“We were treading water.” Experiences of healthcare providers in Canadian ICUs during COVID-19 visitor restrictions: A qualitative descriptive study.

ABSTRACT

Purpose: To explore and describe the impact of COVID-19 restrictive visitation policies on healthcare providers (HCPs) and to identify ongoing challenges and pragmatic solutions that could inform recommendations for patient and family-centered care (PFCC) in the ICU during pandemic conditions. 

Methods: We conducted a qualitative descriptive study within a constructivist paradigm. We used two sources of data collected simultaneously: semi-structured interviews conducted remotely via video or phone and written comments gathered through open-ended response boxes in a questionnaire to explore the perspectives of HCPs working in Canadian ICUs during visitor restrictions resulting from the first wave of COVID-19. Between June-September 2020, eligible participants were invited through email or Twitter by their professional societies: The Canadian Critical Care Society, the Canadian Association of Critical Care Nurses, and the Canadian Society of Respiratory Therapists. Interview transcripts were analyzed inductively to create a thematic framework, and written comments were analyzed using deductive content analysis to support a richer description.

Findings: Healthcare providers’ descriptions of COVID-19 visitor restrictions in ICU revealed five main themes: 1) Impacting Healthcare Providers, 2) Communicating and Connecting, 3) Perceiving the Impact on Families and Patients, 4) Proposing Solutions with Caveats, and 5) Considering End-of-Life. 

Discussion: If restrictive visitation policies are justified in the interest of infection prevention and control, healthcare leadership must consider the impact on HCPs, and strategies for mitigating the associated harms, and identify important considerations for PFCC in the context of COVID-19 visitor restrictions. Specifically, there is a need for enhanced communication with patients and families, and between administrators, management, and the healthcare team.

Key Words (5): intensive care, COVID-19, visitor restrictions, patient and family-centered care, critical care

Implications for Nursing:  Nurse leaders should consider the impact of work demands, communication with families and within teams, and end-of-life (EOL) issues on Patient and Family Centered Care (PFCC) during restrictive visitation policies. Proposed solutions include using technology as a substitute – but not a replacement – for family presence, provision of specific guidelines for when and how to communicate with families, clear communication with families about restrictive visitation policies, and cohesive team communication to reduce inconsistent messaging. This work has implications for improving PFCC in the intensive care unit (ICU) when families are geographically distant from their loved ones or when other barriers prevent them from being physically present at their loved one’s bedside.

Background

Open visitation policies are the foundation of patient-centered care in ICU (Vaeza et al., 2020). Guidelines have previously identified best practices for Patient and Family-Centered Care (PFCC) in the ICU, which include: 1) Family presence in the ICU; 2) Family support; and 3) Communication with family members (Davidson et al., 2017). The Canadian Association of Critical Care Nurses (CACCN) endorses PFCC (CACCN, 2018). PFCC is known to reduce ICU length of stay and costs, while increasing family satisfaction, patient experience, medical goal achievement, and patient and family mental health outcomes (Goldfarb et al., 2017). Family participation in bedside care, including decision making and contributing to care, is essential for facilitating PFCC (Oczkowski et al., 2017; Patient and Family Involvement in Adult Critical and Intensive Care Settings: A Scoping Review, 2016). Family members’ contributions to care in the ICU include active presence, patient protector, facilitator, historian, coach, and voluntary caregiver (McAdam et al., 2008). Contributions to daily care (e.g. bathing, massaging, and cleaning) help loved ones to feel useful, improve communication, facilitate close physical and emotional contact with their relative (Mitchell & Chaboyer, 2010; Mitchell et al., 2009), and increase families’ perceptions of respect, collaboration, support in the care partnership (Mitchell et al., 2009). Loved ones may also play a role in reducing delirium (Kandori et al., 2020; Kotfis et al., 2020; LaHue et al., 2020; Mitchell et al., 2017; Pun et al., 2021) and by using ICU diaries, impact depression, anxiety, and quality of life in ICU survivors (Barreto et al., 2019).

