Clinician perceptions of the impact of ICU family visiting restrictions during the COVID-19 pandemic: an international investigation

doi:10.21203/rs.3.rs-2222776/v1

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Research Article

Clinician perceptions of the impact of ICU family visiting restrictions during the COVID-19 pandemic: an international investigation

https://doi.org/10.21203/rs.3.rs-2222776/v1

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published 21 Jan, 2023

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Background: To guarantee the safety of the public, clinicians and patients during the COVID-19 pandemic, hospital visits were severely restricted internationally. There is limited data on the precise impact of these visiting restrictions on Intensive Care Unit clinicians. Our objectives therefore were, to explore the impact of family visitation restrictions on clinicians and care and describe innovation and areas for potential improvement.

Methods: A qualitative approach, using focus groups was employed. We recruited members of the multi-disciplinary team from Spain, France and the UK. Framework analysis was used to synthesize and interpret data.

Results: In total, 28 staff from multiple international sites contributed to data across six focus groups: 12 from the UK, 9 from France and 7 from Spain. In relation to the key aims, we derived four themes: the emergence of new technologies; relationships and rapport establishment, communication challenges and end of life care provision. Across each theme, the overarching concepts of clinician emotional exhaustion and emotional distress emerged alongside the negative impact on job satisfaction.

Conclusion: The impact of COVID-19 family visitation restrictions is far reaching. Future research should examine the wider impact of family presence in the ICU.

family

visiting

COVID-19

Clinician burnout

The COVID-19 pandemic has placed unprecedented demands on hospitals and Intensive Care Units (ICUs) internationally(1, 2). Clinicians have managed complex care situations, alongside their own personal safety, in a highly demanding environment(3). To guarantee the safety of the public, clinicians and patients, hospital visits were severely restricted(4, 5). The impact of these practice and policy changes are still emerging.

There has been a proliferation of quantitative literature examining the negative consequences of pandemic care provision on clinicians(6, 7). The psychological consequences include increased anxiety, signs and symptoms of posttraumatic stress disorder (PTSD) and Clinical Burnout Syndrome (CBS)(8, 9). For example, one recent European-wide study, undertaken during the pandemic, estimated a prevalence of self-reported burnout of over 50% in ICU clinicians(10). Specific mechanisms for these psychological sequalae include the impact of managing personal safety, the delivery of palliative care and the challenges associated with family visitation restrictions(11).

Over the last decade there has been an increased focus on the delivery of family- centred care within ICU(12). This includes the inclusion of family members in decision making and care provision, facilitated by open and often non-restricted visiting(13). Yet, there is limited data on the precise impact of these visiting restrictions on clinicians, and what innovations, if any, were successfully adopted to maintain family-centred care during the pandemic.

Therefore, the aims of this study were: explore the impact of COVID-19 family visitation restrictions on ICU care delivery and describe innovation and areas for potential improvement across three different European countries.

This study was approved by the Scientific Officer of the West of Scotland Research Ethics Service as Service Evaluation (UK approval); the Hospital Clínic of Barcelona Medical Research Ethics Committee (HCB/2021/1115) (Spanish approval) and the research ethics board Sud Méditerranée (2020-A00809-30; CNRIPH: 20.03.27.73019) within the framework of the BURDENCOV study (French approval).

All participants provided written informed consent. The Consolidated Reporting of Qualitative Research (COREQ) checklist was used to report findings (S1) (14).

Design and Setting

A qualitative approach was used to address the study aims. We chose qualitative inquiry as we wished to hear participants describe their experiences in enough detail to enable a comprehensive understanding of the interplay between family visitation policies and clinician experience. Focus groups were chosen as a method of data collection as the interaction between those involved is thought to help participants consider and reflect upon aspects of daily life (and work), that are sometimes taken for granted(15). We undertook data collection until data saturation was achieved. Data saturation was examined via iterative discussions between the researcher groups in each international site.

Clinicians were recruited from three international sites to understand if staff experiences differed across international contexts. Details of the international policy related to hospital visitation is provided in Table 1. Interviews were undertaken in the local language and translated into English. Participants were recruited through advertising this research in staff areas; staff interested in participating were then given the option to attend a focus group. Focus groups were facilitated by experienced researchers and were undertaken in-person (in the hospital setting) and virtually.

