Infection prevention and control across the continuum of COVID‐19 care: A qualitative study of patients', caregivers' and providers' experiences

Abstract Introduction Healthcare facilities adopted restrictive visitor policies as a result of the COVID‐19 (COVID) pandemic. Though these measures were necessary to promote the safety of patients, families and healthcare providers, it led to isolation and loneliness amongst acute care inpatients that can undermine patient rehabilitation and recovery. The study objectives were to (1) explore how infection prevention and control (IP&C) measures impacted stakeholders' perceptions of care quality and interactions with others and (2) investigate how these experiences and perceptions varied across stakeholder groups and care settings. Methods A qualitative descriptive study was conducted. Patients and their families from an inpatient COVID rehabilitation hospital and healthcare providers from an acute or rehabilitation COVID hospital were interviewed between August 2020 and February 2021. Results A total of 10 patients, 5 family members and 12 healthcare providers were interviewed. Four major themes were identified: (1) IP&C measures challenged the psychosocial health of all stakeholders across care settings; (2): IP&C measures precipitated a need for greater relational care from HCPs; (3) infection prevention tenets perpetuated COVID‐related stigma that stakeholders experienced across care settings; and (4) technology was used to facilitate human connection when IP&C limited physical presence. Conclusion IP&C measures challenged psychosocial health and maintenance of vital human connections. Loneliness and isolation were felt by all stakeholders due to physical distancing and COVID‐related stigma. Some isolation was mitigated by the relational care provided by HCPs and technological innovations used. The findings of the study underscore the need to balance safety with psychosocial well‐being across care settings and beyond the patient–provider dyad. Patient and Public Contribution This study was informed by the Patient‐Oriented Research Agenda and developed through consultations with patients and family caregivers to identify priority areas for rehabilitation research. Priority areas identified that informed the current study were (1) the need to focus on the psychosocial aspects of recovery from illness and injury and (2) the importance of exploring patients' recovery experiences and needs across the continuum of care. The study protocol, ethics submission, analysis and manuscript preparation were all informed by healthcare providers with lived experience of working in COVID care settings.


| INTRODUCTION
The COVID-19 (COVID) pandemic has required a rapid and drastic response by healthcare systems worldwide, including major changes in how organizations and staff function to deliver patient care. 1 The infection prevention and control (IP&C) measures used to enhance the safety of patients, caregivers and healthcare providers (HCPs) were unprecedentedly widespread and generated unique challenges for all stakeholders. One of the most prominent IP&C measures that was adopted worldwide involved strict 'no visitor' policies. 2,3 While IP&C measures like physical distancing, isolation, use of personal protective equipment (PPE) (e.g., masks, face shields, gowns) and visitation restrictions created important layers of protection, they undoubtedly resulted in negative consequences for patients such as anxiety, depression and loneliness. [4][5][6] Visitation restrictions, in particular, proved to be especially challenging, as large-scale disasters-such as the COVID pandemicintensify stress and basic human needs to feel safe and connected. 7 Balancing high-quality care and human connection with the safety of patients, families and HCPs during a pandemic proved extremely challenging. 8 HCPs were in an especially difficult position as they attempted to fulfil their own needs for human connection while simultaneously meeting those needs for their patients. 9 This dichotomy between human connection and IP&C measures engendered feelings of mistrust, confusion and hurt amongst patients, families and HCPs alike. 10 Although video conferencing technology was recognized as having the potential to reduce the risks associated with patient isolation, 2 its success depended heavily on patient and families' existing technology access and digital literacy, as well as HCP availability to support implementation. 11 While there is a growing body of evidence pertaining to the impact of IP&C measures during the early period of the pandemic, the majority of these studies have focused on single care settings (typically acute care and long-term care), providing little insight into how IP&C measures impacted stakeholders' experiences both within and across care settings and how challenges precipitated by IP&C measures were addressed across settings. Further, most studies have focused on HCPs' perceptions of IP&C measures, revealing common themes around the need for resiliency in the face of resource and staff shortages, burnout and infection concerns to provide high-quality patient care. [12][13][14] However, very few studies have explored patient experiences with IP&C meaures, 6 and none have included family caregivers' views. In turn, we investigated the COVID care pathway from the perspective of patients, caregivers and HCPs ('stakeholders'). Specifically, our goals were to (1) explore how IP&C measures impacted stakeholders' perceptions of care quality and interactions with others and (2) investigate how these experiences and perceptions varied across stakeholder groups and care settings (i.e., acute care, inpatient rehabilitation and community).