Policies restricting visitation were enacted rapidly and extensively throughout Canadian ICUs in the early months of the COVID-19 pandemic. Prior to March 2020, 73% of Canadian hospitals had “accommodating” visiting policies (Canadian Foundation for Healthcare Improvement, 2020). By April 2020, hospitals from all provinces and territories reported suspension of visitation or significant visitor restrictions (Canadian Foundation for Healthcare Improvement, 2020). A recent environmental scan of Canadian adult intensive care unit (ICU) visitation policies during the first wave of COVID-19 revealed that 86% of hospitals altered their policies to prohibit or restrict visitors (Fiest et al., 2021). The rationale for these restrictive visitation policies included protecting patients and preserving personal protective equipment (Fiest et al., 2021). Fear of infection, elevated workloads, and emotional exhaustion caused stress for healthcare providers (González-Gil et al., 2021; Trumello et al., 2020). Compared with before the COVID-19 visitor restrictions, critical care providers in Canada reported increased feelings of stress (115/219; 53%) and decreased morale (99/217; 46% (O’Brien et al., 2021). Meanwhile, more than half (52%) of critical care providers in the USA identified expressed concerns of emotional distress and burnout (52%) and about their health (44%) (Wahlster et al., 2021). Yet, healthcare providers (HCPs) also expressed reservations about hospital policies preventing families from visiting a COVID-19 positive patient (Wakam et al., 2020). Restrictive visitation policies have been further criticized as lacking compassion and failing to protect the psychosocial needs of healthcare providers,  patients, and their loved ones during end-of-life (Jones-Bonofiglio et al., 2021). Patients’ family members described difficulties establishing a connection with healthcare providers in ICU and maintaining a connection to their loved one (Kentish-Barnes et al., 2021). Inability to feel connected to the patient and informed about their care contributed negatively to the stress and uncertainty felt by loved ones (Chen et al., 2021). These adverse effects were widely shared in the media prior to scientific publication, and in response, the Institute for Patient- and Family-Centered Care spearheaded a campaign to eliminate restrictive visitation policies (Institute for Patient-And Family-Centred Care, 2020), change the perception of families as visitors to one where family members are seen as essential partners in care, and highlight best practices for advancing PFCC during the pandemic.

In the context of early COVID-19 visitor restrictions – prior to the availability of any vaccines – HCPs balanced infection prevention and control and shortages of personal protective equipment with the principles of PFCC such as family presence, caregiver support, and communication for shared decision making (Robert et al., 2020). Recommendations to support PFCC during the COVID-19 pandemic included helping families to understand the rationale for visitor restrictions and routine and scheduled communication from the healthcare team (Hart et al., 2020). Where communication structures adapted to include non-ICU affiliated staff to support family communication, loved ones appreciated transparency about the patients’ situation, the attention to their well-being, and predictability of daily communication in a time of insecurity (Klop et al., 2021). Yet, primary family contacts have identified they carry an additional emotional burden (Klop et al., 2021).  Bedside HCPs have adapted by facilitating video calling or creating virtual rounds to connect family members (Arya et al., 2020; Buba & Delude, 2020; Kennedy et al., 2020; Kettle et al., 2020; Sasangohar et al., 2021; Wakam et al., 2020).

We conjectured that COVID-19 visitor restrictions would have multiple substantial impacts on healthcare providers in Canadian ICUs and on PFCC. To identify the impact of sudden and severe COVID-19 visitor restrictions in ICU, we asked the following research questions: 1) What do HCPs perceive to be the impact of COVID-19 visitor restrictions on PFCC in Canadian ICUs? 2) What ongoing challenges are identified by HCPs that can inform recommendations for PFCC during pandemic conditions?  3) What solutions are identified by HCPs that can inform recommendations for PFCC during pandemic conditions?

Methods

Design 

We approached the study from a constructivist orientation and conducted a qualitative descriptive study (Bradshaw et al., 2017; Sandelowski, 2000) to explore the impact of COVID-19 visitor restrictions on HCPs in Canadian ICUs. A qualitative descriptive approach is characterized by its subjective epistemology, inductive process, acknowledgement of researcher subjectivity, and emic position of the researcher. This study was approved by the institutional research ethics board (University of Saskatchewan; BEH-1955, June 5th, 2020). Interview participants received a written informed consent form in advance and provided verbal audio recorded consent at the time of interview, questionnaire responses implied consent.

Researcher Characteristics

Semi-structured interviews were conducted by a registered nurse (FB) with experience in emergency and intensive care settings prior to COVID-19. Qualitative thematic analysis was performed by all team members (two intensive care physicians, a registered nurse, two patient partners, two students, and one research associate). Further details are reported according to the Consolidated Reporting of Qualitative Research checklist (eSupplement 1).

Patient and Patient Family Partnership

To ensure interview questions, data analysis, and the knowledge translation plan were meaningful to patients and patient families, we collaborated with two Patient Family Partners. Patient partners were core members of the research team, contributing a patient perspective to study design, data collection, analysis, knowledge translation, and determining the next steps for research.

Setting and Context

This study explored the perspectives of HCPs working in Canadian ICUs during the COVID-19 pandemic. Data were collected after the first wave of COVID-19 (Fiest et al., 2021) between June-September 2020.

Sampling and Recruitment

We used a purposive sampling design seeking maximum variation to target HCPs working in Canadian ICUs via their professional societies (the Canadian Critical Care Society (CCCS), the CACCN, and the Canadian Society of Respiratory Therapists (CSRT)). This sampling technique was appropriate in attracting information-rich cases – participants with a range of experiences working in a Canadian ICU during COVID-19 visitor restrictions. First, professional societies circulated an invitation to an online questionnaire (O’Brien et al., 2021), and respondents were invited to leave contact information for potential participation in a semi-structured interview. We targeted ten interviews with participants with varying lengths of practice from various healthcare professions and geographical locations within Canada. We interviewed volunteers from four provinces and one undisclosed location.

