hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh Copyright © 2022 Tehran University of Medical Sciences. This work is licensed under a Creative Commons Attribution-Non Commercial 4.0 International license https://creativecommons.org/licenses/by-nc/4.0/). Non-commercial uses of the work are permitted, provided the original work is properly cited. Original Article Abstract In intensive care units (ICUs), patient privacy is of particular importance due to the structure of the ward environment and the critical situation of the patients. The aim of this study was to identify the dimensions of patient privacy in ICUs. For this purpose, a descriptive-qualitative-exploratory study was performed. The data collection methods included observations and interviews, which were handwritten and analyzed using qualitative content analysis with a conventional approach. A total of 27 participants were selected based on purposeful sampling and with maximum diversity of health-care providers and recipients. The study environment was the ICUs of two selected hospitals affiliated to the medical sciences universities of Isfahan and Tehran, Iran. The data were analyzed into 4 classes and 12 subclasses. The classes included physical, informational, psychosocial, and spiritual- religious privacy. *Corresponding Author Alireza Irajpour Address: Isfahan University of Medical Sciences, Hezarjerib Street, Isfahan, Iran. Postal Code: 8174673461 Tel: (+98) 31 37 92 76 16 Email: Irajpour@nm.mui.ac.ir Received: 3 Apr 2022 Accepted: 1 Aug 2022 Published: 25 Oct 2022 Citation to this article: Tajdari S, Irajpour A, Shahriari M, Saghaei M. Identifying the dimensions of patient privacy in intensive care units: a qualitative content analysis study. J Med Ethics Hist Med. 2022; 15: 6. Findings of the present study identified hidden layers of patient privacy as a multidimensional concept that is influenced by various factors. In order to provide holistic care, preparing the grounds for patient privacy and familiarizing the staff with its various dimensions seem necessary. Keywords: Patient rights; Privacy; Intensive care units; Iran. Identifying the dimensions of patient privacy in intensive care units: a qualitative content analysis study 1. PhD Candidate of Nursing, Student Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran. 2. Professor, Social Determinants of Health Research Centre, Critical Care Nursing Department, School of Nursing and Midwifery, Nursing and Midwifery Care Research Centre, Isfahan University of Medical Sciences, Isfahan, Iran. 3. Professor, Adult Health Nursing Department, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran. 4. Professor, Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran. Setareh Tajdari 1, Alireza Irajpour 2*, Mohsen Shahriari 3, Mahmoud Saghaei 4 mailto:Irajpour@nm.mui.ac.ir Identifying the dimensions of patient privacy in intensive care units: a qualitative content analysis study J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 6. 2 Introduction One of the basic human rights is respect for one’s privacy (1). Privacy is a critical issue in the field of ethics and medical sciences (2, 3) and is very important in health-care centers (2, 4). The World Health Organization (WHO) has included this concept in the Statement of Patients’ Rights as part of the principles of medical ethics (5). Patient privacy has been emphasized as one of the main codes and basic principles of care standards of international organizations and associations (6). In Iran, 1 of the 5 most important clauses of the Patients' Rights Charter is dedicated to patient privacy. Accordingly, the provision of health services to patients should be based on respect for their privacy and the principle of confidentiality (7). In recent years, numerous studies have been conducted in the field of patient privacy, and often, the level of patients’ satisfaction with the health team’s respect for their privacy has been reported as moderate or poor (8 - 10). Additionally, in studies conducted with the aim of comparing the perceptions of patients and members of different groups of medical sciences about the level of patient privacy, significant differences have often been reported. Despite the importance given to patient privacy by health system employees, including nurses, the level of compliance from patients' point of view and their satisfaction is very low (11 - 13). The results of studies performed in Iran on patients' views about privacy during care are indicative of the undesirable privacy level (9, 11, 14). Privacy has an indefinite and relative meaning for which several definitions have been proposed. This is due to the fact that the norms and cultural and religious values of each society and the specific positions of individuals within them are effective in defining and determining its scope (15, 16). Privacy is of special importance in Iran, where the official religion is Islam (12), and has been mentioned many times in the Holy Quran (Surah Noor, verses 27, 28, 30, and 31). In order to provide appropriate health services and culturally suitable care, a qualitative study of the concept of privacy from the perspective of beneficiaries (providers and recipients of health services) is particularly important (11). In health- care centers, intensive care units (ICUs) are considered as dynamic, complex and stressful care environments necessitating numerous ethical decisions. In these wards, professional staff with specific skills and expertise work together