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Open visitation in a neonatal intensive care unit: nursing team's perceptions


Fábio Luiz BanharaI; Francely Tineli FarinhaII; Tatiane HenriqueIII; Ana Paula Ribeiro RazeraIV; Nadja Guazzi Arenales AlvesV; Armando dos Santos Trettene VI

I Nurse. Craniofacial Anomalies Rehabilitation Hospital of University of São Paulo, Brazil E-mail:
II Nurse. Master of Science, Postgraduate Program in Rehabilitation Sciences, University of São Paulo. Brazil. E-mail:
III Nurse. Craniofacial Anomalies Rehabilitation Hospital of University of São Paulo. Brazil. E-mail:
IV Nurse. PhD in Sciences. Full Professor, Department of Nursing, Universidade Paulista, Bauru, São Paulo, Brazil. E-mail:
V Pediatrician. Maternidade Santa Isabel, Fundação para o Desenvolvimento Médico e Hospitalar, Bauru, Brazil. E-mail:
VI Nurse. PhD in Sciences. Craniofacial Anomalies Rehabilitation Hospital of University of São Paulo. Full Professor, Department of Nursing, Universidade Paulista, Bauru, Brazil. E-mail:





Objective: to understand nursing personnel's experience of open visitation in a neonatal intensive care unit, before and after implementation. Method: this descriptive, qualitative study was conducted at a public maternity hospital in Bauru, São Paulo, Brazil, in 2016. The sample, defined by the data saturation method, consisted of seven participants. Data were collected by structured interviews, and thematic content analysis provided the methodological frame of reference. The study after approval by the research ethics committee. Results: the categories identified from the discourse were: professional expectations before open visitation; coping with the difficulties of open visitation; evidencing the benefits of open visitation; and challenges in improving it. Conclusion: the nursing team's initial perceptions were negative, but after implementation of open visitation, the benefits for newborns, parents, companions, and staff became evident.

Descriptors: Nursing; newborn intensive care units; humanization of care; professional-family relations.




The intensive care unit (ICU) is intended for the care of patients requiring complex and specialized care.1 Its environment is stressful and generates an emotionally compromised atmosphere for both professionals and patients and their families. In the expectation of making it more humanized, different policies have been proposed by federal agencies and professional classes.2

Among the various contexts addressed in the humanization policies, it is worth highlighting the presence of accompanying persons during hospitalization, being considered a fundamental process to reach a humanized care practice.3,4

Considering the above, the objective of the present study was to understand the experience of nursing professionals about the open visitation in a neonatal intensive care unit (NICU) before and after its implementation.



Different regulations establish that hospitals provide conditions for the full-time stay of a parent or guardian in cases of hospitalization of the child or adolescent.3,4 In this context, the patient ceased to be the only focus of health care, emphasizing the need to insert the family in the nursing care process, mainly because they are linked to the success of the rehabilitation process and improvement in the prognosis of the patients. patients.5,6

Different populations are treated at the ICU, including the pediatric and neonatal public, where the need for parental stay is indispensable. Although the benefits related to the stay of the companions during hospitalization are evident, their implementation falls short of the ideal.6,7 Clinical instability, the complexity of care and the risk of infection are some of the reasons given by managers and practitioners to oppose this practice.2,6 However, the demands of family members, who are increasingly aware of their rights, associated with the need to comply with what is determined by legislation, have universalized this practice, requiring the services to implement it.

Although studies on the perception of the nursing team regarding the permanence of the parents in the NICU are available, investigations that compare this perception before and after the implementation of the incipient openness.



This is a descriptive study, with a qualitative focus, developed in a public maternity hospital located in Bauru, São Paulo, Brazil, in June 2016.

The population was composed of nursing professionals, including nurses and nursing technicians. The criterion of inclusion was to work in the NICU for a period of more than one year. The intentional and convenience sample was defined by the data saturation method8 and consisted of seven participants, three nurses and four nursing technicians.