Data Collection

We included two sources of qualitative data: 1) semi-structured interviews to explore the impact of COVID-19 visitor restrictions in depth; and 2) comments gathered through open-ended responses in an online questionnaire (O’Brien et al., 2021). We conducted semi-structured interviews with HCP working in the ICU during COVID-19 visitor restrictions to explore HCP perspectives on the impact on PFCC, inform recommendations for PFCC during pandemic conditions, and discover solutions to support PFCC when families cannot be present in the ICU. Interviewees were asked to describe the impact of COVID-19 visitor restrictions on patient care, positive and negative changes encountered, their needs as a bedside healthcare professional, and how COVID-19 visitor restrictions have changed their approach to patient care in the ICU. Audio recorded interviews lasting between 45-55 minutes were conducted remotely via video or phone using a semi-structured interview guide (eSupplement 2). Transcripts were returned to participants to add, amend, confirm, or delete sections of their transcript.

 Written comments were obtained through an online questionnaire in response to the following questions: 1) Can you comment on working conditions during COVID-19 visitor restrictions? 2) How do you think the COVID-19 visitor restrictions have impacted patient care in your ICU? 3)  How have these sources of information and support impacted your experience of the COVID-19 visitor restrictions in ICU? (Supervisor, hospital administration, staff in other areas of the hospital, community-based healthcare providers, colleagues in the ICU, family, and friends); and 4) Can you comment on decision-making during COVID-19 visitor restrictions?

Data Analysis

Based on previously described methodology (Braun & Clarke, 2006), interview transcripts were analyzed through a general inductive approach (Thomas, 2006) using thematic analysis. The thematic analysis aimed to describe 1) the perceived impact of COVID-19 visitor restrictions on PFCC in the ICU; 2) the ongoing challenges identified by HCPs of these visitor restriction policies; and 3) potential solutions identified by HCPs that can inform recommendations for PFCC during pandemic conditions. The thematic analysis allowed us to examine the ways that HCP in the ICU during COVID-19 visitor restrictions make meaning out of their experiences (Evans & Lewis, 2017; Golinski, 2018). Each author performed independent parallel coding of 2-3 interview transcripts using open coding to identify concepts to increase trustworthiness through multiple analysts (Patton, 1999). During a virtual video meeting, each member described their initial impressions of each interview and their initial coding and highlighted similarities and differences among interviews. Through iterative discussion, we collapsed codes into themes. Each team member returned to the transcripts to confirm patterns and themes with the data. At a second virtual meeting, we reached a consensus on a framework of themes and sub-themes. Themes were determined primarily based on their contribution to answering the research aims (impact, recommendations, and strategies), rather than their frequency across the dataset.

Next, the written comments were analyzed deductively using content analysis, with the thematic framework serving as the coding framework to ensure informational redundancy (Lincoln & Guba, 1985), to support validity (Patton, 1999), and to support a richer description of working in Canadian ICUs during the COVID-19 visitor restrictions across a broader sample of the target population. In a third meeting, incidents of convergence, complementarity, and divergence/dissonance were highlighted. This influenced our thematic framework by clarifying two subthemes, renaming a subtheme, and adding a subtheme.

Findings

Participant Characteristics

 Eight HCPs were interviewed.  Participants included five nurses, two intensive care physicians, and one clinical nurse specialist. Four participants had less than 10 years’ experience working in ICU, two participants had between 11-20 years, and two participants had more than 31 years’ experience in ICU. Of the nurse participants, one had recently retired during and because of the COVID-19 pandemic; another was an ICU nurse practitioner. Participants’ practice locations included two in BC, four in Ontario, one in Newfoundland and Labrador, and one undisclosed.

One hundred eighty-seven respondents provided 524 written comments (WC) in response to open-ended questions. These respondents included nurses (149/187, 80%), intensivist physicians (18/187, 10%), respiratory therapists (16/187, 9%), and allied health professionals (3/187, 2%), and one undisclosed occupation. Responses originated from every Canadian province and one territory: British Columbia (45/187, 24%), prairie provinces (45/187, 24%), Ontario (66/187, 35%), Quebec (11/187, 6%), Maritime provinces (18/187, 10%), territories (1/187, 1%), and one undisclosed.  Participants were primarily aged 39-49 years (104/187,56%), with the remainder of participants aged 50-69 years (56/187, 30%), 19-29 years (25/187, 13%), and two unspecified.  Written comments were provided primarily by female respondents (159/187, 85%), with the remainder of comments obtained from males (24/187, 13%) and four undisclosed (4/187, 2%).

Thematic Framework

A thematic framework derived from healthcare provider interviews is presented in Table 1.