as a Tajdari S., et al. 3 J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 6. team to provide the best health services to critically ill patients (17). Some factors affecting patient privacy in ICUs include complexities of patients' clinical status, the ward’s physical structure, attitudes, beliefs and behaviors of health team members (18, 19), and even organizational factors such as the culture governing the relationships, interpersonal and interprofessional relationships, and management (20). In Iran, most of the previous studies have addressed the level of patient privacy in general wards, although a few studies have investigated the conceptualization of patient privacy, especially in ICUs and with the participation of all stakeholders (8 - 10). Qualitative studies seek to examine and deeply understand the studied phenomenon and identify it clearly and comprehensively by using different methods of data collection (21). Therefore, the most reliable way to determine how to protect patient privacy is to directly examine events, experiences, values and norms (22). Purposeful observation of the clinical field and reviewing the experiences of health-care providers and recipients can be effective in evaluating, maintaining and promoting patient privacy (23). Since the concept of privacy is influenced by culture, religion and individual preferences (2), the researcher has directly identified and analyzed the participants’ beliefs and values by being in the field, observing events and interviewing all groups of stakeholders. This qualitative study was conducted to identify the dimensions of patient privacy in ICUs. Methods This manuscript presents some of the findings of a PhD dissertation. In the larger original study, the WHO Clinical Guidelines (24) were used to design and develop interprofessional patient territoriality clinical guidelines for ICUs. The present study was performed in 2021 in the form of a descriptive- qualitative-exploratory study, using the content analysis method with a conventional approach. The study environment consisted of ICUs, coronary care units (CCUs), and dialysis wards of two selected hospitals affiliated to Isfahan University of Medical Sciences and Tehran University of Medical Sciences, Iran. Data Collection The data collection method included observations and semi-structured, in-depth interviews. During the 5 months of continuous presence in the study environment on different days and shifts and using various observation methods, the researcher recorded all her findings in the form of a field diary and its summary on paper, and later on the same Identifying the dimensions of patient privacy in intensive care units: a qualitative content analysis study J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 6. 4 day prepared them for analysis by filling in the details. In-depth, semi-structured interviews were applied to assess patient privacy requirements. The study population included recipients and providers of health services in ICUs of two selected hospitals affiliated to the medical sciences universities of Isfahan and Tehran, Iran. In order to select a small sample with maximum diversity of key informants, the purposive sampling method was adopted and sampling continued until data saturation. The health-care recipients included all patients hospitalized in ICUs of two selected hospitals affiliated to the medical sciences universities of Isfahan and Tehran, or patients with a history of hospitalization in ICUs of those hospitals and their families. Patients who had been unconscious during hospitalization in intensive care units were often unable to fully recall the experiences and explain the details, and were reluctant to participate in the study and collaborate. In the case of patients admitted to the ward, only conscious patients could participate. The study inclusion criteria for health-care recipients included consciousness, being over 18 years of age, and having been admitted to the ICUs, and for family members, willingness to participate in the study, possessing time and place orientation, having no history of mental illness, and having the ability to communicate, express and recall information-rich experiences. The health-care providers included all professional and non- professional staff with at least 1 year of experience in the ICUs who were willing and free to participate in the study and had the required communication skills. In case of unwillingness of the participants or treatment/care-related factors prohibiting them from collaboration, they were excluded from the study. Thus, 27 participants entered the study: 12 health-care providers from different professions, 3 patients, 2 family members, and 10 individuals who had relevant experience in different roles (for instance, health-care providers with a history of hospitalization in intensive care units). At the beginning of each interview, the researcher introduced herself and explained the purpose of the study. After gaining the trust of the participants, the researcher obtained their written informed consent to conduct and record the interviews and save their demographic characteristics, and by asking preliminary questions, provided the grounds for a better and easier interview. In order to conduct in- depth, semi-structured interviews, the researcher began with general and open-ended questions. For example, the patients were asked, "What are your needs and expectations with regard to your privacy in the ICU? Tell me about your