Family members' beliefs and attitudes towards visiting policy in the intensive care units of Ghana

Abstract Aim This study aimed to investigate family members' beliefs and attitudes towards the visiting policies of intensive care units (ICUs). Design It employed a descriptive cross‐sectional quantitative design. Method This study recruited four public hospitals in Ghana with a sample of 200 family members. The study was conducted using a self‐administered questionnaire. The data were collected and analysed with SPSS version 16. Results This study revealed that while family members believed in the beneficial effect of adhering to open visiting policies in ICUs, their attitudes were sceptical and restrictive. Most family members preferred the acceptable number of visitors within 24 hr to be two, and according to them, only one person should be allowed to enter at a time. There was a meaningful relationship between the families' beliefs and religion (p = 0.02), educational level (p = 0.03) and family status (p = 0.02). Furthermore, a meaningful relationship was also observed between the families' attitudes and status (p = 0.04) and their level of education (p = 0.05). The studied family members showed concern in this regard and did not want the community style of visiting to be implemented, which could hinder patients' recovery.

Traditionally, families in these communities live together in the same extended residential unit. In this arrangement, grandparents, parents and children live in the same compound or nearby and have Why is this research or review needed?
• A crucial part of a person's health is the social factor concerning his/her family members and significant others who can help coordinate patient care.
• A comprehensive understanding of the evolution of today's visitation policies and practices can aid in elucidating the context of change in addition to the everyday challenges of developing, recommending and implementing new guidelines on family visitation, presence and participation.
• Strict visiting restrictions reflected concern and a lack of information about the effects of visiting on patients and their families.
• ICU visitation is emerging as an important phenomenon in Ghana.
• Ghana is an underrepresented setting in scientific research concerning critical care.
What are the key findings?
• A well-developed policy for visitation schedules on admission should be in place so that each family has a plan that suits its unique dynamics. How should the findings be used to influence policy/practice/research/education?
• Understanding families' beliefs and attitudes about visiting policy at ICUs, through the findings of this study, will allow stakeholders to suggest changes in the existing policies to safeguard patient care to attain greater satisfaction among family members in our critical care wards.
• Cultural dynamics, which are critical according to the families, should be taken into consideration when recommending a visiting policy. an equal share in good and bad times. Thus, a person is always surrounded by close ones during a period of difficulty (Yaw & Baffour, 2005). Such family connections serve as a means of social, economic and psychological security in troubled times. Thus, the family is the bedrock of Ghanaian society. It transmits cultural heritage and serves as the first line of social security. In Ghana, there is no guideline or formal recommendation about the visiting policies followed in ICUs. Every institution determines its own individual visitation strategy based on traditional practice, belief or self-intuition without any empirical evidence.
Based on anecdotal evidence and the first author's experiences in Ghana in ICUs, where nurses are clearly in charge, visitation is commonly viewed as a privilege, not a right; it depends on several factors such as the patient's condition and the particular nurse's beliefs and attitudes. Certain families clearly benefit from selective visitation, whereas others report experiencing stress owing to rigid rules. In case of selective visitation (a form of restricted visiting), a patient's immediate caregiver is required to document a limited number of people who would be unconditionally allowed to visit the patient at a stipulated time (Bettina, White, Graham, & Alexandrov, 2014). A study conducted in Iran by Tayebi, Dehghan Nayeri, and Borimnejad (2017), concerning the dominant strategies adopted about visitation in selected ICUs, concluded that the most suitable strategies implemented to bring about positive impacts of visiting on the process of physical and mental recovery of ICU patients were seemingly related to personalized cultural traits of individuals and individualized visiting.
Hence, much of the research conducted since the 1980s has concentrated on nurse's perspectives pertaining to their beliefs and attitudes as well as on the needs of the families of critically ill patients. No literature related to Ghana or even Africa as a whole was found on familial beliefs and attitudes or in relation to their satisfaction with visiting policies and hours. Since, in Ghana, family members are integral to the care of a patient, it is imperative to evaluate the beliefs and attitudes of family members with regard to the visitation policies of ICUs.

| Aim
To investigate family members' beliefs and attitudes towards visiting policies in ICUs.

| Study design
A descriptive cross-sectional design was employed in this study, the location of which is Ghana.