The research began after approval of the project by the Research Ethics Committee of the Paulista University, through opinion 1,784,675 and CAAE: 60181016.0.0000.5512. The participants formalized their adhesion by means of a Consent Form, in accordance with the ethical and legal principles in force. The study was conducted according to the consolidated criteria for qualitative research reports – COREQ.9

For the data collection, a structured interview was used. The triggering element was: tell me about your perception regarding the open visitation in the NICU before and after its implementation. It was considered as an open visitation the possibility of the companion's stay full time with the newborn during his stay in the NICU.

The interviews took place in a private setting, outside of the work shift and recorded for the audio. The content of the recordings was transcribed to facilitate the process of analysis of the emerging data, as well as to improve and deepen the subsequent interview.8,10

To identify the speech and to guarantee the maintenance of the anonymity, the letter P of professional for each subject, as well as sequential Arabic numbers was used. The average duration of the interview was 30 minutes. In addition, the participants were characterized according to age, gender, marital status, professional category, training time and time of operation in the NICU.

For the qualitative analysis, the methodology of thematic content analysis was used, in which the data processing is performed by the inference and interpretation of the contents, organized and similarity, being systematized in the following phases: pre-analysis - the floating reading of the contents of interviews through the principles of completeness, representativeness, homogeneity and relevance; material exploration - coding operations were built through the identification of key words and related topics, with subsequent aggregation of information into thematic categories; interpretation - data processing, inference and interpretation.8,10



Seven nursing professionals participated, of which 3 (43%) were nurses and 4 (57) were nursing technicians. The mean age was 37 years old (±11), all of them female, 5 (72%) married and 6 (86%) with children. The average time to work in the NICU was 5 years (±3) and that of professional training was 8 years (±5).

From the speeches four categories were identified: professional expectations before the open visitation, facing the difficulties of the open visitation; demonstrating its benefits and challenges in its improvement.

Professional expectations before open visitation

Expectations regarding how parents would react to the procedures performed with their children, since they did not have knowledge about them, were evidenced. Still, it was observed the concern of the professionals about the collections with the team.

We were afraid that the parents would not understand the intercurrences and they would not allow us to carry out the procedures on the babies [...] of the parents to observe and collect. (P3)

We were not accustomed to working with parents watching our work [...] not because we did wrong things, but they are not aware of the procedures [...] it is more anxiety, insecurity about what they think of our work. (P5)

Concerns about how parents would react to the procedures and behaviors performed with their children refers to their unfavorable situation, often with physical and psychological stress due to hospitalization, since the NICU represents a hostile environment of clinical severity and demise risk. 11,12

The safety of professionals in dealing with equipment and materials is sometimes interpreted by parents, family and companions as of coldness, mechanisms and dehumanization. In this sense, the hegemony of knowledge on the part of professionals tends to be defended.12 Thus, the assimilation of a new way of being and being in the NICU, based on co-responsibility for the care and sharing of knowledge with parents, encounters resistance. However, it is understood that these reactions are forms of resistance and self-protection.13

Parents and caregivers have a different view of the reality of care, particularly in relation to procedures that may cause pain or discomfort to newborns and are considered as abuse and not as a necessary therapeutic measure. It is observed that the lack of scientific knowledge, as well as the necessity of the procedure, triggers in the parents insecurity, suffering and resistance. Thus, clarifications on the need for interventions, use of techniques to reduce the discomfort of the newborn and preparation for procedures tend to reduce the negative impact on the parents, generating understanding.5,12,14

The concern of the professionals about possible difficulties of reception and accommodation of the relatives in the NICU was also evidenced, since the environment was not planned to receive them continuously.

We were worried that parents would always stay with babies because space is limited. This could overcrowd the NICU. (P1)

I thought about how the parents would stay the whole time, because the NICU is tight, the beds are very close, we cannot accommodate them well. (P6)

Some difficulties are pointed out as restricting the implementation of open visitation, including inadequate physical space.15,16 Despite the relevance given by the team to questions of this kind, they are pointed out as being of lesser importance by family members, who prioritize the reception with accurate and clear information about patients. 17,18

Facing the difficulties of open visitation

The professionals expressed difficulties in the implementation process, which included the limitations of understanding and lack of adherence by the parents to NICU rules and routines, leading to conflicts with the team. Parents are usually anxious and worried, and the difficulty of understanding the whole implies the intense search or solicitation of nursing, causing discontent in the professionals.