experiences.” Tajdari S., et al. 5 J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 6. Then, according to the stated issues and by asking progressive and clarifying questions, the interview was guided to cover the objectives of the study. The continuation of the interview process depended to some extent on the questions that arose spontaneously and as a result of the interaction between the interviewer and the interviewee. The in-depth, semi-structured interviews were conducted individually. Initially, a preliminary interview was conducted in order for the researcher to be familiarized with possible and unforeseen issues and to formulate the arrangement of the questions and complete them. The interviews lasted 35 to 90 minutes. Due to the occurrence of the COVID-19 pandemic, the time, place and type of the interviews (face-to-face or non-face-to- face/virtual) were determined by the participants. Overall, 14 face-to-face interviews and 13 non- face-to-face interviews were conducted using the WhatsApp Messenger. Data Analysis In this study, the qualitative content analysis method with a conventional approach was employed to analyze the data. Initially, all recorded observations and interviews were carefully typed and analyzed using the MAXQDA software (VERBI GmbH, Berlin, Germany). Then, the key words or phrases were identified, and code-naming was performed by continuing this process. The codes were then divided into subclasses that were more abstract than the original codes based on the similarities and differences among them. In order to create the classes, the subclasses extracted in the previous stage were combined according to the existing relationships and differences and similarities. Rigor To ensure the validity and reliability of the study, Lincoln and Guba’s criteria were taken into consideration (25). To enhance the validity of the qualitative content analysis, the researcher used the strategies of continuous observation, continuous and long-term involvement in the desired phenomenon in the field and complete immersion in data, triangulation, peer review and transparency, and review by the participants. To ensure the credibility of the study, the researcher listened carefully to all interviews and then typed them verbatim. To verify the dependability of the study, the researcher tried to carefully record and report the research process in the course of the study to allow others to repeat the study if necessary. In order to ensure transferability, the researcher tried to provide the necessary grounds for judgment and evaluation by Identifying the dimensions of patient privacy in intensive care units: a qualitative content analysis study J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 6. 6 others by accurately describing and explaining the study. Moreover, participants of maximum diversity in terms of demographic characteristics were invited in a targeted manner. Ethical Considerations The Ethics Committee of Isfahan University of Medical Sciences approved the research stages in terms of ethical considerations (IR.MUI.RESEARCH.REC.1398.424). The researcher explained the process of the observations and the research goals to participants. All participants gave verbal and written informed consent before each interview and observation, and were able to withdraw from the study at any time. The confidentiality and anonymity of the participants were preserved at all times, and their data were protected in accordance with the Iranian regulations in force. Results In this study, 5 months of clinical observation and 27 In-depth and semi-structured interviews were conducted with the associated beneficiaries. The participants included patients, patients' family members, nursing staff, physicians, clinical pharmacists, nutritionists and physiotherapists who met the study inclusion criteria. The majority of the participants (70%) were female, and their ages ranged between 28 and 78 years, with an average of 45.15. The minimum and maximum work experience of health-care providers in ICUs was 2 to 31 years, respectively, with an average of 11.75 (Table 1). Following the analysis of the observations and interviews, 374 primary codes, 12 subclasses and 4 classes (including physical privacy, information privacy, psychosocial privacy, and spiritual-religious privacy) were extracted (Table 2). Tajdari S., et al. 7 J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 6. Table 1- Participant characteristics Participants Education Work Experience in ICU, Y Job Status Marital Status Age, Y Gender Number Patient's family member Master’s degree --- Bank manager Married 52 Male P1 Patient's Family member + Staff PhD candidate 4 Faculty member Married 40 Female P2 Staff PhD candidate 3 Nurse Married 34 Female P3 Staff PhD 2 Faculty member + Nursing manager at university Married 57 Female P4 Patient's family member + Staff Bachelor’s degree 20 Head nurse Married 51 Female P5 Patient's Family member + Staff Master’s degree 25 Nurse Single 49 Female P6 Staff Bachelor’s degree 12 Nurse Married 38 Female P7 Patient's family member High school diploma --- House worker Married 53 Female P8 Staff PhD 8 Educational supervisor in hospital Single 42 Female P9 Staff Bachelor’s degree 20 Nurse Married 47 Female P10 Patient + Staff Master’s degree in Critical Care Nursing 6 Nurse Single 36 Female P11 Staff Fourth year resident of Anesthesia 8 Resident Married 40 Female P12 Patient's family Member + Staff PhD in Nursing 4.5 Faculty member Married 47 Female P13 