Table 2.

Identified themes and subthemes for effects of restricted visitation described by patients/family members, physicians, registered nurses, and decisions-makers

Quotation number	Theme and subtheme	Exemplar quotation(s)
Acceptance of restricted visitation
Q1	Acceptance of circumstances	“…in terms of the greater good to the public and especially, to nursing homes and long-term care facilities, I think we all understand that if one family member brings it into the hospital unknowingly, even if they're asymptomatic, that can have devastating effects…” –Family member
Q2	Appropriateness	“Restaurants, bars were opened…why was it not possible to visit someone liberally in the hospital?” –Physician
Q3	Appropriateness	“...family was such an important part of our patient care in the ICU and involving the family and having them come in and support the patient as they either progressed or unfortunately didn't progress.” –RN
Q4	Appropriateness	“I just thought it was too bad that they couldn't somehow meet him, escort him in with all the proper PPE, take him to his mom and they could spend time together.” –RN
Impact of restricted visitation
Q5	Psychosocial impact	“So there's just a lot of anxiety and probably some PTSD to begin with, so to be talked to and to know that, that's not the policy. I really don't believe that policy is only one family member can get a report, or that a nurse doesn't have enough time just to say, ‘They made it through the night.’” –Family member
Q6	Psychosocial impact	“We all felt badly that we couldn't see him, and we felt badly that he must have suffered through his last few days and not understanding what was going on around him and why no one was coming to see him. We feel guilty about that.” –Family
Q7	Psychosocial impact	“An individual in their 30s with children and a husband, mother and a father, die without any of them being present, without any of them seeing how hard we worked for the very short time that they were with us. It's quite sad to think about that and to think that the families had no chance to say goodbye.” –RN
Q8	Psychosocial impact	“The family member has three children and only one of them is allowed to visit. That caused a lot of distress for the family and caused a lot of distress for the staff.” –Physician
Q9	Patient care	“…I got to make sure that when you're having conversations some people remember it all and for me, you know, I might forget something five minutes after somebody told me and maybe I forget to relay it to her, you know what I mean? So an extra set of ears is a lot better than just getting fed information, right?” –Patient
Q10	Patient care	“So, as I said, my father is elderly, and was not happy about being sick and being in the hospital, and the visits that he did receive before the restrictions came down, did lift his spirits a great deal, and encourage him. So when the visits were restricted, he did suffer. He was not as comfortable, not as uplifted, emotionally. So I do believe that the restrictions had a negative effect on him.” –Family member
Q11	Patient care	“…patients, I'm quite certain that having family members there, orienting them, providing consistency, helps ward against things like delirium and improves outcomes.” –Physician
Q12	Patient care	“…family members are important to me in terms of my care to connect with a patient, to connect more thoroughly, in a more well rounded way instead of just watch their blood pressure, manage the medications. It's helped when I have a family member to talk to, to ask about the patient. It enhances a bit of the overall care.” –RN
Q13	Relationship	“…then you're having these conflicts with families, that you don't even agree with the policy, but you have to stick with it. And you're escalating it on the back end and they don't know, so they're getting mad at you and so you end up being this middle person…” –RN
Trust in the healthcare system during the pandemic
Q14	Transparency	“Because we weren't allowed in there ourselves, we have no assurance that that was actually done for every person that needed it or should have had some sort of somebody there so that they knew that they didn't die alone, that people cared for them and that even if they didn't understand that it wasn't possible for us to be there, at least they weren't alone. We have no assurance that that was actually done.” –Family member
Q15	Transparency	“For example, intubated patient who's dying, the families don't often appreciate it until they see how much we're doing for the patient, how much we're trying to save them or what are we doing to make them comfortable, how are we caring for them at the bedside.” –RN
Q16	Trust	“The biggest issue was that if anyone complained to senior management about the policy, they overruled the policy and allowed the family to visit.” –Physician
Q17	Trust	“… I started to hear about the, not necessarily loopholes, but different ways that people found to get around the policies, like finding a back door and sneaking family members in and going out to meet them in person.” –Physician
Modes of communication
Q18	Virtual platform	“So we got iPads donated to all the critical care units and all the COVID-19 units that were in the hospital so that was really nice. I personally never used it, but their main use was for patients to use Zoom with their loved one.” –RN
Q19	Phone	“Sometimes, I think early on, there were a few that I did not even with video conferencing. It was just over the phone, which I found very impersonal and very challenging to discuss such an in-depth, personal topic with someone about. When it got to more of a virtual platform where we were able to actually see people, I think it became a little bit easier. But still I found that it just lacked that connection that you would have with a family when you're with them in person.” –Physician
Q20	Virtual platform	“I almost felt the video chat was worse. Because nursing staff weren't necessarily always there for the video chat, so then they'd have these ... They basically have a family member with no medical knowledge seeing their loved one intubated. And people when they're intubated don't look ... They look very unwell. And they're seeing this and they know they can't visit. So I don't know that there was much benefit from that or if it just distressed the families a bit more.” –RN
Impact of policy implementation on clinical practice
Q21	Organizational factors	“… you easily spend the entire half a day just monitoring the donning and doffing of equipment”–Physician
Q22	Changes in communication structure	“I think it’s easier to convey difficult news in person, because you can share in that emotional exchange rather than in the more sterile phone environment. So, the difficult stuff was more difficult, I think, via the phone. The update as to progress, specifically if progress was good, I found was fine in that. And I think that that can be done on the phone and often is. It was more so if things weren't going well, that was challenging.”–Physician

PPE = personal protective equipment; PTSD = post-traumatic stress disorder; RN = registered nurse