The population we serve is very poor and has less access to information [...] they are unguided families and often with social problems. This makes our work very difficult, because they do not understand the need for NICU procedures and norms and routines. (P3)

There are parents who cause disorders and do not respect the rules [...] (P4)

Other difficulties reported included the team's concern about being observed during care and the resistance or discontent of parents regarding the performance of invasive procedures.

The greatest difficulty was performing the procedures with parents observing [...] some show resistance in allowing examinations to be performed and sometimes see procedures as maltreatment to the baby. (P1)

I am guarded by them [...] They ask a lot! [...] Sometimes they ask the same question for various professionals to see if they are talking the same thing [...] The team had professionals who were angry because they were not accustomed and felt pressured. (P3)

Nursing professionals tend to retract and consider as invasive the presence of parents, claiming lack of space, interference in routines and noncompliance with standards, pointing out the need to train the team to deal with such issues.13,19

The nursing team is often resistant to offering information to family members, which can lead to feelings of insecurity and fear, generating greater stress for parents and caregivers. In this context, the importance of guidance and clarification of doubts as an effective intervention with family members is emphasized.5,17,14,20

Family members and companions wish to receive information from the doctor regarding the clinical condition of their bodies. However, they expect to receive information from nurses and their staff about hygiene care, nutrition, exams, among others.21

Another aspect to be considered refers to the need to be attentive to non-verbal communication, because it offers evidence of undisclosed needs. 22 The fact that the hospital is public, and therefore serving a socially disadvantaged population, should be considered, since low schooling, for example, may influence the understanding of communications.

It is emphasized that in the NICU, field of the present study, in the admission of the newborn is offered to the parents or companions a folder containing information regarding the unit, as well as its norms and routines. This folder is read by the nurse next to the relatives, to facilitate the understanding, although it contains language accessible to lay people. However, it is evident that some parents or companions are resistant to certain rules, including the use of adornments, cell phones, curiosity to visualize the other babies, needing to be approached constantly by the team.

Providing printed material, such as explanatory leaflets, along with clear information, assists in the understanding of standards, routines and care performed at the ICU, generating greater acceptance and reduction of stress to parents, chaperones and staff.23

Regarding the fact that parents request information from various professionals to validate or test the response obtained, it is inferred that it may result from lack of understanding and not from distrust. Low-education populations have difficulty understanding technical terms, drawing on other staff members for more simplified information. 24

Strategies are presented to facilitate parents' understanding and improve communication between staff and family, including using easy-to-understand comparisons, explaining technical terms, validating information with parents, asking what they understood, providing information gradually, other.25,26

Evidence of the benefits of open visitation

In relation to the nursing team, professionals reported changes in behaviors related to professional posture.

We begin to police ourselves [...] mainly in relation to conversations and attitudes, because the parents pay attention to what we say and how we act. (P1)

The behavior of the team changed for the better after the open visit [...] We were more careful not to get an inappropriate image. (P2)

Another benefit linked to open visitation was related to the greater confidence and safety of the parents in the nursing team.

When they are inside the unit, they see care and stop thinking that the baby may be being neglected or poorly cared for [...] They value our work more. (P7)

When visiting hours were restricted, the charge and fear of the companions were greater [...] they did not know how their children were being cared for [...] now they were more confident and confident in leaving their children under the care of the staff . (P6)

The evaluation of the team results from the process of positive evaluation by the parents in relation to the care, considering the zeal, the interaction with the newborn during the technical procedures and the provision of adequate information to the relatives. This is necessarily due to the observation of the team by the parents and, vice versa, to establish a bond and knowledge between both parts.27,28

With open visitation, the parents were encouraged and inserted in the care of their children, which provided the interaction between them, strengthening their confidence in the delivery of care. It is also worth noting the parents or caregivers learning about the care that should be continued at home.29

It was also found that the parents felt more secure and satisfied since they were able to follow up on the procedures and check the quality of care.