Table 1

Visiting policies across the international contexts
Country	Date	Guidance
UK	Pre-COVID-19	Open visiting for all ICU patients
	March 2020	UK Lockdown. One visitor at the end of life, visitor then follows COVID exposure guidelines and self isolates following the visit
	July 2020	One named designated visitor plus additional visitor at end of life
	August 2020	Two designated visitors plus additional visitor at end of life
	September 2020	End of Life visiting only
	April 2021	One named visitor
	July 2021	Two visitors
	August 2021	Full person-centered visiting
	January 2022	End of life visiting only
	March 2022	One interchangeable visitor per day
	May 2022	Full patient-centered visiting
Spain COVID ICU	Pre-COVID-19	3 times a day (7:15 − 7:45; 13:00–14:00; 20:00–21:00), any visitor, maximum 2 at the same time. Exceptions were made depending on the patient
	March 2020	No visitors allowed. Exceptions were made: one visitor at the end of life. Information was provided by phone
	June 2020	No visitors allowed. Exception included patients admitted for more than 8 weeks
	November 2021	One visitor 1 hour (13h or 20h). Exceptions were made depending on the patient
	May 2022	2 times a day (13:00–14:00; 20:00–21:00), one visitor. Exceptions were made depending on the patient.
Spain Non-COVID ICU	Pre-COVID-19	3 times a day (7:15 − 7:45; 13:00–14:00; 20:00–21:00), any visitor, maximum 2 at the same time. Exceptions were made depending on the patient
	March 2020	Spain Lockdown. One visitor at the end of life
	April 2020	One visitor 1 hour (13h or 20h)
	May 2021	2 times a day (13:00–14:00; 20:00–21:00), any visitor, maximum 2 at the same time in the room
	July 2021	One visitor 1 hour (13h or 20h)
	September 2021	2 times a day (13:00–14:00; 20:00–21:00), one visitor
	October 2021	3 times a day (7:15 − 7:45; 13:00–14:00; 20:00–21:00), any visitor, maximum 2 at the same time. Exceptions were made depending on the patient
	November 2021	2 times a day (13:00–14:00; 20:00–21:00), one visitor
	December 2021	One visitor 1 hour (13h or 20h)
	February 2022	2 times a day (13:00–14:00; 20:00–21:00), one visitor
	May 2022	3 times a day (7:15 − 7:45; 13:00–14:00; 20:00–21:00), any visitor, maximum 2 at the same time. Exceptions were made depending on the patient
	June 2022	2 times a day (13:00–14:00; 20:00–21:00), one visitor
	September 2022	3 times a day (7:15 − 7:45; 13:00–14:00; 20:00–21:00), any visitor, maximum 2 at the same time. Exceptions were made depending on the patient
France	Pre-COVID-19	Open visiting for all ICU patients
	March 2020	France Lockdown: No visitors allowed in the hospital. Saint Louis ICU allows one visitor at the end of life. No waiting room
	April 2020	The ICU at St Louis decides to allow one visitor/patient/day. In end-of-life situations, more than one visitor allowed as long as the visitors do not come at the same time. No waiting room
	June 2020	Open visiting for all ICU patients during the day. However only one visitor at a time. No waiting room
	October 2020	Open visiting for all ICU patients as before COVID

A semi-structured topic guide was developed a priori (S2); questions were open ended, and participants were encouraged to explore issues they considered relevant. Questions were reviewed by participants for clarity before utilisation. Demographic data was collected from participants which included gender, age, profession and number of years of experience in critical care.

Data Analysis

Data were analysed using thematic analysis, informed by framework analysis(16). This analytical framework allows structured and systematic analysis of data and has been used in previous critical care research(17, 18). The data was systematically analysed against the research aims: explore the impact of family visitation restrictions on care delivery and clinicians; describe innovation and explore areas for potential improvement. The Framework Analysis technique was used to analyze data across these concepts, through seven stages: 1) Transcription; 2) Familiarization; 3) Coding; 4) Developing a working analytical framework; 5) Applying the analytical framework; 6) Charting data into the framework matrix; 7) Interpreting the data (16).

