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NormandinL, etal. BMJ Open 2024;14:e083948. doi:10.1136/bmjopen-2024-083948
Open access
In- depth mixed- method case study to
assess how to support and communicate
with the families of hospitalised
patients during COVID- 19: a social
innovation embedded in clinical teams
Louise Normandin,1 Cécile Vialaron,1 Imane Guemghar,1,2 Justine Sales,3,4
Danielle Fleury,5 Kathy Malas,5 Caroline Wong,6 Fabrice Brunet,2,5
Marie- Pascale Pomey 1,7
To cite: NormandinL,
VialaronC, GuemgharI,
etal. In- depth mixed- method
case study to assess how to
support and communicate with
the families of hospitalised
patients during COVID- 19: a
social innovation embedded
in clinical teams. BMJ Open
2024;14:e083948. doi:10.1136/
bmjopen-2024-083948
►Prepublication history for
this paper is available online.
To view these les, please visit
the journal online (https://doi.
org/10.1136/bmjopen-2024-
083948).
Received 03 January 2024
Accepted 20 September 2024
For numbered afliations see
end of article.
Correspondence to
Professor Marie- Pascale Pomey;
marie- pascale. pomey@
umontreal. ca
Original research
© Author(s) (or their
employer(s)) 2024. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published by
BMJ.
ABSTRACT
Objectives The purpose of this study is to describe
and evaluate, in a real- life context, the support and
communicate with families (SCF) team’s contribution
to maintaining communication and supporting relatives
when patients are at the end of their lives by mobilising
the points of view of SCF team members, healthcare
professionals, managers and the relatives themselves.
Design An in- depth mixed- method case study
(quantitative and qualitative). Individual interviews
were conducted with members of the SCF team to
assess the activities and areas for improvement and
with co- managers of active COVID- 19 units. Healthcare
professionals and managers completed a questionnaire
to assess the contribution made by the SCF team.
Hospitalised patients’ relatives completed a questionnaire
on their experience with the SCF team.
Setting The study was conducted in a university teaching
hospital in the province of Québec, Canada.
Participants Members of the SCF team, healthcare
professionals, managers and relatives of hospitalised
patients.
Results Between April and July 2020, 131 telephone
communications with families and healthcare
professionals, 43 support sessions for relatives of end- of-
life patients and 35 therapeutic humanitarian visits were
carried out by members of the SCF team. Team members
felt that they had played an active role in humanising care.
Fully 83.1% of the healthcare professionals and managers
reported that the SCF team’s work had met the relatives’
needs, while 15.1% believed that the SCF team should be
maintained after the pandemic. Fully 95% of the relatives
appreciated receiving the telephone calls and visits, while
82% felt that the visits had positive effects on hospitalised
patients.
Conclusion The COVID- 19 pandemic forced the
introduction of a social innovation involving support
for and communication with families. The intention of
this innovation was to support the complexity of highly
emotional situations experienced by families during the
COVID- 19 pandemic.
INTRODUCTION
During the first wave of the COVID- 19 pandemic,
which took place in the province of Québec,
Canada between 1 March and 27 July 2020,
0.7% of the Québec population contracted the
SARS- CoV- 2 virus. Of these confirmed cases,
12.2% were hospitalised and 9.7% died.1 On
13 March 2020, faced with this unprecedented
health situation,2 the government of Québec
declared a state of health emergency under the
Public Health Act (section 118, chapter S- 2- 2).3
With the implementation of this exceptional
measure and in an effort to protect the health
of the population, one of the initial measures
put in place, in 2020, was a ban on visits to
hospitals and other healthcare institutions to
limit the spread of the COVID- 19 epidemic.
As a result, no family members were allowed to
STRENGTHS AND LIMITATIONS OF THIS STUDY
⇒To our knowledge, this is the only mixed- method
study to assess how a dedicated team was able to
support and communicate with the families of hos-
pitalised patients during the COVID- 19 pandemic.
⇒This study provided an opportunity to gather the
views of the various people involved in the creation
of the support and communicate with families (SCF)
team in order to assess its contribution to family
and friends during the COVID- 19 pandemic: the SCF
team members, the patients’ relatives, healthcare
professionals and managers.
⇒The 20.4% participation rate among healthcare
professionals reects the difculties experienced
collecting data during a pandemic, so we cannot
conrm whether data saturation was reached.
⇒The customer satisfaction questionnaire complet-
ed by relatives of hospitalised patients was ad-
ministered by the SCF team with a risk of social
undesirability.