Patient + Staff PhD in Nursing 10 Faculty member Married 41 Male P14 Patient's family Member + Staff PhD Candidate 10 Nurse Single 33 Female P15 Staff PhD in Nursing 16 Academic member Single 59 Female P16 Staff PhD in Nursing 31 Faculty member Married 60 Male P17 Staff Anesthesiologist 32 Faculty member Married 61 Female P18 Patient's family Member + Staff Diploma 10 Nurse assistance Married 40 Male P19 Patient Diploma --- Businessman Single 30 Male P20 Patient + Staff Bachelor’s degree 8 Nurse Single 29 Female P21 Staff PhD in Nutritional Sciences 2 Researcher Single 31 Female P22 Staff Bachelor’s degree 4 Physiotherapist Single 28 Male P23 Staff Master’s degree 11 Physiotherapist Married 37 Female P24 Patient's family Member + Staff PhD in Disaster and Emergency Health 12 Faculty member Single 41 Female P25 Patient HND --- Retired teacher Married 78 Female P26 Patient High school diploma --- Retired military officer Married 65 Female P27 Identifying the dimensions of patient privacy in intensive care units: a qualitative content analysis study J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 6. 8 Table 2- Primary codes, subclasses and classes of qualitative content analysis Classes Subclasses Primary Codes Physical privacy Bodily privacy Level of patient consciousness and dependence Aggressive procedures Providing service in the presence of others Unnecessary touches Gender conformity Physical environment of the ward Ward noise Facilities and equipment Common space Human resources Privatization of units Absence of staff Recruitment policy Employment in other centers Informational privacy Confidentiality Access to patients’ records and information Patients’ ignorance Unintentional disclosure of information Professional and interprofessional rounds Interviews in the presence of others Patient’s awareness of his/her condition Knowing about the progress of the disease Knowing the diagnosis Psychosocial privacy Patient’s psychological status Readiness to receive services Preferences and priorities Interpersonal interactions Talking to the unconscious patient Shyness Distance from family Cultural diversity Refusing blood transfusion Wearing local clothes Spiritual-religious privacy Religious values and beliefs Tying the green cloth to the patient Observing hijab Facilities for performing religious duties Helping patients to pray Ritual bathing and ablution Private space for religious practices Spiritual care Identification of spiritual needs Class 1: Physical Privacy The physical privacy class comprised of 3 subclasses of bodily privacy, physical environment of the ward, and human resources. The researcher's observations and the experiences of the participants showed that physical privacy was one of the most important dimensions of patient privacy in ICUs. It is, however, affected by various human and environmental factors, for instance complex and critical disease status, level of patient Tajdari S., et al. 9 J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 6. consciousness and dependence, gender conformity, number and composition of human resources, environmental conditions and facilities, and application of numerous and often aggressive procedures. With regard to patient privacy preservation, an ICU physiotherapist said, "Often when we dress a patient or change his/her position, we do not draw the folding screen. We forget, or think the patient is unconscious. Sometimes, we do not even draw the folding screen for aggressive procedures, because it interferes with our work. Well, conscious patients or the rest of the staff can see. We may be more careful when the patient is conscious, because he/she can tell us what he/she wants." [Participant No. 23] On the subject of the need for protecting physical privacy in observation 17, the researcher wrote, "Before visiting hours, one of the ward staff pulled a barrier tape in front of the door of each room so that patients’ companions could not enter the rooms. When the ward door opened, the visitors entered the main hallway of the ward and went to the room where their patient was. The folding screens were not drawn and the visitors could see all the patients. If their patient was awake, they would talk to him/her in a loud voice so that he/she could hear." Based on the study findings, the gender composition and distribution of the employees in different shifts was such that it was not always possible to observe gender conformity. The participants cited the organization's policies on hiring, staff absenteeism and lack of appropriate replacements, the low number of male nurses, and their employment in other centers as the main reasons for non-compliance with gender conformity. With regard to the ward environment, a 65-year-old female patient said, "All the male and female patients are hospitalized in the same hall or room on beds next to each other or opposite each other, and there are patients who are unconscious, or critically ill. Most of the time, the folding screens are not drawn, unless the staff want to clean or bathe the patient. Patients who, like me, are conscious can see others and hear what the staff say." [Participant No. 27] Considering the findings, the privatization of some service units in the hospital was associated with a decrease in the recruitment of sufficient human resources in these units. This policy had an impact on providing high-quality services while respecting gender conformity in ICUs. In this regard, a participant stated, "Due to the self- regulatory administration of the hospital, many Identifying the dimensions of patient privacy in intensive care units: a qualitative content analysis study J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 6. 