Two researchers (JM and KP) independently undertook preliminary sweeps of the data and initial codes were identified. The codes were checked against the study aims, resulting in the development of a preliminary coding framework. These initial codes were used to develop a thematic framework by grouping themes, which linked concepts. Thematic sets were then created and organized into a framework matrix to create the final themes (S3). Following the creation of this matrix, researchers examined potential international differences. Key quotes to support findings were extracted by JM and KP.

Member checking with participants was undertaken. Member checking, also known as participant validation, is a technique for exploring the credibility of results. Data or results are returned to some participants to check for accuracy and resonance with their experiences(19). Participants who had agreed to ongoing contact with the research team were involved in this process (n = 3).

In total, 28 staff from three international sites contributed to data across six focus groups. These participants represented multiple ICU professions including nursing, medicine, physiotherapy, pharmacy and health care support workers. Focus groups were undertaken between June 2021 and July 2022. Each focus group lasted between 45 and 80 minutes. Participant demographics are detailed in Table 2.

Table 2

Demographics of focus group participants
Demographic	n (%)
Participant Region: UK France Spain	12 (43) 9 (32) 7 (25)
Sex Female Male	21 (75) 7 (25)
Age, Years, Median (IQR)	39 (IQR:32–47)
Professional background Nurse Medicine Physiotherapy Healthcare Support worker Advance Practitioners in Critical Care Pharmacy	10 (36) 10 (36) 3 (11) 2 (7) 2 (7) 1 (3)
Years of ICU experience Less than 5 5–10 years 11–15 years 16–20 years 20 years +	6 (21.5) 6 (21.5) 8 (29) 4 (14) 4 (14)

In relation to the aims, we derived four themes from the data: the emergence of new technologies; relationships and rapport establishment, communication challenges and end of life care provision (Table 3). Within each theme the impact on clinicians, care delivery and potential improvements were delineated. Across each theme, the overarching concepts of emotional exhaustion, emotional distress and low job satisfaction emerged. Following a robust examination, we found no differences across international sites, indeed the findings mapped in an identical manner internationally. A selection of representative quotes across international sites are presented in Table 3.

Table 3: Representative quotes illustrating key themes

Staff

Care Delivery

Improvements and Innovations

Emergence of new technologies

UKP: The phone calls were one of the most stressful things…Trying to reassure them, without actually knowing anything… There was not any reassurance I felt I had to give… I think there was a lot of anxiety just around phone calls and communication.

FP: We were also able to find alternatives, that is to say give online meetings and that was really a way for us to be able to at least give something.

UKP: It put a huge barrier on communication

FP: At worst it was anxiety provoking for families to see the person. A first visit to ITU seeing all that is destabilising, so on the screen … oh dear… with interference because the networks are rubbish. You didn’t hear well …. It was stressful.

UKP: The majority of people didn’t have passwords and trying to get people to explain it to you, to show it to you. They are busy.

SP: The initiative of tablets appeared, to make video calls with families, which as an initiative can be super-good and was very necessary, but at the level of workload, it was often incompatible… there were no hands or people to dedicate the time to it.

Relationships and Rapport Establishment

UKP: The family brought the patient to life for us.

SP: It meant much more wear and tear to care for patients, no longer at the level of techniques or things, but at the “human” level.

FP: No family, no relatives and everything so it was often the nursing teams who had to make up for this deficit when we went to zero visits.

UKP: We went from being totally holistic and patient-centred to just very task oriented.

FP: There was also a feeling of disconnect from reality for the families.

UKP: “The volunteer service… was really helpful, where people were able to drop the things off, and then the volunteers were bringing them up. That felt like a really big step, even being able to have a few personal items from home.”

SP: Felxibility of schedules was something that could be allowed more

Communication Challenges

SP: It is not the same to talk on the phone than to talk in the face-to-face situation... I think especially the proximity, the flexibility and the face-to-face situation.. it always makes it more human.

