Open visitation in the NICU: nurses’ perspectives on barriers and facilitators^†

This descriptive, cross-sectional study was conducted from October 20th to December 10th, 2019, after obtaining the ethics code (IR.TBZMED.REC.1398.585) from Tabriz University of Medical Sciences. The research setting included the NICUs of 3 educational and medical centers of Al-Zahra, Children, and Taleghani, 3 main referral centers for premature infants in northwest Iran. Due to the limited nature of the research population, all nurses working in the NICUs of the 3 hospitals who met the inclusion criteria and signed the informed consent form were included in the study using the census method. The inclusion criteria were being employed in the NICU, having at least 6 months of work experience, and willingness to participate in the study (by signing the informed consent). The exclusion criteria included failing to answer >20% of the questionnaire.

After the initial and face-to-face meeting with the head nurses of the 3 hospitals, the researcher explained the objectives of the project and the implementation method. Afterward, according to the number of nurses in each ward, the questionnaires were handed over to the head nurses to be delivered to the ward staff. In order to encourage the nurses to complete the questionnaire accurately and to appreciate the time spent completing it, a small gift was prepared and presented to the nurses participating in the study when the questionnaire was delivered. To ensure the quality of the given answers, the questionnaire statements were placed randomly to avoid “response elicitation” and possible perceptual errors such as “stereotype errors,” “providing conservative answers,” and “distribution error” (high tendency to agree, disagree, or moderate). The participants were given enough time to complete the questionnaire; they had 72 h to complete and deliver it to the head nurse of the NICU. Moreover, a small gift was presented to them in appreciation for completing the questionnaire.

The data collection tool consisted of 2 sections. The first section was related to the demographic information of the participating nurses, including gender, age, level of education, work experience in NICU, employment status, type of work shift, marital status, and the number of children. The second section was “The Beliefs and Attitudes toward Visitation in NICU Questionnaire” (BAVNIQ). This questionnaire was prepared by modifying the questionnaire “Attitudes towards visitation in adult intensive care units” by Professor Philip Moons, used in 2007 in Berti’s study.²⁵ Therefore, after correspondence and obtaining permission from him, the questionnaire was modified and adapted for NICUs by a group of professors and neonatologists. The modified questionnaire consisted of 2 sections: nurses’ attitudes toward open visitation and effective facilitators and barriers to implementing it. The questionnaire’s first and second sections consisted of 52 and 12 expressions, respectively. The items were rated according to the 5-point Likert scale (strongly agree, agree, neutral, disagree, and strongly disagree). In the first section of the questionnaire, items were scored from 0 to 4. A score of 4 and 0 was assigned to the “completely agree” and “completely disagree” options in the positive expressions, respectively. The negative expressions were scored conversely. Thus, a score of 208 indicated the most agreeing view, and a score of zero indicated the most disagreeing view of open visitation. In evaluating the calculated scores, a score of 70 and below was interpreted as “weak,” a score of 70–140 as “moderate,” and a score above 140 as “good” views. The second section of the questionnaire was likewise rated based on the 5-point Likert scale (strongly agree, agree, neutral, disagree, and strongly disagree), and the level of nurses’ agreement and disagreement on the factors inhibiting or facilitating open visitation was measured using inferential statistics (frequency, percentage, and cumulative percentage).

For the validity of the instrument, first, the main questionnaire was translated into Persian by the translator. Afterward, to determine the content validity and adapt it to the field of neonatal nursing, the questionnaire was provided to 7 experts (including 2 neonatologists, 2 NICU head nurses, and 3 faculty members of the Department of Pediatric Nursing) and their comments on whether to correct or change some items were obtained. After collecting the submitted suggestions and applying the necessary corrections, 10 faculty members of the School of Nursing and Midwifery were provided with the modified questionnaire to confirm the face and content validity; Content Validity Ratio (CVR) = 0.93 and Content Validity Index (CVI) = 0.96 were obtained for its items. To evaluate the reliability of the questionnaire, the questionnaires were handed over to 30 nurses at the beginning of the study. The obtained data were analyzed, and a Cronbach’s alpha coefficient of 0.8 was obtained, confirming the reliability of the questionnaire. In our study, an effective response rate of about 10% was obtained by dividing the received responses (113 complete questionnaires) by the total number of nurses invited to participate in the study (122 nurses), which can be justified considering the limited number of eligible samples despite the use of the census sampling method.