10 hospital wards have been privatized and few staff have been recruited. For example, we only have 1 male physiotherapist who cares for all our patients. He does not have enough time to provide adequate services to all patients. He gets tired too because many of our patients are unconscious or unable to cooperate." [Participant No. 11] Class 2: Informational Privacy The second class was informational privacy with 3 subclasses of confidentiality, unintentional disclosure of information, and patient’s awareness of his/her conditions. Based on the study findings, employees' inattention when providing patients’ information to others and speaking loudly on professional/interprofessional rounds or in interaction with patients were the most common reasons for unwanted disclosure of patients’ information. The participants believed that in cases where patients had specific personal/health issues, the importance of paying attention to this dimension of privacy became more apparent. Regarding the patient's health and personal information, which is considered a taboo, one of the participants said, "The patient does not want others to know his/her history. He/she does not like to be stigmatized. When we speak loudly on rounds, others hear us. I think guidelines in this regard must be observed, whether or not the patient is conscious." [Participant No. 13] Based on the results, sometimes the patient's family preferred their patient to be unaware of his/her illness. In this regard, one of the participants said, "My mother was a candidate for cardiac angiography. Before the angiography, one of the nurses came to the front door of the ward and called me. He asked very quietly, "Did you know that your mother has hepatitis B?" I was shocked. I said no and started to cry. I asked the nurse not to tell my mother anything about it, as I believed her condition would get worse. I decided we could tell her later, when the time was right." [Participant No. 8] The findings also indicated that some colleagues expected to be provided with patient records and information. Observation 56 was indicative of this: "During the visit, a young woman said to a resident standing at the door, 'I am a pharmacy student at this university and he is my uncle (pointing to her patient). Can I take a look at his file?' The resident said, 'No, you are not allowed to.' The young woman continued, ‘So tell me what his problem is. They say he has a malignant tumor, is that true?’ The resident answered, ‘I’m not at liberty to discuss this with you. This information is only given to the patient or one of his first-degree relatives." Tajdari S., et al. 11 J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 6. Class 3: Psychosocial Privacy The third class was psychosocial privacy, consisting of the 3 subclasses of patient’s psychological status, interpersonal interactions, and cultural diversity. Based on the study outcomes, failure to identify the psychosocial needs of unconscious patients or those with infectious and emerging diseases such as COVID- 19 affected the provision of holistic care. In this regard, participant 12 stated: "A very important thing in hospitals is whether the patient likes to be visited or not. I really did not want anyone to come into the room. Sometimes, patients are not in a good mood and these visits threaten their privacy. I think the conscious patient should at least be asked whether he/she wants to have a visitor and how long he/she would like the visitors to stay.” The findings showed that shyness, separation from family, readiness to receive services, and values, beliefs and preferences also affected social interactions and how psychosocial privacy was preserved. Another finding of the study was related to the diversity of ethnic groups with different subcultures in the society and the need for employees to get acquainted with them. In this regard, one of the participants said, "We have many ethnic groups in our country, such as Kurds, Lurs, Turks and Arabs, each of whom have specific beliefs they are passionate about. We need to be familiar with these subcultures in order to be able to inspire satisfaction and peace in patients and their families." [Participant No. 25] One thing that worried and upset conscious patients was the loud noise and fast movements of the staff during the resuscitation of patients. Observation 20 confirmed this issue: "At 10 o'clock in the morning, the patient in bed number 4 had a cardiac arrest. His nurse said loudly, "Guys, my patient had an arrest. Bring the trolley". She opened the patient’s screen on one side. The screens of most of the patients were open, and the conscious patients who were awake were watching the events. The head nurse, 2 nurses and 2 doctors were talking at the patient's bedside. The equipment was moved quickly in the ward. At the same time, a conscious patient was crying, and another was murmuring prayers.” Class 4: Spiritual-Religious Privacy The fourth class was spiritual-religious privacy, which included the 3 subclasses of religious values and beliefs, facilities for performing religious duties, and spiritual care. The study findings emphasized identification of spiritual and religious needs and pointed out the necessity of facilities for ablution and ritual bathing as well as private environments for religious practices such as Identifying the dimensions of patient privacy in intensive care units: a qualitative content analysis study J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 6. 