FP: It helps us to know what the patient was like before … We learn things… Medications, treatments, their way of life ….. how independent they are … All that.

SP: you had to really make an over effort to explain things in great detail so that they could get an idea, and explain the steps, and without creating like too much hope… It is difficult to make the family understand what is happening without them being present.”

FP: I felt there was a total lack of understanding on the phone, and that I couldn’t help the families at all, on the phone.

SP: Someone on the team has to dedicate themselves to family. Knowing that they can’t get in or out in any way, that they can’t take off their robes in any way.

UKP: Doing some, almost simulation training, of communication over video.

End of Life Care

UKP: I actually found the end-of-life stuff the hardest…I think, there are just so many different situations, where we weren’t allowed to let families in… I think the emotional burden of that was massive.

FP: But it was a shock from 24 hours a day to 0 and after, except for the people who were dying …. No, not at all, no ……they died alone …yes, they were alone.

UKP: Only having visitors at the end of life made me think a bit differently about decisions to change the focus of care to palliation. I felt I had to make sure I got it 100% right. There was only going to be one chance, they definitely had to be dying. They were only going to be allowed to visit once. If they didn’t die in that visit then they weren’t allowed back in because they were isolating.”

FP: I sometimes had to arrange video and phone calls at the same time, they all wanted to say goodbye. I would bring the phone to the patient’s ear. It was not easy. Patients would not be able to speak, so we have to translate, in our own words. The most difficult is finding the right words.

SP: I once have a doctor whispering to me: “I told them they could all come in, the 4 of them.” I just said minutes before, that they could only come 2 by 2, we couldn’t have more at the same time, given the organisation of the ward. As a consequence, we are not credible. Yes, that is another consequence of having mixed, blurred messages: the lack of credibility.

FP: The restrictions, they were much longer in the other departments and much more draconian.

Emergence of new technologies

The introduction of new technologies for the facilitation of family communication were discussed. The rapid pace at which technology was implemented caused anxiety for participants. Anxiety was due to a perceived lack of governance arrangements in relation to data protection, alongside worries about how families may feel when viewing their loved one during video calls.

French Participant (FP): ‘but if the patient had been in the prone position, I tried to find an angle that wouldn’t shock the family… and taking those picture, it stayed with you.’

Participants also described anxiety around access to technology from the family perspective. Inequalities in access to technology, especially with elderly patients, caused apprehension with staff.

UK Participant (UKP): ‘I really felt for the generations in the family. They were saying ‘I don’t know if I have got that type of phone, or I’ll need to wait until my granddaughter comes round.’ I was anxious about that. ’

Across the focus groups participants also described how the ‘non-technical’ skill of communicating with families became a ‘technical skill’. Organic conversations within ICU, which staff described as being important to delivering consistent care, were formalized into ‘factual’, prescribed telephone conversations:

Spanish Participant (SP): ‘I think the most horrible part from my perspective is that it became a very cold situation… if a patient dies, it is very painful and ugly, but when you see the family is when it hurts on a personal level. This by phone, because it is done as something more mechanical and cold. It was horrible, it was cold.’

Potential improvements in relation to virtual visiting were explored. Improvement activities were primarily focused on education and training needs of staff, alongside the provision of logistical requirements such as password access. Participants highlighted that training in undertaking virtual visiting required as much focus as ‘technical’ caring duties:

UKP: ‘There was nothing about how we were going to communicate with families. We were practicing proning, we were practicing all the kind of treatments and the things we were going to do, but there was no discussion about how we were going to communicate with families.’

Relationships and Rapport Establishment

Participants highlighted the crucial role which families play during ICU admission. A participant from Spain highlighted the importance of family relationships in care delivery:

SP: It is like cleaning a patient, maybe it is a burden, but in the end, it is for the wellbeing of the patient. The family is the human part that is not a burden. I think it is something necessary. Does it take time? Yes. Do we have to adapt to that? Yes. Are they sometimes difficult? Also, a lot. But it is necessary. Super-necessary.