| Study setting
This study was conducted in four ICUs, two from university teaching hospitals (Komfo Anokye Teaching Hospital in the south and Tamale Teaching hospital in the north) and two from public regional hospitals (Bolgatanga Regional Hospital in the north and Tema General Hospital in the south). The Komfo Anokye Teaching Hospital (KATH), which is situated in Kumasi in the Ashanti Region, is the second-largest hospital in Ghana with a capacity of approximately 1,000 beds. It has a paediatric ICU and a general ICU, which admits adults and has only eight beds.
On the other hand, the Tamale Teaching Hospital is affiliated to the University for Development Studies' School of Medicine and Allied Health Sciences. It is located at the regional capital, Tamale, in the northern region of Ghana. It serves as a referral hospital for the following three northern regions of Ghana: Tamale, Upper West and Upper East. Furthermore, it also serves a few neighbouring countries such as Burkina Faso, Ivory Coast and Togo. It has a bed capacity of about 800 and a general ICU with a bed capacity of 16. The Bolgatanga Regional Hospital is situated in the Upper East regional capital and has a General ICU with a capacity of only two beds. The Tema General Hospital is located at the Tema Municipality, which is close to the Tema ports and harbour. It serves all the Tema communities present in the Greater Accra region of Ghana and has a General ICU with a capacity of four beds.

| Study participants
In this research, the study population included the family members of patients who had been admitted to ICUs. The sampling procedure that was adopted was simple convenience sampling with a confidence interval of 95% and a power test of 90%. In the frame of sampling, first-and second-degree relatives as well as their confidants aged above 18, who were of sound mental health and were willing to participate in the study, were recruited. Most families in Ghana live under an extended family system, wherein every member resides in the same large house. Moreover, there is no significant difference in terms of family members' beliefs and attitudes. The sample size of this study was 200. The inclusion criteria included family members who had visited their relatives who were admitted to the ICU; they needed to be at least 18 years old and had to be willing to participate in this study. Literacy was not considered in the selection of participants. The exclusion criteria of this study comprised those who visited the patients but never identified themselves as their family.
Ghana largely constitutes a typical African society, with a typical communal life. The sense of collectivism means that neighbours who have lived in the same community for a while are often regarded as families and confidants. These connections serve as a means of social and psychological support to community members in times of crisis. To this end, everyone in the vicinity wants to share in the pain and empathize with their neighbours in the event of sickness or ill health.

| Data collection
Data were collected between June 2017-December 2017. The first author was present on-site to supervise the data collection process. Demographic information concerning the patients' families included seven questions pertaining to gender, age, religion, ethnicity, relationship with patient, employment status and level of education. Moreover, data were collected by means of a standard instrument called Beliefs and Attitudes Visitation Questionnaire (BAVIQ), which has been developed by Berti, Ferdinande, and Moons (2007); permission to use the instrument was granted by Dr. Philip Moons (Academic Centre for Nursing and Midwifery, University of Leuven). The BAVIQ was developed to assess nurses' beliefs and attitudes about the visiting policies adopted in ICUs.
Moreover, this permission was sought and granted to eliminate the questions that were nursing focused and those that could not be ascertained by the family members. As a result, five questions were eliminated from the said questionnaire because they were based on the beliefs and attitudes related to the haemodynamics of patients, open visiting policy interference with the relationship between nurses, psychological stress experienced by nurses, nursing processes and visiting policies that make nurses feel in control.
It must be noted that these changes did not alter its reliability or validity. Additionally, minor revisions were made to improve the ease of understanding and to reflect the content to ensure suitability for the families' use.
In this study, content and face validity were established. The questionnaire was submitted to five faculty members of the intensive care nursing department of the Tehran University of Medical Sciences and four master's degree ICU nursing candidates for review and to ensure that the tool was suitable to be used for the family members participating in this study.
A pilot study was conducted with a convenience sample of 20 family members whose relatives were admitted to the ICU. This was done to evaluate the metric characteristics of the modified questionnaire (internal consistency, reliability and validity) in addition to the stability of the measurement used by the family members. The English version of the questionnaire was used, and the illiterate family members who could not read were assisted. Each item or line was explained to them to ensure that the content was well understood before they made a choice.
The structured questionnaires comprised 14 items assessing the participants' beliefs and 14 items assessing their attitudes. The questions elicited responses according to a five-point Likert scale format, which had answers ranging from "strongly agree" to "strongly disagree." It was a self-reported questionnaire, and where necessary, the questions were clarified to those who had difficulties in understanding.
The said questionnaire contained both positively and negatively formulated questions. To calculate an overall score of the families' beliefs, a few of the responses were reverse-coded and the questions were negatively formulated. Subsequently, the average score of all the belief items was computed. A score of zero corresponded with beliefs that are strongly opposed to open visitation, whereas a score of four corresponded with beliefs that are strongly in its favour. In the scoring system, "agreed" and "strongly agreed" and similarly, "disagreed" and "strongly disagreed" were added for the purpose of determining the belief or the attitude status of the respondents for each item that they responded to. However, the responses stating "neither agree nor disagree" were not computed but were considered to be neutral. A score of at least more than 50% was considered to be of high value and was reported.

