George Ward is a general surgical ward specialising in colo-rectal surgery. It also has trauma patients with multiple injuries from the HEMS project. Much of the colo-rectal surgery is specialist regional or supra-regional work, with patients from all over the United Kingdom. Overall, the majority of work is emergency. The local East London population gives a very wide ethnic and cultural diversity of patients, many of whom do not have English as a first language.

Visiting hours are currently 8am to 8pm with preferably only two or three visitors to each bedside, although this may depend on individual patients and circumstances. A dying patient in a side room may be allowed unlimited visitors, whereas patients located in one of the small bed spaces in the 'Big End' of the ward are often critically ill and thus 'two to a bed' would be enforced. The unwritten policy of the ward is always to try and be flexible. There is no overall Trust policy on visiting.

The 'visiting problem' seemed to relate mainly to patients of ethnic minorities but also to a few local white East Londoners. These patients had either large volumes of visitors - up to 10 or 12 at one time, or visitors arriving after the ward visiting time had ended.

Difficulties and frustrations for staff arose when they asked patients to have only 2 or 3 visitors at the bedside for reasons of safety or when they asked visitors to leave at the end of visiting hours. Sometimes staff were met with verbal abuse or were ignored. Staff would also receive complaints from patients in adjacent beds about the amount of visitors that an individual had and more junior staff expressed concerns that they were not able to deliver care to many of these patients.

Additionally there were 'near miss' incidents involving young children visiting with their parents such as a toddler who looked like he might put his hand into a sharps bin left attached to a drug trolley; another put his head through the railings on the balcony.

There can be a requirement for a wider range of relatives and family friends, including spiritual leaders and elders to visit in small groups e.g. Afro-Caribbean patients may be visited by their church 'family' and by choir members. These visitors may wish to pray, sing and read the scriptures to help strengthen their loved ones. (12) Similarly for Muslims in Britain, the obligation to family members, in particular, to the sick are very strong and everyone who can visit, must - this duty is outlined in the Koran.

Thus the phenomenon of visiting is an important process for the welfare of the patients as well as for their relatives. But its characteristics are highly variable from one health care institution to another and also from one ward/unit to another and between individuals of different cultures.

The research question was defined as, "What do our patients think that visiting hours on George Ward should be and how different is this from the staff's expectations?"

A convenience sample was chosen, since only patients admitted to or transferred to George Ward were included. There were no exclusion criteria. The sample size was initially agreed as 100, to facilitate easy calculation of results. Of the staff sample, all permanent nursing staff were chosen, both qualified and non-qualified staff. Anonymity was guaranteed for patients as no record was kept of names or bed numbers or hospital numbers. Staff could be identified by their handwriting.

Questionnaires were handed out to patients, in the ward, by the staff nurse when she was on duty or by any other staff when she was off duty. Patients were asked to return the questionnaires to any member of staff or to put them directly in the box in the main corridor of the ward. Staff questionnaires were put in the staff post tray, and returned to the staff nurse in the same manner or were put into the box in main corridor.

Patients' questionnaires were collected from the box at intervals and collated. Further photocopies of the original 100 patient questionnaires were made since not all questionnaires were returned. No formal records were kept of the response rate, more questionnaires were sent -out in order to reach the target of 1 00 patient responses. At the end of the three-month period, 54 responses were received from patients and 14 from staff. (Note: the staff nurse left Trust employment during this time, so the author re-checked and collated the data).

Of the patient questionnaires, 56% of patients (n=30) were told what the visiting hours were, compared to 44% (n= 24) who were not. But the majority 61 % (n=33) were not told how many people were allowed at each bedside, although 31 % (n=17) knew it was ideally two to a bed.

The majority of patients 61%, felt that the length of visiting hours was about right, compared to 7% (n=4) who thought they were too short and 30% (n=16) thought they were too long. 56% did not specify what visiting times they wanted but there were comments added that it should be "any time" or "up to staff" from two respondents.

On the subject of the number of visitors, only 7% (n=4) thought that there were always too many, 44% thought there were sometimes too many but it did not bother 48% (n=26). When asking how many visitors should be at the bedside at one time, most people thought it should be 2 or 3 although 22% (n=12) thought 4 visitors was acceptable and 1 3% (n=7) wanted as many as they chose!                

Most of the patients felt that children should be allowed to visit - 42% Yes, 48% sometimes. Of children visiting, a fifth wanted any children to visit, only 2% said "No children" and the remainder wanted family: either own children, grandchildren or any child relatives.

The response to the ideal age of children visiting, were; 24% any age can visit, 26% no children under five and 24% said parents should be allowed to choose. 2% commented that the "ill person" should choose.

22% (n=12) of patients wanted a rest period, 35% did not and 41 % said that they would want one on 'some days'. Only one person did not know. Therefore, the majority, 63%, seem in favour of it.              

There is no ward policy regarding visiting yet staff have an unwritten understanding that this is between 2 and 3 visitors per bed since 85% (n=12) of responses stated this. This was in line with staff expectation that two to four should be the maximum per bedside 93% (n=13) of answers fell in this range.