Table 1

Themes and subthemes about the impact of COVID-19 visitor restrictions in the ICU

Impacting Healthcare Providers

HCPs described the impact of visitor restrictions on their working conditions, including managing work demands, distress, team morale, and safety.

 Managing Work Demands: “There was a lot more work for us”

HCPs identified the impact of changing work demands. Overall, “the staff [were] just so busy and trying to keep up with the workflow” (HCP #8, British Columbia). They described decreased patient bedside assessment due to infection control practices, where staff infection prevention procedures and limitations on entering negative pressure rooms resulted in reduced time for patient care: “…it really changed the way that I did bedside nursing, …I felt like I was not doing … a very important part of my job by not getting to do a full assessment without the auscultation…” (HCP #4, Ontario).  Yet some HCP felt visitor restrictions helped them to manage patient care with fewer interruptions, leading timely patient care (getting tasks done). Healthcare providers reported spending “more time on the phone updating family as opposed to at the bedside” (WC #214, British Columbia).   Written comments supported and enriched this theme through additional descriptions of the need for HCPs to play new roles of both advocating for patients and families, for example “We are not given decision making options related to visitor restrictions. We may advocate to management if we feel that a visitation is warranted. These are only permitted in very specific circumstances” (WC #510, Ontario), and becoming gatekeepers to family presence:

Many complaints received from families. This added to burden of working with COVID. Considerable amount of time every day spent trying to communicate with families. Even so many were dissatisfied. Administration placed burden on physicians to be gatekeepers for the odd visitor (e.g., for end-of-life discussions) but then occasionally criticized those decisions. Quite frequently family members would express profound …anger with visitor restrictions, and care team members were recipients of this frustration, and occasionally, frank abuse.” (WC #173, Ontario)

Distress: “We were treading water”

HCPs reported the environment was highly charged during COVID-19 visitor restrictions; heightened stress and emotions sometimes resulted in aggression from families. HCPs reported their own emotional distress, the added emotional burden of supporting distressed families, and fear of the virus. Distress commonly originated from lack of support from leadership, conflicting information, from variable application/interpretation of the policies themselves, and from inconsistency/differences of interpretation of communication within healthcare teams. One interviewee described an increase in negative coping behaviors in her co-workers. She indicated that there were “so many repercussions to nurses as far as their emotional health, their psychological health. I saw a lot of people that I know dealt with it by, by drinking alcohol, by smoking more, by binge eating” (HCP #6, Ontario).

Moral distress was one way in which distress was evident – knowing what was right but not being able to carry it out under the circumstances: Staff experienced distress when having to prevent family from visiting loved ones, particularly when family members were distressed: “[m]orally it has been challenging at times keeping families apart in times when they so desperately want to support loved ones” (WC# 205, British Columbia). Another wrote “it seems inhumane to have to pick… people who can see the patient especially if they have a large family…This is causing undue moral distress on families, patients, and staff.” (WC# 144, Prairies).

The amount of additional work, the need to reassure families who could not be present at the bedside, and the expressed lack of adequate debriefing were perceived to lead to HCP burnout; For example, participants reported they “were really all so drained from dealing with it” (HCP #6, Ontario) and “Increased stress, anxiety, and burnout of staff in regard to dealing with unhappy family members over the phone” (WC #129, Ontario).

Team Morale: “The team coming together”

Healthcare providers reported a feeling of “coming together” as a healthcare team: “a positive thing we saw was just the support for one another in the team and supporting each other. I think the team in some ways was closer… I think the… ICU team as a cohesive unit was supporting each other quite well” (HCP #8, British Columbia). Interviewees also expressed gratitude for the support they were receiving from the public and community that they served; it felt good to be publicly appreciated: “[The public] cheering for health care workers, that was most emotional for me” (HCP #6, Ontario). Written comments also illuminated that heightened stress was causing nurses to leave ICU for other opportunities: “Stress levels are palpably higher, morale is lower. Since COVID we have had …RN’s leave the unit for other opportunities” (WC #263, Maritimes).

Safety: “Having visitor restrictions allows you to feel more confident”

A need to feel safe was expressed prominently by participants;interviewees expressed fear of infecting their families. Infection prevention and control (IPC) practices (e.g. personal protection equipment (PPE) shortages, family non-adherence to (IPC) practices, and/or needing education) added to the HCPs’ stress.

Healthcare providers felt safer with visitor restrictions, leading to fewer infection control breaches. According to one participant, “Having visitor restrictions allows you to feel more confident that proper PPE practices are being followed and gives you the time and space to do the work you need to do with acutely ill patients. When visitors of COVID patients come to the unit you worry that they may also have exposure and it adds to the distress of caring for these patients (WC #207, British Columbia). HCPs also identified benefits of visitor restrictions including protecting families and the supply of PPE, and fewer risks to immunocompromised patients in ICU.  HCP #1, for example, noted that the restrictions were “for the safety of them [families], the patient and the healthcare providers,” while HCP #3 highlighted that visitor restrictions were useful for “…infection control practices and the safety of having large numbers of people coming into visit in the intensive care unit, especially given our population is highly immunocompromised.”