During the initial stage of the COVID-19 pandemic, participants described a move from personalized family interactions to ‘transactional’ relationships. This loss of relationship and rapport had several negative consequences for clinicians including increased anxiety about the care family members were receiving and the creation of a ‘cold’ working environment:

FP: ‘It suddenly became very cold…it was very strange frankly, it was a bit dehumanizing…. it was a bit glacial.’

This change in relationship dynamic between staff and family members was also perceived to have a negative impact on care delivery. Participants described how care became depersonalized, with a loss of person-centered care:

UKP: ‘Even if someone had been sedated for a few weeks, I feel like you were able to get a really good picture of their homelife. Their families would bring up photographs and tell you stories about who they were. If that person woke up, you felt that you had a relationship with them because of their family. With COVID, it felt like everybody was just the same…You didn’t know who they were as people, it made it really difficult to be as empathetic and provide that side of care.’

The creation of tools to improve relationships and rapport between patients, families and staff were discussed. In addition to the introduction of virtual visitation, these included the use of electronic ‘what matters to you tools’ as well as individualised solutions such as personalized family messages and recordings:

UKP: ‘A family put up videos, recorded videos of themselves talking to the patient, just saying reassuring things, hearing familiar voices and playing music they were familiar with. They uploaded the video and you could have it playing at the bedspace continually… I remember thinking it was really good.’

Communication challenges

Across international settings, participants described the challenges which visiting restrictions brought to communication. One of the most challenging aspects was the difficulty in describing the clinical ’situation’ without family members present. Participants recounted that pre-pandemic, family members would often be at the bedside much of the day and could comprehend via formal and informal conversations, as well as through direct visualization, the progress, or lack of progress which a patient was making. As such, communication without families present was more difficult:

FP: ‘They (families) need to be informed and very often need to be reassured in a visible and concrete way…I wait for the family to be there to do a session so that the relative can see the evolution and the progress.’

The challenges with communication were perceived to have a direct impact of care delivery. Not having families present to provide commentary and support, made care delivery challenging. A physiotherapist described the negative impact of fragmented communication:

UKP: ‘When patients were fit enough to begin rehab, they tended to be at a much lower physical ability level. The global effect on the patient was huge….you had the psychological distress, there were huge chunks of their life missing. They didn’t have their family with them, they had no idea what was going on…Getting patients to engage without that sense of familiarity was an added challenge on top of their physical limitations.’

The contribution of family members in supporting communication and care during rehabilitation was also discussed within the context of delirium management:

SP: …most of them are super disorientated, agitated and very restless and I think that in those circumstances seeing a familiar face, a relative, always helps. Apart from the fact we were strangers…with the mask…I mean we were in disguise.’

Innovations and improvements to support communication were described. One area of innovation included the development of local ‘environment’ films. These included be pre-recorded films describing the ICU environment, alongside noises and equipment, which families could view, to allow contextualization and visualization of how care was being delivered. This was utilized in place of in-person visits to ICU where families would encounter the machines and technologies present in an ICU setting and thus facilitate improved communication during telephone conversations with staff.

UKP: ‘I think it would have been helpful if there was something we could have sent them electronically…this is the ventilator, this is the computer, this is the monitor, these are the infusion pumps…this is what to expect in ICU.

End of life care

The provision of end-of-life care was explored in-depth. In relation to the impact for staff, there was the need for a change in roles for clinicians. Participants across all disciplines acknowledged that this was particularly difficult for nursing staff; they described nurses had to adopt the role of family members in palliative situations, as relatives were unable to be present in the hospital.

FP: ‘Sometimes we would feel a certain transference. We would say ‘if it was someone in our family, wouldn’t we like that someone in the ward stayed with him or her as she passes away? Can’t we make that gesture at least?’.

Changes to the delivery of care ‘rituals’ during palliation were also described by participants. A participant from France spoke about some of these changes:

FP: ‘For palliative cases, we would open the doors to families, put a bed in, try to support them… and it is exactly the opposite, people are dying and we shut the doors, it is a bit bewildering, surprising to do the opposite. ’

A lack of standardization across visitation restrictions and inconsistent implementation locally, caused anxiety and frustration. In relation to improvement activities, staff described the importance of a consistent approach as being key to improving and delivering care:

SP: ‘That’s when our ethical dilemma begins: ‘okay I will let you in, but because it me, I assume responsibility of that, but tomorrow maybe not’’.