We seek them participate in the proceedings and seek to clarify all their doubts. They always cling to someone [...] establish a relationship of trust. (P 1)

For the parents, this experience was positive because they do not have that desperation to leave the child [...] the doctors and nurses talk at any time [...] they have access to the information, properly. (P 2)

From the establishment of the trust relationship between parents or caregivers and the nursing team, complicity and understanding are observed, including in performing invasive procedures with the newborns, since they understand the need for them and that all efforts and interventions are aimed at their recovery. It is emphasized that the reduced number of visits, as well as the limited time, is related to lower satisfaction of parents and relatives.22

The insensitivity, the lack of information and the unavailability of the professional when requested, as well as the verification of a deficit in the number of employees, generate feelings of helplessness and tend to favor the resistance of the companion to the cooperation. However, constant observation and permanence in the unit tend to make the parents more understanding and collaborative with the team.11,27

As for the benefits of open visitation for newborns, the strengthening of parenthood and the stimulation of neonatal sensitivity to the emotional state transmitted by the parents were included.

When the parents are present the baby gets calmer [...] they recognize the parents' voice and we perceive a better evolution. The bond between parents and babies increases [...] What is essential is the bond that is strengthened. (P 2)

Parents better understand their child's condition and are less insecure and anxious [...] they feel better prepared for post-discharge care. (P 6)

The contact with the newborn and the involvement of the parents in the care have the potential to strengthen the bond and attachment that may be shaken by hospitalization or the figure of the child who escapes the narcissistic standards of perfection. The parents' sense of guilt associated with these cases may lead to negligence and should be worked during hospitalization. 30,31

On the other hand, open visitation provides a better understanding of the clinical state of the newborn, as well as the procedures performed, even in unfavorable cases.

As for the benefits related to newborns, in addition to strengthening the bond with their parents, professionals reported improvements in the clinical conditions and emotional aspects of parents and babies. It is extremely important to include families in the therapeutic decisions and in the care of their children to promote a positive therapeutic relationship. 29,32 Advanced or flexible visitation hours are indicated as more important than their duration, because they provide adaptations to the needs of each particular case.6

The kangaroo method, with the participation of parents as companions with free access to the NICU, is one of the pillars; a study carried out with the objective of evaluating its results in Brazil, found benefits related to the promotion and maintenance of breastfeeding.33 Other advantages of this methodology include reduced length of hospital stay and neonatal mortality.24 These results highlight some of the benefits of open visitation.

Challenges in improving open visitation

The professionals spoke about the challenges related to physical space - providing comfort to parents and families and improving the reception process.

Comfortable chairs and nearby restrooms should be offered for added convenience [...] to improve the information provided by the team and give more attention. (P 3)

It takes a little more space, a reception or waiting room [...] some orientation before entering the NICU, especially the first time.

It should have a parenting group with a multidisciplinary team [...] should work more with parents, give more information, psychological support [...]. (P 5)

As an impediment to open visitation, among others, the absence of suitable space for accompanying patients is included. Research indicated that 51% of Brazilian ICUs do not offer any comfort to family members.6 Among the suggestions proposed to improve the NICU's reception process, it includes the assistance of a multidisciplinary group of parents and family support.6,17

Although the legislation guarantees appropriate conditions for the full-time stay of parents and caretakers, in practice it is perceived that this determination is not fulfilled, posing a great challenge to managers and the health team.3,4,24



The professional expectations of the nursing team regarding the open visitation in NICUs initially were negative, causing insecurity and resistance. Subsequently, with its implementation, the difficulties were faced and minimized, and, finally, benefits were shown for newborns, parents, companions and staff. However, there was a need to improve aspects regarding the reception and comfort of parents and caregivers. In short, the implementation of open visitation can be referred to with a process where the nursing team is the protagonist.

It is hoped that the findings of this research will contribute to demystify aspects of the implementation of open visitation in NICUs and to adopt strategies for their falsification and improvement.

As a limitation, it is pointed out the monocentric characteristic of the study that does not allow the generalization of the results. Thus, considering the relevance of this theme, the performance of other studies in different contexts is encouraged.



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Direitos autorais 2018 Fabio Luiz Banhara, Francely Tinelli Farinha, Tatiane Henrique, Ana Paula Ribeiro Razera, Nadja Guazzi Arenales Alves, Armando dos Santos Trettene

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