Communicating and Connecting

Interviewees described two distinct forms of communicating and connecting; the first was with patients’ families and the second was within health care systems and teams.

With Patients’ Families: “Everybody had a phone in their pocket”

HCPs expressed the importance of communicating with families during visitor restrictions, despite challenges, and reported spending more time talking on the phone. They identified frequency of communication with families as being inconsistent and physician-dependent but suggested that COVID-19 visitor restrictions are pushing HCPs to innovate new ways to communicate with patient families, for example, Facetime visits. Recognizing that some patients may not see family members again, HCP #7 noted “I would make more of an effort than I technically would have to make sure that we have a Facetime, or they are allowed to talk by phone before we get all the procedures that we need to do.”

Visitor restrictions allowed nurses to “have a little bit more control” (HCP #3, Ontario) over when to communicate with families, but required limit-setting, as loved ones could not be connected as much as they sometimes wanted. HCP encountered families who would say “connect us again, you owe us” (HCP #1, province undisclosed). Additionally, HCPs found it hard to communicate changing policies and visitation restrictions; they wanted the healthcare system to provide a single source of information for families. When it came to connecting with their patient, HCPs found it difficult to completely understand the needs of sedated patients when families were not there to speak on their behalf.

Within Healthcare Systems and Team: “Things changing so quickly”

Interviewees reflected on the impact of communication strategies, reporting that repeated messaging, town halls, in person communication, and electronic communication helped staff feel supported and informed: “…when they had that information, they felt comfortable, safe, and able to work” (HCP #2, British Columbia). However, challenges included rapidly changing information, conflicting information, and frustrated families: “I don’t think anybody would say there was a lot of consistency but that’s just a function of things changing so quickly” (HCP #7, Ontario). Communication among members of the healthcare team was identified as being a reliable source and a source of comfort. HCPs found strength from their co-workers and being able to talk to someone who was living a similar experience.

Perceiving Family and Patient Impact

In both interviews and written comments, HCPs recognized the impact of visitor restrictions on patients and their families. They witnessed “scared and nervous” patients and families who could not see each other (HCP #2, British Columbia).

Families: “They are not able to come in”

HCPs perceived many families were understanding about the reasons for COVID-19 visitor restrictions but were less prepared for changes in their loved one’s health when they could not be at the bedside: “… it was quite shocking. Even though they could kind of see them over Skype, it not the same as seeing them [loved ones] face to face and to see the deterioration (HCP #8, British Columbia). HCPs empathized that, while the situation was difficult for staff, it was even more difficult for families. For example, HCP#3, from Ontario, for example, claimed “I couldn’t imagine how hard it would be to have a loved one in the ICU and not be able to see them or either a loved one and not being able to communicate normally with my family.”

Exceptions to visitor restrictions were made for some families, and while HCP felt strongly that exceptions should be made, the rationale for the exceptions must be clear. HCPs also recognized the frustration that families felt due to inconsistencies in information.

Patients: “We saw a higher degree of delirium”

HCPs reported distress among patients due to visitor restrictions; patients were frightened and asking for their families to visit. Family presence was recognized as valuable in calming delirium through familiar faces and voices. In the absence of family presence, HCPs reported “a high degree of delirium” (HCP #8, British Columbia), resulting in increased use of chemical and physical restraints: “we’re using more drugs that …we’ve gotten away from using things like Versed for sedation… We actually were using a lot more Rocuronium and paralyzing people. So, I think we saw a higher degree of delirium because of … not having family or that familiar voice there and presence. …it’s also made it harder for patients to … come out of the delirium (HCP #8, British Columbia). Family presence was also noted to be a key factor necessary for understanding the patient as a person and sharing patient needs and preferences with healthcare staff. One participant stated, “there wouldn’t be the things around the room that would remind you that there really is a patient in the bed. And their people, you know the things that make somebody them, I think that that’s what we were missing” (HCP #6, Ontario).   

In contrast, one interview participant and a minority of written comments reflected that patient care was not impacted or was positively impacted, as there were fewer interruptions to care.

Proposing Solutions with Caveats

Our third research question asked, “What solutions are identified by HCPs that can inform recommendations for PFCC during pandemic conditions?”  Interviewees identified both adaptations to practice (e.g., technology as a substitute for family presence) and proposed solutions (e.g., guidelines, clear communication about policies, and cohesive team communication).  These ideas included adaptations that were trialed or suggestions that could be adopted in ICU during the COVID-19 visitor restrictions.

