Table 2.

Exemplary quotes by theme

Quote ID	Exemplary quote
Theme 1: Balancing infection control and family presence
Q1	“I think everybody … understood why it had to happen, but felt really sad for the patient, obviously, and also the family members who have to go through this alone or with very little support, right. At best, you had one more person to support you when your child is very ill, critically ill. But I think everyone understood why it had to happen. I just think it was difficult to see that.” HCP008, Respiratory therapist (RT)
Q2	“I think it was a necessary precaution that had to take place to protect children and families in our community from COVID-19.” HCP007, Registered nurse (RN)
Q3	“Having lived through the ‘only one person’ bedside, I can do this standing on my head because that was so traumatic for me personally. Denying a parent access to their critically ill child, that was brutal. So I can do two parents at the bedside easily.” HCP006, Social worker (SW)
Q4	“[The restrictions] just don't feel fair or right for the families. Especially when it came into ‘open for summer’ and people can go drink in bars and have gatherings outside, yet a grandparent can't come see their critically dying grandchild. It put a lot of moral distress on a lot of our nurses.” HCP011, RN
Q5	“I think an inordinate amount of importance was placed on the infectious disease science part of things. And I think that unfortunately we ignored the science around mental health and the profound effects that this had on people at the time and will have that they will carry forward.” HCP009, Physician (MD)
Theme 2: Feeling disempowered by hospital and policy-making hierarchies
Q6	“I feel like we voiced a lot of our concern because we were the ones that would go in the room every hour. But I don't think it made a really big impact. Because again, we're a big hospital, and the people that make the rules are higher up and not necessarily going into the room to make their check every hour. So they’re not taking that into consideration what we have to say.” HCP001, RT
Q7	“Interviewer: Did you guys feel like you had a voice in [policy] decisions? Participant: I don’t know. I mean yes, we did [have a voice] because our division had and our unit manager, our patient care manager were advocating for us. But I think … But no [we didn’t actually have a voice] … Like no amount of advocating was going to change the inevitable. So we were speaking into the wind.” HCP002, MD
Q8	“There was a lot of conversations that happened about caregiver and family presence, probably with some of the right people. But I don't think that nursing perspective heavily weighed in, at least from [the] frontline. But I think if you would ask those questions and involve the right people to begin with, we probably could have addressed [issues] sooner.” HCP007, RN
Q9	“It put health care providers working very closely at the bedside with families in a bit of a precarious position because we didn't really have any control, we didn't really have any autonomy, and the decision-making power was not within us to use our critical thinking or our clinical judgement. It was very micromanaged by people at the top, higher.” HCP006, SW
Q10	“I think giving your staff a little bit of credit. Because things are not always black and white, especially in an area like [the] PICU. But just knowing that sometimes there are going to be exceptions to the rule, and we can use our critical thinking and our clinical judgement. Because we do it with everything else that we do each and every day.” HCP007, RN
Q11	“We just … we stopped asking, maybe. Do you know what I mean? Like if you ask enough and you get no as an answer, you're not going to keep banging your head on the door, right” HCP002, MD
Q12	“Interviewer: And was there a process for you if you formally disagreed with a decision that was made around the restricted family presence? Participant: Absolutely not. I know emails were sent, emails were brought forward to leadership, and there was never any follow through. There was a, “Thanks for letting us know,” and that was it.” HCP007, RN
Q13	“I think our nursing colleagues would be at the forefront, to be honest, because they incredibly would identify these families that would fall through the cracks. And so I think it's really important to them to be part of the decision-making.” HCP002, MD
Q14	“There were some like emails sent around to staff with COVID updates daily. But honestly, they got so many. At one point, you would get like seven update emails a day. So hearing it right from the staff that you’re working with, leadership that you're working with, just to reiterate the policy was really helpful. Because nobody has time to read seven long emails every 12-hour shift.” HCP014, RN
Q15	“Parents being told mixed messaging, and then us having to go in and be the bad guy, to say, no, you actually aren't allowed to leave or you aren't allowed to have your spouse come in.” HCP010, RN
Q16	“I think just knowing that you have your leadership behind you to come in to support your decision. Like our manager has been very clear. Even as recently as a staff meeting this week, to come in and say, “If you’re having pushback and I’m in the building, call me and I’ll come down and just reiterate the policy to them from a leadership standpoint,” so that it doesn’t actually all fall on the RNs because so much has over the last year and a half.” HCP010, RN
Q17	“For the vast majority of families, they understood what was happening. They got it. They understood that it was out of our control. And we made that very clear.” HCP002, MD
Theme 3: Empathizing with family trauma
Q18	“So I was just exhausted with like feeling for them because they were like suffering so much.” HCP003, RN
Q19	“I've seen some horrible stuff. But in the last year and a half, having to deal with that one parent at the bedside, that was the hardest thing I've ever done. Denying people access to their critically ill and injured children was brutal.” HCP007, RN