The majority of staff (79%, n=11) felt that visiting hours were too long and 14% (n=2) thought that it was about right, 79% went on to request shorter visiting hours. The modal average that 36% (n=5) staff chose was 2pm to 8pm.

All the staff thought that children should be allowed to visit but comments were made such as "it depends on the age of the children and the situation of the patient", "parents don't supervise them properly", if supervised by adults and not disturbing others".

In terms of children's ages, 29% said that it did not matter, one person said that it did not matter unless the children were crying and screaming in which case they should be removed from the ward. The remainder gave a variety of opinions as to age restrictions, which included "no babies", "must be older than 6 years and well behaved", "no under 12 years unless visiting their mother or father and must control the period of time". There was no consensus for the majority.

All staff (n=14) thought that there should be a rest period although the timing of this varied from mornings, to part of the afternoon and 21% (n=3) felt that it would be difficult to enforce with ward activity.

14% of staff do not feel that visitors affect their work but the remainder all describe instances when work is affected and the safety of patients is compromised. Some of the comments include "Increases stress", "some-times they are useful as they may wash relatives but I think this should be by prior arrangement with the nurse in charge", "they physically get in the way, cause too much noise".

Some comments that were received included some common themes such as "We all need a firm policy which we all agree to stick to", "keep the bottom doors of the ward closed with clear notice of visiting times"and "everybody needs to be more assertive about visiting times and asking people politely to leave".

The expectation of most staff and patients is that two to three visitors per bedside are adequate (85% of staff and 61% of patients). However staff did not always communicate this to patients (61% of patients did not know); neither did they always communicate what the visiting hours were (44% were not told). It must also be noted that 22% of patients thought that 4 visitors at the bedside was satisfactory and 13% wanted as many as they felt like, so for these people, the health and safety aspects must be stressed by staff, to ensure compliance of the two to three to a bed regime.

As to visiting hours, the staff stated that they were too long (79%) and 30% of patients also thought they were too long. 14% of staff and 61% of patients stated that visiting was 'about right'. It must be considered that there is a conflict of expectations here with the majority of staff wanting shorter hours and the majority of patients happy with the way things are. In terms of ideal visiting hours, both patients and staff gave a wide range of answers but of those wanting a change, the most popular was 2pm to 8pm which was n= 5 staff and n=5 patients.

The expectation of staff and patients matched broadly with regard to children visiting in that all staff and most patients thought they should visit. The differences occurred with regard to age limits where there was a very broad range of answers, so much so that recommendation for change is difficult to make.

There is a matched expectation in terms of a rest period, where all staff and 63% of patients would like a rest period. However there are staff concerns about making it work and 41% of patients stated that they would only want one, some days. A third of patients also stated that they did not want one, n=19 (35%). As only 22% of patients said that they wanted one daily, it may not be feasible to implement without further consultation with patients or a pilot study or redesign of ward accommodation to give more side rooms and smaller bays to facilitate this.

Comments on how visitors affected staff working can be applied to other patients who comment on the fact that "other people's visitors do not respect some patients' need to rest", "visitors are too noisy and treat the ward like a social club" and "visitors should be restricted in the smoking area and not allowed in the dayroom".  There is a sense that some visitors are disrupting the patients' day through noise pollution, invasion of space and privacy. This may be detrimental to patients' recovery as much as their presence may be beneficial to their friend/relative.

In summary it seems that expectations of staff and patients are broadly matched in all aspects other than length of visiting hours.

It is useful to review the research process in terms of its reliability and validity as there may be a future requirement to replicate it or to build on its findings as well as to use the data in decision making about changes to visiting arrangements

Factors such as language, patient illness, ethnicity and culture were discussed in background but were not fully explored as variables.  For example, the questionnaire was only produced in English and those with poor command of written English may have found difficulty in completing it. These factors would need to be addressed if the questionnaire was to be used on a wider scale. If patients are unable to read or write English, they often have visitors who do. This adds another variable since the 'interpreter' may add his/her own bias. In spite of this, most of the questions were answered, (question 7 about children visiting and question 10 comments/suggestions being the exceptions i.e. n<54) and thus the data sought has been received which gives the tool validity. Whilst questionnaires can enforce choice, individuals have added in their own  answers where appropriate.

Due to the study design one can not elicit whether it was a representative patient population for George Ward, particularly with the small sample size. It was hoped that the distribution of patient questionnaires was random with many of the ward staff handing out questionnaires, thereby minimising selection bias which could have been present if only one person was doing this. More formal study of the cultural needs of our local population is needed to ensure that we are able to provide holistic and trans-cultural nursing care.

The response rate to questionnaires is unknown for patients but for staff, there was a 50% response rate, which included all grades of staff and the reasons for this have not been explored with staff but may have been due time constraints or because it was not seen as valuable. Statistical tests were not described due to the author's unfamiliarity with using them, any further study in this area would benefit from their inclusion.

The author has used the research process to identify the answer to the research question and in so doing, has found difficulty given the time frame, in terms of design and implementation. There are areas of technique that can be improved upon for future use and areas for future study identified.

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