Technology: “We were doing what we could”

HCP adapted their practices to include technology as a solution to – but not a substitution for – family presence at the bedside. HCP described using phone, video conferencing, and sending photos to facilitate connection and communication with families, and between patients and families: “When patients are alert enough, we would try and Facetime video chat or Facebook messenger or find other ways to communicate and I think both patients and families felt like we were doing what we could, given the circumstances… and they were thankful for that (HCP #3, Ontario). Platforms included Facetime, Facebook Messenger, and Zoom, but HCPs noted this solution was temporary and insufficient for engaging families: “communication by phone/Skype not great substitute but did best we can” (WC 169, Prairies). To help patients, “the hospital lent cellphones to some patients so their family and the patient could see and talk to each other through Skype, Facetime etc.” (WC# 393, Quebec).

Specific Guidelines of When, How to Communicate with Families: “An expectation”

Interviewees identified that both HCPs and patient families would benefit from guidance on the expectations for communication. Patient families would benefit from knowing how frequently (e.g., daily, hourly) they should expect communication from members of the healthcare team, and how frequently it was acceptable to phone their loved one’s nurse: “an expectation or kind of a guideline… every day you will hear from your physician and you can call your nurse … X number times per shift, I think it will be helpful perhaps both for families, but also for clinicians to have an expectation, because … this nurse lets them call every hour but I am only letting them call once a shift …so it might be useful to have some kind of standardization… (HCP #3, Ontario).

Clear Communication with Families About Visitor Restriction Policies: “To help people understand”

Interviewees identified a need for clear communication with patient families around the rationale for visitor restrictions and what current visitor restrictions were at any given time. One interviewee stated “There was very kind of general message on the website (about visitor restrictions), but I think it’s a bit more difficult for families of patients in ICU to appreciate those restrictions when it comes to their individual case (HCP #7, Ontario). HCPs wanted a “handout or something clear from the hospital about our visitors’ policy” (HCP #7, Ontario). HCPs identified that this communication with families should come from one source – ideally management. 

Cohesive Team Communication (RN, MD, Administration): “One single source of truth”

Improving the cohesiveness of team communication was identified as desirable. For example, one interviewee described the volume of new information as such “We had a lot of communication coming at us from a lot of different people… it kept changing frequently… just having clear communication from those who are making decisions would have helped so that we could have supported it better (HCP #8, British Columbia).  Nurses, therapists, physicians, and social workers may not be getting the same information or have the most updated guidelines. One participant commented “visitor restrictions seemed to change daily, so always going to our Health Authority’s webpage and or asking fellow staff was helpful” (WC #343, Prairies).  Interviewees reported that these HCPs have all provided different information to families, and a single source of truth was desirable: “…have one person …that single source of truth would come from this person… that way you are not bombarded with… lots of different emails … …everyone was well intentioned, but it got confusing when one person was sharing something that they didn’t realize was actually… yesterday’s policy and had been updated… it just caused a lot of confusion (HCP #8, British Columbia).

Considering End-of-Life in the Context of Visitor Restrictions

In the context of end-of-life care, interviewees acknowledged a great deal of distress when families are not let in, and the need for clear guidance around flexibility and exceptions.

Feeling Distress when Families Aren’t Let In: “This is not a good end”

For patients who were dying in the ICU, HCPs noted that families had a difficult time grasping the severity of illness and extent of deterioration of their loved one. As a result, families were less prepared for discussions pertaining to goals of care, or transitions to end-of-life care: “it’s harder to make those decisions when families can’t see how their loved one is doing” (HCP #7, Ontario).

HCPs continued to hold compassionate end-of-life care as a priority throughout the spectrum of care.  Before intubation, HCPs reported supporting patient-family connection, as patients “may not get to speak to their families again” (HCP #7, Ontario). At the end-of-life, HCPs were distressed by the lack of physical presence and the comfort this presence can provide. Seeing patients dying alone, without family, or with family watching by videoconference was particularly harrowing for many that we interviewed. Some HCPs would spend more time at the bedside during a withdrawal of life sustaining therapy, attempting to provide comfort when families could not: “If we couldn’t have family in… for some patients I would spend more time in the room when we would withdraw life support more than I typically would be (HCP #7, Ontario) 

Needing Flexibility and Exceptions: “We did make exceptions”

While HCP identified a need for flexibility and exceptions, they also needed consistent guidance for visitation policies and when exceptions could be made. For patients who were dying of COVID-19, some ICUs allowed visitors to watch through the glass at the end of life, or allowed limited numbers of family members to be in the room with their dying loved one after being coached through proper use of PPE: “there were other situations where if you know their loved ones were dying in the ICU, we would allow them to come in and visit, as long as their family member wasn’t COVID positive” (HCP #3, Ontario).  Specifically, one interviewee described an exception made for a family member because they were an HCP perceived to be capable of donning and doffing safely. In doing so, HCPs were able to support family members, in this case colleagues, to navigate the personal issue of losing a loved one. One interviewee argued that “not having the physical presence is substandard. I don’t know if people feel that there is no real substitute for the physical presence. I think that it remains very, very difficult for everyone” (HCP #2, British Columbia).