2NormandinL, etal. BMJ Open 2024;14:e083948. doi:10.1136/bmjopen-2024-083948
Open access
visit a hospitalised patient or a person in a long- term care
facility. This situation also applied to residents of intensive
care units, which represented an unprecedented scenario. In
fact, despite all the measures taken to keep patients alive until
family members could be by their side at the time of death,
patients died alone.4
It has been shown that the physical presence of family
members before the death of a loved one5 helps reduce
the risk of long- term psychological consequences for
survivors.6 Moreover, while the restrictions were under-
standable as an initial crisis response to the pandemic,
they raised fundamental ethical issues.7 Solutions there-
fore had to be found to address these issues to avoid
terrible harm and suffering for families and patients, and
for clinical teams and managers.
Aware of the negative impact that COVID- 19 could
have on both patients and their relatives, the Centre Hospi-
talier de l’Université de Montréal (CHUM) implemented the
Techno- COVID- Partnership (TCP) programme.8 9 The
aim was to develop innovative solutions with the ultimate
goal of allowing relatives to continue communicating
with patients and clinical teams as well as keep relatives
informed about the condition of their loved ones.
In this context, senior management at CHUM decided,
in April 2020, to create a team to support and communi-
cate with families (the SCF team) in order to: (1) establish
communication with families; (2) provide support to the
relatives of end- of- life patients and (3) organise human-
itarian visits for therapeutic purposes. This decision was
made by family members and frontline teams and was
supported by the hospital’s executive department.
The purpose of this study is to describe and evaluate, in
a real- life context, the SCF team’s contribution to main-
taining communication and supporting relatives when
patients are at the end of life by mobilising the points
of view of SCF team members, healthcare professionals,
managers and the relatives themselves.
METHODS
Research design
An in- depth mixed- method case study (quantitative and
qualitative) was conducted at CHUM to evaluate the
SCF team’s contribution10 during the first wave of the
COVID- 19 pandemic. The choice of a case study design
makes it possible to conduct an in- depth examination of
the implementation processes in their real context and to
analyse their effects.11
Study populations
Three populations were evaluated. The first population
consisted of members of the SCF team and the second
one was healthcare professionals from nursing depart-
ments and multidisciplinary services, including doctors
and managers who were in contact with patients hospital-
ised in cold (patients with no COVID- 19 infection), warm
(patients awaiting results on COVID- 19 infection) or hot
(patients with COVID- 19 infections) care unit areas and
who received services from the SCF team.12 The third
population consisted of relatives of hospitalised patients
who benefited from the services offered by the SCF team.
Qualitative data
At the end of the first wave, the five members of the SCF
team were invited, by email, to participate in a videocon-
ference interview. For the interview, a semi- structured
guide was developed and was pilot- tested prior to use.
It focused on: (1) their motivation to participate in SCF
activities; (2) their integration into clinical activities that
support families; (3) improvements made during the
implementation; (4) the lessons learnt from the experi-
ence; (5) suggestions for improvements in the event the
implementation process needed to be repeated and (6)
the need to maintain (or not maintain) the SCF team
after the pandemic.
Moreover, two healthcare professionals from clinical teams
in hot zones as well as two managers were interviewed to
ascertain their perceptions of the activities performed by
members of the SCF team and their opinions on whether or
not to maintain the team after the pandemic.
The interviews lasted, on average, 60 min and were
conducted by people experienced in qualitative research
(M- PP, CV and IG), video- recorded on the Microsoft
TEAMS platform and then transcribed.
Quantitative data
All activity reports and summaries of SCF team meetings
were collected.
A satisfaction questionnaire assessing the achievements of
the SCF team was emailed to healthcare professionals and
managers.13 The questions focused on: (1) the adequacy of
the services offered by the SCF team concerning the needs
of the relatives; (2) the workload allocated to the coordina-
tion of the SCF team’s activities by the clinical team and (3)
whether or not to maintain the SCF team after the health
crisis. The questionnaire was sent to 245 healthcare profes-
sionals and 15 managers who had worked with the SCF team
between 17 June and 15 September 2020. Two reminders
were sent out during this period.
A customer satisfaction questionnaire was also completed
by relatives of hospitalised patients, 3 weeks after they had
visited the hospital. This questionnaire was administered
by telephone to assess: (1) whether the visit took place as
explained; (2) the nature of the support received by the facil-
itator; (3) whether or not the visit had beneficial effects for
the relatives and (4) whether or not the visit had beneficial
effects for the hospitalised patient. The relatives could write
comments and suggest improvements. Telephone calls were
made by members of the SCF team, ensuring that the accom-
panying member was not the one conducting the inter-
view. Up to five telephone calls at different times of the day,
including one in the evening and on weekends, were made
over a 1- week period. Voicemail messages were also left.