| METHODS
This paper draws on data from a study investigating the implementation and impact of COVID care within a hospital network comprised of an acute care and inpatient rehabilitation facility based in Toronto, Canada. We used a qualitative descriptive approach, which entails a concise and descriptively rich analysis that remains true to participants' own words. Thus, it produces a data-near report that is representative of participants' views, making it meaningful for key stakeholders and relevant for justifying actionable change. 15,16

| Participants
We recruited HCPs working in or supporting an acute or rehabilitation COVID unit by email using the hospitals' COVID unit listservs. We recruited patients from a database of people discharged from inpatient COVID rehabilitation between March and September 2020. We contacted patients via telephone or email. All patients were initially admitted to an acute care facility with a COVID diagnosis before being discharged to the inpatient rehabilitation hospital's COVID unit. When we contacted patients, we also asked for their caregiver's information (either telephone or email) to enable us to recruit them. Patients were eligible to participate if they were English speaking, cognitively able to provide consent and had been discharged in the past 6 months.
Caregivers were eligible if they were a friend or family member supporting a patient who fulfilled these criteria and were themselves English speaking and cognitively able to provide informed consent.

| Data collection
This study was approved by the Research Ethics Board at Sunnybrook Health Sciences Centre. Informed consent was obtained before data collection. One trained qualitative researcher (S. G.) conducted all interviews via telephone or Zoom between August 2020 and February 2021 (see Table 1 for an overview of the interview guide). One pilot interview was conducted with each stakeholder group, followed by discussion between the interviewer and the first author to ensure that the questions were clear and eliciting appropriate responses. These consultations indicated that no major modifications to the interview guide were required.
Data were collected until saturation of ideas was reached. The interviewer and the research team were embedded within the inpatient rehabilitation hospital, and participants had no prior relationship with the interviewer and understood that the study goals were to explore stakeholder experiences with COVID care.
Interviews ranged from 30 to 80 min, were audio-recorded and • What was it like to support your loved one while they were receiving care at (acute care site) for COVID-19?
• Overall, what went well during your loved one's stay at (acute care site) and what could have been improved?
• Can you tell me a little bit about your experience as your loved one was preparing to leave (acute care site) to go rehab?
• How prepared did you feel for your loved one's transition to rehab? How did the transition go?
• What was it like to support your loved one while they were receiving care at (rehab facility) for COVID-19?
• Overall, what went well during your loved one's stay at (rehab facility) and what could have been improved?
• How did you feel about your loved one getting ready to go home? How did the discharge to home go?
• After your loved one returned to home, did you feel like you had the necessary information and resources to support their continued recovery from COVID-19? • Once your loved one was home, what were your top concerns and needs?

HCPs
• To start, could you tell me a little about your clinical role and work history?
• What were your thoughts and expectations when you first heard that a portion of (unit) was going to be converted into a COVID zone? • What were your top concerns, questions, and needs when you learned that you would be working in the COVID zone?
• How do feel your needs/questions/concerns were addressed by managers, administrators and other senior leaders?
o For managers/administrators/senior leaders: How did you address the needs/questions/concerns that staff had? • What has the actual experience of working in the COVID zone with COVID patients been like?
• What are your thoughts on the extent and quality of care that was delivered to COVID patients? transcribed verbatim. All identifying information was removed from the transcripts, and transcripts were uploaded to NVivo for organization and analysis. Sociodemographic information was collected from patients and family caregivers, and clinical characteristics of the patients were also collected. We also collected professional practice information from HCPs (e.g., profession, years of practice, practice setting).