Discussion

We found five themes to describe the impact of visitor restrictions from HCP perspectives: 1) Impacting Healthcare Providers, 2) Communicating and Connecting, 3) Perceiving the Impact on Families and Patients, 4) Proposing Solutions with Caveats, and 5) Considering End-of-Life.

HCPs identified many changes to their working conditions because of the visitor restrictions, and experience of their working conditions was intricately linked with communication. Communication with families and comforting patients, in a system where policies changed frequently, added to the workload as well as emotional burden. Yet, the HCPs in this study reinforced the importance of communication in the ICU –among healthcare teams, with families, and between families and patients. Literature shows that communication is important for PFCC as well as the medical care of the patient (e.g., family proxy assessment of pain) (Devlin et al., 2018). Previous work has recommended early, routine, and bi-directional communications with patients and families to assess their needs and preferences, expectations around frequency and modality of communication, and to allay fears and reduce psychological suffering (Akgün et al., 2020). Our findings reinforce previous work that suggests hospital- and unit-based rules place the burden of communicating these policies upon frontline nurses (Baird et al., 2015; Hancock et al., 2020; Sasangohar et al., 2020; Wahlster et al., 2020). Additionally, we found telehealth and videoconferencing are imperfect solutions to facilitate communication between families, patients, and HCP, similar to other studies (Kennedy et al., 2020; Kettle et al., 2020; Sasangohar et al., 2021).

The description of the impacts of visitor restriction policies on patients and families, though viewed through the lens of the HCP, was particularly heartbreaking.  Due to the limited communication with family, HCPs describe a lack of knowledge of the patient as a person, which is a key component of PFCC.  Patients dying alone without families to comfort them, and increased delirium treated with the use of pharmacologic and physical restraints paint a harsh picture of the inadvertent consequences of visitor restriction policies.  Finally, families themselves, receiving varying degrees of communication from HCPs, had difficulty understanding their loved ones’ condition, and were less prepared for news that their loved one was dying.  The literature supports and reinforces our findings, showing that family presence is protective against delirium, is necessary to understand the patient’s condition, and prevents delayed end-of-life decisions (Azad et al., 2021; Krewulak et al., 2020; Pun et al., 2021; Van Rompaey et al., 2009).  Our findings contribute to the voices drawing attention to the damage done when patients are alone in the hospital and ICU due to visitor restriction policies (Canadian Foundation for Healthcare Improvement, 2020; Haines, 2020). Of note, the interviews and written comments did not appear to view family as a part of the healthcare team; this contrasts with recent recommendations from the Institute for Patient- and Family Centered-Care to view family members as essential care partners, not simply visitors (Institute for Patient-And Family-Centred Care, 2020). This emerging paradigm of families as essential care partners will require a fundamental shift in how healthcare providers conceptualize their team.

Over 52% of HCPs have experienced burnout and distress during the COVID-19 pandemic in North American ICUs (Hancock et al., 2020; Sasangohar et al., 2020; Wahlster et al., 2020). Previous studies have identified increasing workload, changing and inconsistent communication, high intensity and emotional situations, and moral distress as risk factors for burnout (Hancock et al., 2020; Sasangohar et al., 2020; Wahlster et al., 2020). Our study particularly highlighted the following risk factors for burnout: 1) increased workload due to communication demands and emotional support for families; 2) conflicting information about visitation policies; 3) variable interpretation and application of the visitation policies; and 4) moral distress from seeing patients die alone. Our findings contribute to the need identified in similar work for hospital leadership to consider these sources of distress and work towards providing clear and consistent information about visitation policies, ongoing support and guidance for front line healthcare providers in operationalizing these policies, and psychological support for those who experience burnout and associated symptoms (Canadian Foundation for Healthcare Improvement, 2020; Devlin et al., 2018; Hancock et al., 2020; Wahlster et al., 2020).

The qualitative descriptive design using two sources of data from the target population strengthens our findings, as does our approach to analysis that united perspectives from a diverse team including intensivists, a registered nurse, a researcher, and two patient-family partners. While the findings of 8 interviews could be considered insufficient to reach saturation, sample size in qualitative health research is an area of conceptual debate (Malterud et al., 2016; Vasileiou et al., 2018). Qualitative researchers consider thematic saturation, contribution to answering the study questions, and pragmatic concerns such as the availability of interviewees (Vasileiou et al., 2018). We achieved saturation through deductive analysis of written comments according to the thematic framework of interview themes and subthemes. Therefore, we feel that the richness of the qualitative data and use of multiple analysts mitigates this limitation. Written comments complemented existing themes (e.g., Perceived Impact on Families: “some phone conversations are also challenging when English is not the first language of family members, as [it is] more difficult to understand each other on the phone,” and “retail stores were open and people [were] intermingling there; families [were] distraught why, in light of the public intermingling, they were still unable to see loved ones”), and elaborated on subthemes (e.g. the subtheme Managing Work Demands was expanded to describe adapting to changing roles as gatekeeper and advocate).