12 praying, the role of spiritual care specialists, the attention of officials, and staff training. In this regard, one participant stated, "If a patient is awake and wants to pray, there’s no prayer hall, and no place to perform ablution. Well, we must have tayammum soil or provide the conditions for patients to perform ablution. The patient wants to fulfill his/her religious duties even in the worst circumstances, to communicate with God so that he/she can calm down for a while." [Participant No. 16] Regarding the provision of spiritual care in ICUs, another participant said, "In my opinion, there is no spiritual care at the bedside at all. No one expects this from health personnel because we do not have the workforce trained for the purpose. In addition, the workload is so overwhelming that even if someone wants to provide spiritual care, there won’t be enough time. We have limited spiritual care to visitation by a cleric from a cultural institution every few months." [Participant No. 18] Discussion The present study was carried out with the aim to identify the dimensions of patient privacy in ICUs. Based on the researcher's field observations and participants' experiences, patient privacy has 4 dimensions: physical privacy, informational privacy, psychosocial privacy, and spiritual- religious privacy. In several studies, physical, informational, psychological and social dimensions have been presented for the concept of patient privacy (2, 3). In the present study, hidden layers of the patient privacy concept appeared, which could be related to the type of study, different data collection methods, the diversity of participants, and the nature and extent of the study environment. The findings of the present study revealed that one of the most important dimensions of patient privacy is physical privacy, which is affected by human and environmental factors. An examination of the experiences of hospitalized patients regarding respect for patient privacy in Iran showed that there are 2 dimensions of bodily and physical space privacy, and observing the patient's physical privacy creates a sense of calm and control and reduces anxiety in the patient (26). The results of a study in Turkey showed that observing physical privacy is actually having respect for the patient's body. Even if the patient is not able to express his/her thoughts and feelings, his/her body is valuable and respectable (27). In a study by Nayeri and Aghajani in the emergency department, more than half of the patients felt that their physical privacy had been violated. In this study, Tajdari S., et al. 13 J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 6. unnecessary touching and exposure of patients’ body parts during the examination were the main causes of violation of physical privacy (11). Based on the experiences of male nurses in Australia, providing intimate care for female clients was a violation of patients' privacy and a major challenge for nurses (28). The study findings showed that the security and confidentiality of the patient's personal/health information is very important in the health system. In many areas today, technological capabilities have surpassed the legal privacy guidelines. There have also been significant changes in the type and speed of interpersonal communication, such as e- mail, which has replaced traditional methods, but is inherently subject to interception and surveillance by others (29). A systematic review concerning the security and privacy of the electronic health record (EHR) focused on developing policies to ensure the confidentiality of patients’ information and control the access of others. Accordingly, only members of the professional team who were in direct contact with the patient were given access to the patient's information (30). Based on the results of a study in Iran, patients expected information that was directly related to their health status to be used for care-treatment purposes only, and to determine the time and conditions of the provision of information to other individuals and organizations themselves (26). In this study, the third class that emerged from the data was psychosocial privacy. The findings suggested that some factors that promoted patients' feeling of comfort and relaxation included: identification and timely fulfillment of their needs, flexible visiting conditions, and familiarity of employees with the subcultures of the society. Based on the results of a study conducted in Iran, the patient visitor policy varied according to the environmental conditions of ICUs, culture and individual needs of patients. One of the predominant strategies for visiting patients in the ICU was an observational visit that was performed remotely (through a window) without interacting with the patient. This study stated that individualized visits were the most appropriate strategy to enhance the positive effects of visiting on patients’ physical and mental recovery (31). The results of a qualitative study in Canada suggested that patients had little knowledge of their rights, such as hospital privacy rules. Patients' perspective on the concept of privacy, demographic characteristics, personality and culture were factors influencing privacy concerns (32). The results of another study conducted to evaluate patients' experience of privacy in the hospital demonstrated Identifying the dimensions of patient privacy in intensive care units: a qualitative content analysis study J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 6. 