrictions on the number of people visiting the patient at any one time, ranging from two (53.3%) to three (46.7%) visitors. Visitation policy in the six hospitals that did not participate in this study did not differ significantly from that in the participating centers.

Beliefs about the consequences of visiting on the patient, family, and unit

Most nurses believed that visitation has a beneficial effect on the patient (75.1%) and that visitors can help the patient to interpret information (60.2%) (Fig. 1). Interestingly, nurses did not believe that an open visiting policy was important for the recovery of the patient (55.9%) or that it offered more comfort to the patient (57.8%). Most nurses believed that open visiting impeded adequate planning of the nursing care process, that it interfered with direct nursing care (73.8%), and that it caused nurses to spend more time in providing information to the family (82.3%).

Fig. 1
figure 1

Nurses' beliefs about how visiting affects the patient, family, and organization of care

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The overall score on this scale was 1.87 (SD = 0.5), indicating that nurses tended to be slightly skeptical toward unrestricted visitation. Recall that a score of zero corresponded to ‘strongly opposed to open visitation’ and a score of 4 to ‘strongly in favor of open visitation’.

Attitudes toward visiting

Nurses were in favor of exceptions to a restricted policy when the patient was dying (98.7%), when the family had practical problems complying with the policy (83.8%), and when the patient had emotional needs (70.2%) (Fig. 2). A slight majority (57.2%) wanted the visiting policy to be flexible during the first 24 h of a patient's hospitalization.

Fig. 2
figure 2

Attitudes toward visiting

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On the other hand, nurses were against giving the patient control over the time of visits, the duration of visits, and the number of visitors allowed (70.4%). In cases in which restrictions existed on when visitation hours started (72.4%), nurses still wanted the length of visits to be limited at all times (88.9%). Most nurses did not want to liberalize the policies on the number of visitors within a 24-h period (86.9%) and the number of visitors visiting the patient at the same time (96.9%). The majority of the nurses did not want an open visiting policy in their unit (75.3%).

Discussion

Although empirical data indicate that unrestricted visitation is associated with fewer cardio-circulatory complications [18], the present survey suggested that ICU nurses tend to be skeptical toward an open visiting policy. The majority of the ICU nurses believed that open visiting policies interfered with the nursing care process, namely by hampering adequate nursing care planning, by interfering with direct nursing care, by making the nurses spend more time in providing information to the family, and by being of no help to support caregivers. Some articles largely support our findings of rather negative beliefs toward visitation and its impact on the care process [14, 20], while others reveal more positive beliefs of nurses on the effect of visitation on the quality of nursing care [3, 13, 21]. A consistent finding was the belief that including the family in the healing process enhanced nursing care because of the valuable information obtained [3, 14, 16]. Visitors provide information that helps nurses to better understand the patient's personality and coping style [5]. Conversely, receiving information was the most important need of relatives of ICU patients [22].

The literature [3, 23] indicates that nurses preferred a visitation policy that includes some restriction of hours and time, but allows for individualization based on special circumstances and on evaluation of the needs of the patient and families. The conservative attitudes toward the number of persons visiting a patient may be attributed to environmental and practical aspects, such as limited space in the patient's room, guaranteeing the privacy of other patients, limiting the noise on the unit, the number of patients per nurse, and other various factors.

Implications

The results of this study suggest that the culture in Flemish ICUs is not receptive to open visitation. Hence, it is advised to inform nurses about the available empirical evidence to make them aware about the benefits of less restricted visiting hours. Imposing an open visitation policy against nurses' beliefs is not indicated, because it could result in a higher perceived stress by nurses.

This study investigated nurses' beliefs and attitudes. Hence, intensive care physicians were not included in this survey. However, the results are also relevant for them, because this study might be an opportunity for doctors and nurses to reflect on their policy and on how information is delivered to relatives. In other words, the performance of the ICU team with respect to patient- and family-centered care can be evaluated.

Limitations

Despite the large sample, there were a significant number of non-responders, which tempers the generalizability of the results. Also, although the results are based on a wide sampling of ICUs in Flanders, the interviewed nurses may not be representative of general ICU nurses in the rest of Belgium or in other countries. Indeed, the restricted policies applied in the participating ICUs might have impacted on the answers. For instance, nurses might tend to defend their current visitation policy.

The hospitals were not randomly selected; instead, selection was based on their cooperation with the Centre for Health Services and Nursing Research of the University of Leuven. This fact may have led to a selection bias in that only hospitals were included that had common practices and beliefs and that were directed by one particular university.

Although the instrument was comprehensive, it requires further validation and reliability testing. Indeed, some apparent inconsistencies in the results could be found. For instance “the nurses believed that visitation had a beneficial effect”; however, at the same time “they report that the visitation was not important for patient recovery”. The source of these contradictions could be the way how the questions in the instruments are constructed.

Conclusion

This study suggests that ICU nurses have slightly skeptical beliefs and attitudes toward an open visiting policy. This will be a substantial barrier when hospitals want to liberalize their visiting policy, according to the new empirical evidence.