Having patient and family partners on our research team made us more accountable by keeping the focus on the PFCC aspect of visitor restrictions, and consistently requiring us to view these findings as only one piece of the puzzle; as such, our findings do not draw conclusions about patient and family experiences and perspectives. One patient partner encouraged us to interview patients in addition to ongoing interviews with patient family members, even though they have been (and continue to be) difficult to recruit.

Future work should include ensuring that patient and family voices are represented in the conversations to find solutions. With this goal, we are currently undertaking a national study of patient and family perspectives on the impact of COVID-19 visitor restrictions on patient and family centred care in Canadian ICUs.

Conclusion

Our findings have the potential to optimize the Canadian health system’s response to COVID-19 and future epidemics and pandemics. If visitor restrictions are justified in the interest of infection prevention and control, then healthcare leadership should consider the impact on work demands, communication with families and within teams, and care for patients at the end-of-life. Participants in our study proposed solutions such as using technology as a substitute for family presence, provision of specific guidelines for when and how to communicate with families, clear communication with families about visitor restriction policies, and cohesive team communication to reduce inconsistent messaging. This work has implications for improving PFCC in the ICU even when COVID-19 visitor restrictions are eased, such as when families are geographically distant from their loved one, or when other barriers prevent them from being physically present at their loved one

Appendix 1.

Themes, subthemes, and illustrative quotes from healthcare providers about the impact of COVID-19 visitor restrictions in the ICU

Author Notes:

Jennifer M. O’Brien, PhD, Research Associate; Department of Anesthesiology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada.

Faith A. Bae, MN, RN, Research Assistant; College of Nursing, University of Saskatchewan, Saskatoon, SK, Canada.

Joann Kawchuk, MD, FRCPC; Assistant Professor; Department of Anesthesiology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada.

Eileen Reimche, MEd, BEd, BA, Patient and Family Partner, Saskatchewan Center for Patient Oriented Research.

Candace A. Abramyk, Patient and Family Partner, Saskatchewan Center for Patient Oriented Research; Saskatoon, SK, Canada.

Caitlyn Kitts, BSc; Medical Student, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada.

Sana Mohamad, Undergraduate Student Research Assistant (USRA), College of Arts and Science, University of Saskatchewan, Saskatoon, SK, Canada.

Christine Patterson, MD, Anesthesia Resident; Department of Anesthesiology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada.

Yolanda Palmer-Clarke, PhD. Research Coordinator; Department of Medicine, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada.

Sabira Valiani MD, FRCPC, Assistant Professor, Department of Medicine, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada.

Corresponding Author:

Jennifer M. O’Brien, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada.

Telephone:  (306) 655-1183, Email:  Jennifer.OBrien@usask.ca.

Acknowledgements

The authors gratefully acknowledge funding from the University of Saskatchewan College of Medicine Dean’s Summer Student program, the University of Saskatchewan Office of the Vice Provost Research Undergraduate Student Research Assistantship, and the Saskatchewan Center for Patient Oriented Research (SCPOR) Trainee Engagement with Patients (STEP) funding.

Funding and Conflict of Interest:

Caitlyn Kitts was funded through the University of Saskatchewan Dean’s Summer Student program. Sana Mohammad was funded through the Undergraduate Student Research Assistantship and the Saskatchewan Center for Patient Oriented Research (SCPOR). Eileen Reimche and Candace Abramyk received honoraria through SCPOR.  The authors have no conflicts of interest to declare.

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Semi Structured Interview Questions for Healthcare Providers

1. Overview of session
   1. The purpose of this project is to understand the impact of the COVID-19 visitor restrictions on patient family and healthcare provider perceptions of care in Canadian ICUs.
2. Use Telephone consent and answer any questions they may have.

• Interview questions
• Describe your role and length of experience in the ICU.
• What has been the impact of the visitor restrictions implemented on March 14, 2020, on patient care?  Can you give some examples?
• Can you describe some of the changes/ challenges that have been encountered since the COVID-19 visitor restrictions (with examples if needed).  Can you suggest any solutions to those challenges?
• What are your needs as a bedside healthcare professional during this time? (Include educational, moral, emotional, psychological, spiritual needs)
• What would be the best way to address these needs?
• Can you share some positive changes that you see because of visitor restrictions?
• Can you share what you think is not working with visitor restrictions, or what are some negative changes that you see?
• How can we overcome some of the things that are not working or some of the negative changes?
• Can you share what you think needs to be improved about visitor restrictions?  What can we change to improve this?
• How have visitor restrictions changed how you approach care of patients in the ICU?

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