| Data analysis
We used an inductive thematic approach following the steps outlined by Braun and Clarke, 17 whereby data were deconstructed into isolated fragments, followed by reconstruction into overarching themes that describe the higher-level messaging in the data. Two independent researchers (Z. S. and S. G.) completed the coding process and three additional researchers (C. S., R. S., M. B. W.) participated in the thematic analysis.

| Rigour
Analytic rigour was enhanced by triangulating between multiple individuals throughout analysis, having regular team meetings and exercising reflexivity (discussing and journalling the study team's own biases and experiences that may influence data interpretation).
We also adhered to the COREQ reporting guidelines (see Appendix SA).

| RESULTS
In total, we interviewed 27 participants for this study, which included 10 patients and 5 caregivers (see Table 2 for patient and caregiver characteristics). Thirteen patients and caregivers were eligible for the study, but were either not interested (n = 9) or could not be reached (n = 4). We also recruited 12 HCPs. HCPs were occupational therapists (n = 3), patient care managers (n = 2), registered nurses (n = 2), medical department heads (n = 2), collaborative practice leaders (n = 2) and a pharmacist (n = 1). All HCPs (n = 12) reported  Although technology helped to overcome some COVID-related challenges, it had its limitations. First, not all patients had equitable access to technology. This was particularly prevalent in the initial weeks of the pandemic when both acute care and inpatient rehabilitation did not yet have tablet initiatives. During these initial weeks, some patients explained that they 'had to bring a cell phone from home' (PT07) or because they 'were never offered an iPad, I used the hospital phone in my room' (PT01). Second, many COVID patients were older adults who were not comfortable using technology (e.g., tablets) and either had to quickly learn how to navigate these tools or request assistance from already busy HCPs who 'couldn't always help me much' (PT05). Finally, for many COVID patients, health status was an issue. In the acute care setting, some 'families found the iPad stuff very difficult. Especially if patients weren't doing well medically. Some of them opted not to do those kinds of visits. It was just too hard on everyone' (HCP10). In other cases, acute care patients who were severely deconditioned were 'too weak to hold the iPad' (PT14) and lacked the energy to carry out conversations with loved ones. One caregiver explained that as her loved one's health improved in inpatient rehabilitation, 'she was able to call me on her own, herself. [In acute care], she was never able to do that. I had to go through the hospital, and sometimes that was an inconvenience on both of us' (CG07).

| DISCUSSION
Our study explored the experiences of patients, family caregivers and HCPs with COVID care across the continuum of care. Our findings highlight that the COVID pandemic created conditions that required all stakeholders to balance safety with the need for human connection. The four themes that we identified underscored that While the need for IP&C measures is undeniable, the path forward must ensure that safety is appropriately and rigorously balanced with relational care and maintenance of human connection.
Foundationally, healthcare rests on the notion of 'human beings caring for human beings'. 18 Thus, it is unsurprising that human connection was revealed to be so vital for stakeholders involved in COVID care. 18 The large majority of the existing literature focuses on patient and provider relationships and how 'human connection' with a care provider can make a difference to a patient in distress. 19,20 While our study affirms that the relational care provided by HCPs filled a substantial gap in emotional support due to visitor restrictions, it also underscores that in the context of widespread physical and social distancing, there is also a heightened need for human connection that extends beyond the patient-provider dyad.

| Strengths and limitations
A notable strength of this study is the inclusion of patients, caregivers and HCPs and the exploration of their experiences across care settings (i.e., acute care, inpatient rehabilitation and community). We were successful in achieving robust sample sizes for patient and HCP stakeholder groups; however, family caregivers could have been better represented to further saturate caregiving-specific ideas.
Participants in our study were English-speaking and had mid-tohigh socioeconomic status (SES). Thus, our findings are limited in their transferability to linguistically diverse individuals and those from lower SES. The homogeneity of the sample may also explain the homogeneity of the results. Finally, our study represents a 'snapshot' of a specific period during the pandemic, and thus the perspectives of stakeholders may change or evolve as policies and procedures are modified based on emerging knowledge of COVID.

| CONCLUSION
The safety measures needed to mitigate COVID spread created an environment that challenged psychosocial health and maintenance of vital human connections. Loneliness and isolation were felt by all stakeholders due to physical distancing and COVID-related stigma.