After collection, the data were entered into SPSS software version 19 and analyzed using descriptive statistics (percentage, frequency, and mean) and the Pearson correlation test for predicting variables influential on nurses’ perspectives. The level of statistical significance in all tests was considered <0.05.

The mean and standard deviation of the score of nurses’ perspectives on open visitation in the NICU was 93.04 ± 23.54, with the highest and the lowest scores being 158 and 38, respectively. In general, the attitude of 84 nurses (74.33%) toward open visitation was at a moderate level (total score 70–140). The opinion of 24 nurses (21.23%) was at the weak level (<70); however, 5 nurses’ opinion (4.42%) was at the good level (>140). The Pearson test results showed no significant relationship between nurses’ demographic characteristics and their perspectives on open visitation (Table 2).

The percentage of positive and negative answers given to the expressions related to the barriers and facilitators of open visitation are provided separately in Table 3. The cumulative percentage of the answers of “completely agree” and “agree” to the barriers and facilitators is shown in Table 4.

The results of Table 4 show that from the participating nurses’ point of view, the first barrier to open visitation was “parents’ limited awareness of the sensitivity of the intensive care unit (ICU) for newborns and its hygiene principles” (90.3%). “Physical structure of the ward/lack of sufficient space” and “ long distance from the hospital/having another child” with an equal percentage of 86.8% were determined as the second factor impeding open visitation, by the nurses.

Among the facilitators of open visitation, “supporting employed parents during infant hospitalization” was the first and most important factor from the nurses’ point of view (82.3%), and “providing facilities for the family to stay in the hospital” with a percentage of (79.6%) was the second facilitating factor. The 2 factors, “protection of family privacy in the ward” and “good communication between personnel and family,” with an equal percentage of 78.8%, were ranked third as facilitators.

This study investigated the NICUs nurses’ perspectives on open visitation policy and the barriers and facilitators of its implementation. The results showed that more than half of the nurses had a moderate view of open visitation in the NICU. From the nurses’ point of view, the first barrier to open visitation was “parents’ low awareness of the NICU sensitivity and hygiene principles” (90.3%). The 2 factors of “unit structure and insufficient space” and “long distance of the family’s residence from the hospital and having another child” with an equal percentage (86.8%) ranked second among the factors interfering with open visitation. Regarding the facilitators of open visitation, the nurses participating in our study believed that “supporting employed parents during the infant’s hospitalization” (82.3%) and “providing facilities for family accommodation in the hospital” (79.6%) were among the most important factors.

Despite believing in the effectiveness of open visitation on patients and families, health professionals have a negative attitude toward it.²⁶ According to them, patients and their families greatly benefit from open visitation; however, it increases nurses’ physical and physiological burden and interferes with their duties.²⁷ Other studies have shown that although nurses have a positive attitude toward visitation,¹⁴ they fail to broadly agree with open visitation since they believe that the policy disrupts direct care and planning for nursing care and reduces care quality.^28–30 However, as Liu and Klawetter’s systematic reviews have shown, due to physiological differences between adults and infants, family presence, particularly maternal involvement in infant care, is safe for infants and is accompanied by positive health outcomes,³¹ such as neonatal weight gain, reduction in the infant’s energy consumption,³² hospital stay length, and the number of readmissions.¹² Likewise, in the present study, 80% of the nurses admitted the effectiveness of family visits on the infant, and the general view of open visitation was expected to be above average. However, the barriers proposed by nurses that interfered with their care activities and inhibited the implementation of open visitation in the studied units seemed to influence their views.