| Data analysis
Data were analysed with the help of a descriptive and analytical statistical test employing Statistical Package for Social Sciences program (SPSS) version 16. In addition, these observations were computed using a chi-square test and an independent t test. The first and second authors managed the data and analysis.

| Ethical considerations
Ethical approval was obtained from the following sources: the Komfo

| RE SULTS
A total of 146 out of 200 family members (73%) consented and participated in this study. The study subjects' baseline characteristics included a mean of 28.9 (SD 4.72) years old. It reported the minimum and maximum age of the family members to be 23 and 33 years, respectively, with most (61%) of the respondents being females. Most of them were unemployed (74.6%) and had received a tertiary level of education (71.2%; Table 1).
From this study, it was observed that family members who completed the questionnaires showed great support for the benefits of visitations (61%) and the benefits of visiting policies with a mean score of 3.39 (SD 0.48). From Table 2, it can be noted that most (

| Relationship between the families' beliefs and attitudes
In this study (Table 3), a p value <0.05 indicated a meaningful relationship. So, a meaningful relationship was noted between the families' beliefs and religion (p = 0.02), educational level (p = 0.03) and family status (p = 0.04). Moreover, a significant correlation was also observed between the families' attitudes and family status (p = 0.04) and their level of education (p = 0.05).

| D ISCUSS I ON
There They also believed that such a policy could infringe on the patient's privacy. The consensus in this regard was that while a family might feel there are certain benefits of an open visiting policy for the patient, they were also cautious of the opportunity that it could hinder the recovery of the patient. This can be compared to a "flat gate" cultural response, according to which in Ghanaian tradition, families live together in the same extended large compound. As per this arrangement, grandparents, parents and children live in the same compound or in a nearby one, sharing good times and bad times alike. Hence, one is always surrounded by several family members during a period of difficulty (Yaw & Baffour, 2005). This could hinder a patient's rest, They also believed that it could offer visitors an opportunity to interpret information for patients since the latter could trust and feel more comfortable with their family members who understood them better.

Beliefs and attitudes
Several studies, conducted internationally, support our findings; open visitation increases family members' satisfaction, decreases their anxiety, promotes better communication and contributes to the better understanding of a patient (Fumagalli et al., 2006;Maité et al., 2008;Marco et al., 2006). Furthermore, a consistent finding in this regard was the belief that allowing one's family in the ICU or including them in the healing process enhanced nursing care owing to the valuable information obtained in the process (Berti et al., 2007;Kirchhof, Pugh, Calame, & Reynolds, 1993). Visitors provide information that supports healthcare professionals to better understand the patient's personality and coping style (Gonzalez, Carroll, Elliott, Fitzgerald, & Vallent, 2004).
Our study showed that these Ghanaian family members did not believe that an open visiting policy exhausted the family or that it made nurses frightened of being held accountable for their mistakes.
In In our study, most of the families wanted visitation to be approved by the patient. This is probably because they wanted the visiting policy to be based on the patient's need. This is supported by many studies asserting that patients' visiting policy followed in ICUs must be designed on the basis of the patients' and their families' needs   (Baning, 2009;Berti et al., 2007).
Furthermore, the participants wanted patients to have control regarding the duration of visits and number of visitors that he/she can have at a time. About 80.7% of the participants did not want the visiting policy to be adjusted to the culture/ethnicity of the patient. This is because doing so would not work effectively, considering the multi-ethnic, multireligious and multicultural society of Ghana.
Moreover, the family members thought that a strict starting hour is important, but the length of a visit needed to be flexible, especially during the patient's first 24 hr of hospitalization. This is important for the family members as ICU admissions are often unexpected and families are typically unprepared and stressed. A flexible visiting policy for the first 24 hr of hospitalization will lessen families' anxieties and worries for their loved one. Another interesting finding in this regard is that despite the fact that family members desired a flexible visiting policy, they did not think that the current visiting policy needed to be adapted in cases when a patient was dying. Ghanaians protect the secrets of the dead; the cultural imperative is to not allow other visitors to see the way their relative passed away. Surprisingly, the current finding stands in contrast to the international research conducted in this regard, pertaining to whether ICU healthcare staff members are in favour of an adjustment in the visiting policy in end-of-life situations and/or when the patient is dying (Berti et al., 2007;da silva Ramos et al., 2014).

CLI N I C A L I M PLI C ATI O N S
According to this study's observations as well as the review of the current literature, Ghanaian ICU visitation policies should be made more