Exploring staff perspectives on caring for isolated hospitalised patients during the COVID-19 pandemic: a qualitative study

Response to the COVID-19 pandemic in Melbourne, Australia included a strict lockdown for 4 months in 2020. During this time, visiting in-patients in acute hospitals was severely restricted. A large number of patients presenting with respiratory symptoms or suspected of having the COVID-19 virus were isolated.

Isolation is a gold standard practice in healthcare settings to reduce and prevent the spread of infections particularly those which have the potential to cause serious harm to individuals or the community, or to protect immunocompromised patients from infection [1]. In Victorian acute hospitals, pre-COVID, approximately 12% of patients are in isolation at any one time [2]. A total of 2492 patients were isolated in Victorian hospitals between 25 January and 15 November 2020 [3]. The number of staff employed by the health service increased during this time to meet the increased demands of the pandemic response [4]. A Patients in Isolation Taskforce was established by the health service in response to a cluster of falls and other adverse events in isolated patients in early 2020 [4].

Strict isolation of COVID-19 patients to prevent cross infection to other patients and staff may have serious adverse outcomes for patients. Psychological problems, including depression, lethargy, lack of motivation and anxiety, are common [5, 6] and related to uncertainty and loss of control [5, 7], loneliness and reduced social contact [8], and perceived stigmatisation [9]. Patients in isolation have reported poor quality of life [10] and suffer from reduced human contact [7]. However, healthcare professionals who are encouraging and friendly, and engage with patients while attending to tasks, have been shown to make a positive difference [5, 11]. Patients in isolation have a higher risk of developing delirium [7, 12]. Separation from family and familiar environment, inadequate pain management, use of restraints, immobility and sleep disruption contribute to the development of delirium [13].

The physical functioning and rehabilitation of patients in isolation may be neglected [14] leading to deconditioning [15]. Older people can develop sarcopaenia as well as problems directly related to COVID-19 including cardiac, pulmonary, and neurological deficits [16]. Isolated patients potentially receive reduced patient care, delays to care, and less frequent, shorter interactions with healthcare providers [6]. The prevalence of malnutrition in hospitalised patients with COVID-19 is high [16]. Adverse events, including falls, pressure injuries, medication errors and fluid imbalance are common [8, 10].

Hospital staff caring for patients during a pandemic are at increased risk of adverse mental health outcomes [17‐19]. Additional stressors in an already high-pressured clinical environment include potential exposure to COVID-19 and risk to their families, anxiety about the future [20], overwhelming workload [21], challenges to the standard of care [22], and moral distress [23].

In Australia, previous experience with pandemic management is limited. To optimally manage future similar situations, more information is required on the effect of isolation on key stakeholders. Previous studies have explored this topic from the viewpoint of patients demonstrated in a systematic review and meta-analysis [10] which revealed that patients in isolation rooms commonly felt distressed, alienated, a burden to healthcare staff and uninformed about infection prevention. Additionally, patients in isolation experienced fewer bedside visits and there could be limitations to care [10]. There is very limited research about the effect of isolation on patients and families from the perspective of staff who deliver and are accountable for patient care [24, 25]. Staff working closely with this patient group can provide unique insight into the issues connected with isolation and inform potential solutions. This study elicited the opinions of clinical and non-clinical staff working with patients in isolation.

This study provides insight from clinical and non-clinical staff into caring for patients in isolation. A strength of the study was the diversity of experience shared by participants who were from different clinical disciplines and non-clinical roles. Support services staff were focused on the logistics of providing cleaning and meal services to patients in isolation and removing waste. Clinical staff – nurses, allied health and doctors – were more closely involved with patients’ biopsychosocial needs which was reflected in their views. However, all disciplines were aware of the psychological and practical effects of isolation on patients. Compliance with pandemic restrictions created considerable challenges to ensure that patients received the best possible care. Negative impacts reported included decline in standard of care, distress for families unable to see their loved ones, challenging work environments and moral distress for staff. Staff health and well-being suffered. Some positive impacts included use of new technology, creative problem solving, staff teamwork and camaraderie, and regular communication with families. Staff worked hard to alleviate the negative consequences of the restrictions on the people involved.