14 that all patients, especially female patients, valued their privacy greatly and expected staff to be more sensitive in this regard. This did not mean that they demanded single rooms, but rather consideration for their individual, social and cultural characteristics (33). According to the findings of the present study, the fourth dimension of patient privacy in ICUs was spiritual-religious privacy. The findings showed that several factors were effective on patients’ spiritual-religious privacy in ICUs. In numerous studies, religion and spirituality have been identified as factors affecting the understanding of patient privacy (26, 34). Based on the findings of a qualitative exploratory study in Isfahan, Iran, spiritual care had different dimensions and its provision required sufficient knowledge and expertise as well as close inter-professional cooperation. The participants in this study were patients, caregivers and health-care professionals, and mentioned empathy with patients, hope and comfort as effective factors in this regard (35). According to a review by Timmins et al., regardless of cultural differences, patient privacy in the ICU was an important issue for patients, their families and health personnel, and nurses in particular were the guardians of this aspect of humanity. The results of this study showed that the hospital environment was often considered disrespectful, and staying in the ICU could be a dehumanizing experience for patients and their families. In this study, dignified death was identified as a policy priority of health-care organizations (36). The results of a qualitative study in Canada revealed that patients and health-care providers had various definitions of spiritual care; in this study, empathy and companionship for the patient, active listening, and setting aside time to be with the patient were considered as spiritual care (37). The findings of a study conducted to explain the experiences of ICU nurses regarding religious-spiritual care showed that adhering to religious principles and meeting the spiritual needs of hospitalized patients is a necessity. In times of sickness, religious beliefs are more important than ever in a person’s life and help him/her accept the illness. Religious practices also give the patient hope for life and peace (38). The current study has several strengths. In order to conduct this qualitative study, observation and interview methods were used. The participants in the interviews were selected from different groups of stakeholders, and the research environment included the intensive care units of two selected hospitals of Isfahan and Tehran Universities of Medical Sciences. However, the current research had some limitations. Given the small number of Tajdari S., et al. 15 J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 6. participants, the findings of this study cannot be generalized to all intensive care settings in Iran or to all ICU patients/staff. The Covid-19 pandemic was an important factor in communication with professionals, patients and their families. Additionally, since this was a qualitative study, some participants might have forgotten certain aspects of their experiences or been unwilling to express their true feelings. Also, a number of patients did not want to be interviewed due to unpleasant memories of hospitalization in intensive care units. Conclusion Patient privacy is a very important component of patient rights in ICUs, and is a dynamic and multidimensional concept. The mentioned concept has physical, informational, psychosocial and spiritual-religious dimensions, all of which must receive sufficient attention to ensure provision of comprehensive and holistic care. Based on the results of the present study, patient privacy is influenced by various human, environmental, cultural and religious factors. Therefore, it is necessary to provide a suitable context in health- care centers by emphasizing the observance of the basic rights of patients. The findings of this study provide a clearer and more comprehensive picture of the concept of patient privacy, and can be the basis for preparation and adjustment of programs, protocols and tools for measuring patient privacy, as well as more extensive investigations in this field. This study was the result of analyzing the qualitative content of the researcher's observations as well as experiences of health-care providers and recipients in the ICUs of two selected hospitals affiliated to Isfahan University of Medical Sciences and Tehran University of Medical Sciences, which also receive patients from other cities, provinces, and remote areas. In order to clarify the details of this concept in the social and cultural context of clinical settings, other studies with different methodologies and participants in Iran and other countries are suggested. Funding Financial support for the research and/or publication of this article was provided by Isfahan University of Medical Sciences, Isfahan, Iran (Grant No: 398537). The authors are disclosing receipt of the above-mentioned financial support. Acknowledgements This study was extracted from a nursing PhD dissertation. The authors would like to thank Isfahan University of Medical Sciences for supporting this research. 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