Q20	“I think, too, also just like feeling that huge like empathy for them, right. Like this is the hardest thing that they have ever done. And it was heartbreaking. Like it really was heartbreaking that other people couldn't be here. And that, you know, when kids were dying, it was just like it was awful.” HCP016, Child Life Specialist (CL)
Q21	“We have kids that have been here since pre-COVID with no passes who have changed so much developmentally that when the siblings see them, there's no recognition … so that memory of their relationship is no longer existent. So it's been very difficult as a staff to watch that, to bear witness to that.” HCP004, CL
Q22	“Before COVID, kids might come in and they might get overwhelmed and leave the unit. But I was able to follow them to a safe spot, right. Whereas if they’re on the phone and they decide to hang up, they might not answer my call again. But at least when they were physically here and became upset or couldn't cope anymore, the child was in front of me and I could follow them and take them somewhere safe and sit with them, you know. And so we just didn't have that opportunity.” HCP016, CL
Q23	“It's been hard morally to watch parents go through death and dying situations of their children, and not be able to have the support of their family beside them.” HCP011, RN
Q24	“It was very tiring. And we certainly did not do an adequate job providing social supports because we would never in that situation. We would do our best to support the family. But we don't replace family. We don't replace friends, right. We don't replace colleagues. Like it’s just not the same.” HCP002, MD
Q25	“We were all quite accommodating I found as far as providing Facetime updates and writing things down for the support person who was there so they were able to update the rest of the loved ones.” HCP010, RN
Q26	“When I first posed [the idea], the unit thought I was crazy. But it's now a standard practice that grandparents and siblings will come to the outdoor windows so they at least can look upon their loved one here in the ICU.” HCP006, SW
Q27	“We would take photos and send those home as part of the communication book [between siblings and patients], too. So we tried to get a bit creative … When parents brought it back home, they would review it with the sibling. The sibling could write a message back. Sometimes they would write a message to the nurse to ask the nurse certain questions … We would try to change it every day. And also talk about how there's like a social worker who meets with the family. And there’s a really special doctor that just works on the lungs. And that’s a respirologist. And kind of explain what that means. So we really wanted siblings to feel a part of the journey even though they weren’t here.” HCP015, SW
Q28	“Every exception needed to be advocated for. And so we have advocated for, [for example,] we have a very young family who’s daughter has serious heart disease … and was very, very critically ill … she spent weeks in hospital. And so her parents are young, and need support from the grandparents. And so we have advocated to allow the grandparents in partly for respite but also so that they can see what's going on and better support the parents.” HCP009, MD
Theme 4: Navigating threats to the therapeutic relationship
Q29	“When you're looking at the patient in terms of like the community and the social environment that they're in, yes, that was impacted. Caring for the whole patient was impacted. But caring for the medical disease in front of me was not affected.” HCP002, MD
Q30	“I guess for me what I struggle with is that … I know that there's no going back. And we will [miss opportunities] and we have missed opportunities. And it's timely. And so for me, there's regret. Like there is that regret at times when no matter what the change or what this family needs, we can't accommodate it.” HCP004, CL
Q31	“I would say that there was kind of an increase in frustration or anger expressed towards staff, and not the right people, right. So again, not the people at the end of the day that can really be part of making that change. I think it was directed to the people who were doing their best, and don't have a lot of autonomy.” HCP006, SW
Q32	“I would have really good relationships with family members in the past. But then to have that relationship, and then be like, “By the way, you need to leave now,” was like really hard. So you kind of like were a little bit farther away. And that way it wasn't so challenging to have those conversations. Which isn’t great for relationships in this role in this field.” HCP003, RN
Q33	“The ones who were constantly asking for exception, they were constantly being denied, then we just kind of became the bad guy. And that strained the relationship.” HCP010, RN
Q34	“I was lucky, in general as a respiratory therapist, I don't really have to enforce that rule. So I don't have to directly deal with the families that are upset when you can only have one family member or two family members. So for me, I didn't directly have to implement it. So I guess I don't have a ton of emotional experience with that part.” HCP008, RT
Q35	“[If a parent] was absolutely livid, I would call upon [management] to come talk to the parents to kind of remove me from that decision-making process. […] it kind of protected my role as a support person, right. Because that’s a hard position to be in. My job is parent and family support. And if I'm seen as the person that's denying them something or taking away something, it makes it that much harder. So I'm pretty good at gauging when that line has been crossed, when [it’s] interfering with how I can perform my duties. That’s when I would call in the unit manager to say, “You need to come in and be, you know, the hard ass person that's laying down the law.” And they're very supportive that way.” HCP006, SW

CL = child life specialist; MD = physician; RN = registered nurse; RT = respiratory therapist; SW = social worker