Maintaining the standard of patient care during isolation was a pre-existing problem [7, 8, 10, 29] recognised by the hospital by implementing a task force. The experience of mass isolation during the pandemic accelerated the need to identify creative solutions to be applied to isolation in non-COVID times. Like healthcare organisations globally, innovative use of technology changed communication modes between healthcare professionals, with patients and families and the wider community [30, 31]. Adapting methods to deliver effective communication that was suitable for the new conditions was a priority. Hospital leaders used a combination of electronic briefings, short emails and limited in-person contact to communicate regular updates to clinicians, an approach also used successfully in the UK [32] and elsewhere [33]. Previous research identified that uncertainty about the course of the pandemic, frequent changes to processes and conflicting information, added to staff stress [17, 34]. Considerable skill is required to have difficult conversations with patients and families via telehealth or on the phone; a skill not shared by all clinicians [31].

Personal protective equipment hinders communication between clinicians and patients, especially masks, which obscure the view of the speaker’s mouth and facial expression and reduced voice volume [35]. PPE not only decreases the wearer’s auditory perception and affects the ability to make contact with others [29], but reduces situational awareness which intensifies with an increase in PPE discomfort [35]. Face shields and goggles introduce glare which further limits the view of the speaker’s face [36] and creates a communication obstacle between team members and with patients [37]. The use of personal protective equipment can be depersonalising and alarming to patients, especially those with underlying cognitive impairment [38]. Previous research has reported similar issues to those found in our study including delays in responding to MET calls [39, 40], delivering meals to patients, and preventing falls because of the need to don PPE before entering an isolation room [5].

Decreased staff interactions and family presence meant some patients became lonely and anxious. Marler and Ditton [41] reported that patients who don’t recognise their attendants may develop increased loneliness, confusion and anxiety leading to a liminal experience. A close therapeutic relationship with nurses and other clinicians can mitigate feelings of being an outsider, of being marginalised and kept separate from others [42] but closeness is difficult to foster under these circumstances [34]. Staff were also impacted by the decreased interactions with patients and families.

Telehealth or phone contact only partly alleviated the distress and staff reported some patients felt abandoned. Voo, Senguttuvan [43] suggested that more energy should be devoted to supporting isolated patients with family presence - physical, virtual, or surrogate - although this can create a further burden on an already over-extended workforce. The effect of the separation of dying patients from their families was perceived as particularly traumatic and not easily substituted with telehealth. The experience could potentially cause on-going psychological pain and posttraumatic stress to families [44] and to staff [45].

Denying families access to their relatives who were critically unwell or had other comorbidities such as dementia, sensory impairment or were non-English speaking caused significant moral distress to staff. Moral injury results from actions or lack of them which violate one’s moral or ethical code [23, 46]. The ethical principles of clinical care during a pandemic are complex. The protocols must be followed; however, clinicians may be conflicted when institutional restrictions prevent them from caring the way they consider best for individual patients [47]. Extreme examples of moral injury in which a person feels that their core values are eroded can lead to posttraumatic stress disorder (PTSD) although intervention can sometimes be preventative by cultivating resilience [23]. The need for the staff to debrief about their moral distress during this study highlights the importance of formal and informal debriefing after a major event.

Staff reported an increased camaraderie as they faced difficult situations together. In many cases, workload and stress increased, however teamwork and support from colleagues and managers made the situation more bearable. Informal peer support can alleviate the need for formal intervention, prevent burnout [33], and reduce the stigma of stress [21]. Reinforcing social bonds between colleagues and supervisors is protective of mental health [20], and can facilitate help seeking when appropriate [21]. Feeling protected and supported has been found to promote role confidence and self-efficacy in frontline staff [33, 34].

The COVID-19 pandemic has presented hospitals with an unprecedented challenge, organisationally and individually [17, 48, 49]. However, the experience has identified areas of strength and others that require improvement. Isolating large numbers of patients necessitates alternative models of care and different workflow practices, some potentially enabled by technology, to ensure that a high standard of care is maintained [50]. Patient and family-centred care principles must be embedded into care for all patients, including those in isolation [11]. A more robust system for virtual visiting, and more flexibility with in-person visiting restrictions is recommended [51]. Workable solutions to these problems could be sought using co-design methodology [52], with input from patients, families and staff. The restrictions both in the hospital and the community has had a significant impact on staff health and well-being. Staff were especially vulnerable to emotional distress, given their risk of exposure to the virus before vaccination was established. Appropriate support must be provided to mitigate against long-term psychological effects and maintain a robust workforce [53, 54].

Although isolating numerous patients and severely restricting visitors resulted in good pandemic management, health care workers perceived considerable impact on patients, families, and staff. The insight staff provided will inform planning for future pandemics. Communication technologies and strategies, mental health support for patients, families and staff, and adaptable infrastructure are pre-requisites. Further research is required to understand what improvements are needed from the patient and family perspective and to determine the effectiveness of interventions on isolated patient care.