The first barrier to open visitation from the nurses’ point of view indicated that the nurses were highly concerned about the unrestricted family presence due to sensitivity to infection control in the NICU and low family awareness of the need for adherence to the principles of infection control. In Boztepe’s study³³, from the perspective of Turkish nurses, parents’ level of education and their cultural differences were mentioned as important factors in family participation that led to challenges for nurses and other health personnel. However, a study by Kidszun et al.³⁴ in 2019 showed that following family-centered care and open family visitation, as well as the presence of infant siblings in the NICU, viral infections affected <3% of infants. The results of the study by Horikoshi in Tokyo were in line with it, indicating that sibling visitation in the NICU has no significant relationship with the incidence of viral infections in hospitalized infants.³⁵

Nurses’ other concerns about open visitation were due to some issues, including patients’ privacy and unit management problems.³⁶ In some studies, nurses were also concerned about the probability of reducing their decision-making power through family involvement.²² It should be taken into account that not all visitors meet the environmental conditions and respect the privacy of other parents. Probably the reason for nurses’ opposition to open visitation is, in most cases, their distrust of the visitors and the fear of the unit becoming uncontrollable.³⁶

Regarding the unit structure and space restriction, the study by Ghorbani et al.³⁷ in 2017 showed that the lack of sufficient space and necessary facilities for parents to reside in the hospital prevented the continuous presence of parents and the implementation of family-centered care in the NICUs. Similarly, in the study by Foladi, from the perspective of nurses and physicians, environmental and structural factors in the NICU were mentioned as the most significant barriers to the implementation of developmental care and the continuous presence of parents.³⁸ In other studies, nurses believed there were numerous barriers to open visitation, such as insufficient space and facilities in the unit^21,22,36 and inadequate time available for communication between the nurse and parents.²¹ In developed countries, where the problems related to the structure and space of the hospital are usually inconsiderable compared to developing countries, parent-related factors, such as “long distance between residence and the hospital” and “caring for another child at home,” have priority and are among the primary barriers to open visitation.²³

Concerning the first facilitator of open visitation from the nurses’ point of view, it should be noted that in the socio-cultural context of Iran, the father is responsible for meeting the family’s financial needs; as a result, they are customarily employed. Since the visit times are typically scheduled in the afternoon, they coincide with fathers’ work hours; consequently, they fail to visit their babies on consecutive days. As in the qualitative study by Valizadeh et al.³⁹ restricting parents’, especially fathers’, visit times to specific hours often interferes with their working hours and prevents them from visiting the baby and participating in care. In other words, restricting parents’ entrance to the NICU is one of the factors interfering with the relationship between parents and infants.^8,15 This is particularly true for fathers who, due to issues such as financial problems and working hours, are less likely to visit their babies hospitalized in the NICU unless the fathers’ circumstances are understood and they receive supportive behavior.⁴⁰ Therefore, it can be concluded that in order to implement humane care, families should be encouraged to be present and participate in the ICUs. To this end, it is necessary to alter the hospital structure and adjust its policies to facilitate the 24-h open-door policy.⁴¹ From the perspective of the nurses participating in the present study, providing facilities for the family to reside in the hospital is as important as supporting the employed parents, which facilitates open parent visits. The results of Khaleghparast’s study showed that providing a private environment for the family and the presence of a counselor could be among the managerial facilitators of open visitation.¹⁹

This study was conducted in 3 important NICUs, the main referral centers for sick infants in northwest Iran. Considering that nurses are at the forefront of caring for infants and communicating with families, their point of view reflected the main barriers and necessary facilities for implementing the open visitation policy in the NICUs. The limitation of our study was that the factors preventing and facilitating open visitation were examined only from the perspective of the nurses working in the NICUs. It is suggested that in further studies, the attitude of families in this field be studied.