Staff wellbeing

Across theme generated, there was the manifestation of emotional exhaustion, emotional distress, and loss of job satisfaction for clinicians (Fig. 1).

Emotional exhaustion manifested in several ways; most notably staff described feelings of fatigue and being overwhelmed. A participant described the impact of the introduction of new communication strategies, to ensure that families had access to their loved one and the impact that this had on clinicians:

UKP: ‘….not only giving them a clinical update, but then trying to get hold of their email, trying to sort out technology. I just found it a bit overwhelming on top of the job we already do.’

The negative, longer-lasting emotional consequences that pandemic care provision and visiting restrictions had on staff wellbeing, alongside subsequent emotional distress, also emerged:

SP: ‘For me the satisfaction is that we get people better, although there are people who do not improve and suffer. But for me what has happened with the pandemic, the management of all that pain, I think many of us carry it. I have not been able to manage it.’

In relation to end of life care, staff also described feelings of guilt and frustration, which led to distress. Clinicians delivered heartbreaking news to families, in parallel with enforcing visiting restrictions:

UKP: ‘We were saying ‘yeah you can come up, but you are going to get exposed to COVID, which your loved one is going to die from, and you are going to have to isolate afterwards and not be able to get support from anybody.’’

Visitation restrictions and the consequences of these restrictions appeared to result in a loss of job satisfaction. A participant from France described how their role felt without the presence of families:

FP: ‘It was a feeling similar to working on a production line in a factory, without the contact of families…it was like a factory job.’

This qualitative analysis described the impact of pandemic visitation restrictions had across a diverse range of ICU clinicians, from multiple European settings. It has demonstrated that visitation restrictions implemented influenced care delivery in the ICU. The development of innovation was described, including the use of virtual visiting technology, as well as areas for future quality improvement efforts. Across international sites, clinicians described feelings of emotional distress and exhaustion due to the implementation of visitation restrictions. The absence of visitors also appeared to have a negative impact on job satisfaction. Interestingly, we found no differences across the international sites included, with the mechanisms for the negative impact on clinician wellbeing being mapped in an analogous manner.

The importance of family input into the provision of ICU care is not new(20, 21). Prior to the pandemic, research focused on the type of visitation arrangements (flexible vs fixed) and demonstrated the impact on rates of delirium and ICU acquired infections(22). The present findings extend this previous knowledge by delineating the impact that family visitation has on the entire ICU system, including care delivery and staff wellbeing. While the results of this study do not provide unequivocal evidence, they should be used as a foundation for further empirical research, exploring the contribution of families to ICU care.

Recent evidence has shown that family members appreciate and benefit from virtual visiting and the technology which has been implemented to facilitate virtual visiting(23). However, similar to previous research this analysis found discordant views about the use of technology from the clinician perspective(24). Participants described anxieties around the introduction of this technology including: governance arrangements; ability to undertake filming due to logistical requirements and the inability of some family members to access these films due to digital literacy and technology access. There have been several reports describing the negative impact which virtual clinic attendance has on health inequalities, with those from more socioeconomically deprived areas, and older adults most likely to be disadvantaged(25, 26). To our knowledge, this evidence in not available in relation to virtual visiting for family members. During subsequent development, it is crucial that health inequalities are not exacerbated through this innovation.

Clinicians across the three international settings also described the challenges associated with establishing relationships between families. The importance of non-verbal communication, which could not always be captured through virtual communication, especially when attempting to understand family comprehension and emotions around situations, was highlighted across each focus group. Similar to previous research, this was particularly challenging and, in some cases, deeply distressing, during end-of-life care delivery(27). The identification of an ‘anchor’ family member for consistent interactions and taking time to develop a relationship with families via initiatives such as ‘what matters to you?’, were suggested as key activities which could improve relationships when using technology and phone calls as the primary communication method.

Emotional distress, fatigue and poor job satisfaction have been identified as key contributors to CBS (28, 29). Previous literature has objectively measured a high rate of CBS in ICU clinicians during the pandemic, with visitation policies cited as a key driver (7, 30). This research highlights the crucial need for clinician psychosocial support, to address the potential outcomes of CBS. However, it is crucial that managers and policy makers focus efforts of developing a resilient system which provides environmental and cultural protection from the causes of CBS, and not focus primarily on individual staff psychology and coping skills(31). Uniquely, this present research develops tangible mechanisms by which CBS could be mitigated including adequate training in relation to technologies and the provision and implementation of consistent visitation policies. More novel techniques such as reconnection with patients and family members following hospital discharge have also been cited as potential mediators of CBS, with bidirectional benefits for patients (17, 28, 32). Reconnection could be facilitated via patient follow-up, informal visits back to ICU, or staff and family joint events(33). Future research should examine these low-cost strategies in the context of CBS.

Strengths of our study include the inclusion of rich perspectives from a broad range of professionals, across international sites. There are limitations to these data. Although the use of focus group data collection has multiple advantages, this approach may be subject to bias, as participants are motivated to take part. Finally, we did not explicitly capture or measure CBS or emotional distress. As such, this interpretation warrants further investigation.

In conclusion, the impact of family visitation restrictions is far reaching. We identified that the restrictions had an impact on staff wellbeing and job satisfaction alongside a negative impact on care delivery. Potential improvements to develop care delivery and staff wellbeing were identified and included adequate training in relation to technologies and the provision and implementation of consistent visitation policies.

CBS

Clinical Burnout syndrome

ICU

Intensive Care Unit

PTSD

Post-traumatic Syndrome Disorder

Ethics approval and consent to participate: UK: This study was approved by the Scientific Officer of the West of Scotland Research Ethics Service as Service Evaluation (UK approval); the Hospital Clínic of Barcelona Medical Research Ethics Committee (HCB/2021/1115) (Spain approval); and the research ethics board Sud Méditerranée (2020-A00809-30; CNRIPH: 20.03.27.73019) within the framework of the BURDENCOV study (France approval).

Consent for publication: All participants provided written informed consent for participation in this study.

Availability of data and materials: A de-identifed dataset and the study protocol may be made available to researchers with a methodologically sound proposal, to achieve the aims described in the approved proposal.

Data will be available upon request following article publication. Requests for data should be directed at [email protected] to gain access.

Competing interests: Dr Azoulay reported receipt of personal fees (lectures) from Pfizer, Gilead, Baxter, and Alexion; and institutional research grants from Merck Sharp and Dohme, Pfizer, Baxter, and Alexion outside the submitted work.

Funding: J This study was funded by the European Society of Intensive Care Medicine Family partnership Award (2020). JM is funded via a Fellowship from The Healthcare Improvement Studies Institute (University of Cambridge (PD-2019-02-16).

Author contributions: JM and KP had full access to all study data and takes responsibility for the integrity of the data analysis.

JM and KP conceptualized and designed the study.

All authors contributed to the analysis and/or interpretation of the data.

JM drafted the original manuscript. All authors critically revised the manuscript for important intellectual content.

Acknowledgements: The research team would like to thank staff who took time to participate in these focus groups.

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Competing interest reported. Dr Azoulay reported receipt of personal fees (lectures) from Pfizer, Gilead, Baxter, and Alexion; and institutional research grants from Merck Sharp and Dohme, Pfizer, Baxter, and Alexion outside the submitted work.

ISSMCOREQChecklist.pdf
S1: COREQ checklist
S2focusgroupguides.docx
S2: Focus group interview schedules
S3Codingapproach5.docx
S3: Qualitative analysis coding development

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published 21 Jan, 2023

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Editorial decision: Major revision
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Clinician perceptions of the impact of ICU family visiting restrictions during the COVID-19 pandemic: an international investigation

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Introduction

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Design and Setting

Data Analysis

Results

Emergence of new technologies

Relationships and Rapport Establishment

Communication challenges

End of life care

Staff wellbeing

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Conclusion

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