Data analysis
For the survey data, descriptive statistics were collected
and calculated using Research Electronic Data Capture,
3
NormandinL, etal. BMJ Open 2024;14:e083948. doi:10.1136/bmjopen-2024-083948
Open access
an application for building and managing online surveys
and databases used to administer questionnaires, orga-
nise data collection and analyse data.14
To analyse the qualitative data, the six- step guideline
of15 was followed. First, all the interviews were transcribed
to ensure familiarisation with the data. Second, several
meetings were held between two authors (LN and M- PP)
to construct a codebook containing the six themes of
the interview. Next, a theme- analysis approach was used
to better ‘understand a set of experiences, thoughts or
behaviours’ in these categories.16 We used an inductive
approach to identify themes or patterned responses that
occurred in the dataset.16 Coding was carried out using
QDA Miner Software (V.6.0.2).17 Steps 4 and 5 consisted
of grouping themes according to the framework devel-
oped by Pomey et al.18 All verbatim transcripts were
produced in French, translated into English and then
retranslated back into French to ensure the accuracy of
the translation.19 20 To quote verbatim transcripts and
prevent participant identification due to the small size of
the group of participants, every participant was assigned
an avatar. The Consolidated criteria for Reporting Qual-
itative research checklist was used to report the method-
ology of the study.21
Patient and public involvement
Patients and/or the public were not involved in the
design, conduct, reporting or dissemination plans of this
study.
RESULTS
SCF team activities
The SCF team consisted of eight people: two clinical
nurses, a nurse, two social workers, two psychologists and
a spiritual care provider. This included two people who
had returned from retirement (the clinical nurses) and a
research nurse who had been reassigned.
Figure 1 presents the chronology of the activities of the
SCF team’s mandates over a period of 79 days, from 15
April to 2 July 2020.
Communication with families
The SCF team was initially mobilised to maintain commu-
nication with relatives so that they would be informed
about the patient’s health status. The care teams there-
fore identified the patients and relatives who would
benefit from the services of the SCF team, and they were
provided with the necessary medical information. Contact
with the relatives was made by an SCF team member (if
possible, always the same member) to regularly provide
clinical information about the patients. The SCF team
member reported any problems experienced by the rela-
tives to the clinical team. From 16 April to 3 June 2020,
18 families benefited from such support (table 1). These
families were not selected according to any predeter-
mined criteria. The SCF team contacted them if there
were communication issues with the clinical team, which
was too overworked to answer their questions. The team
Figure 1 Chronology of the support and communicate with families (SCF) team’s interventions and mandates.
Table 1 Telephone calls conducted by the support and
communicate with families team with relatives and clinical
team members
Type of intervention Relatives
Clinical team
members
Number of telephone calls 82 49
Average time of a telephone call
(min:s)
29:00 17:00
Total telephone communication
time per relative
2:54 --
Total telephone communication
time (hour:min)
48:24 13:48
4NormandinL, etal. BMJ Open 2024;14:e083948. doi:10.1136/bmjopen-2024-083948
Open access
logged >62 hours and 131 telephone communications,
either with families or clinical team members. Each rela-
tive received an average of six telephone communica-
tions. The average time spent on a telephone call with a
relative was 29 min. The total average time of telephone
communications per relative was 2 hours and 54 min. The
length of telephone communications was noted by an
SCF team member.
When clinical teams began to feel less pressured, they
took the time to contact families themselves to inform
them of their loved ones’ state of health.
End-of-life visits
Subsequently, a new need emerged among the patients
and their families: that of end- of- life visits. Naturally,
without any decision being made by hospital manage-
ment, the SCF team abandoned the activity of communi-
cating with families and replaced it by allowing relatives
to visit end- of- life patients in general care units, whether
they were COVID- 19 positive or not. The selection criteria
used to organise these end- of- life visits are presented in
table 2. In all cases, life expectancy was determined by the
attending physician or the palliative care team physician
involved in the case.
The visits, accompanied by a member of the SCF team,
were organised while the patient was still conscious, just
before commencement of a medication administration
protocol for pain or respiratory distress. These visits were
provided by the SCF team (n=4), the psychology depart-
ment (n=3) and a spiritual care resource (n=1) during
the day.
In total, 43 support service visits for relatives of end- of-
life patients were carried out between 15 May and 29 June
2020. In 53% of cases (n=23), the end- of- life visits were
for COVID- 19- positive patients in hot care units (table 3).
The average time for a visit was 2 hours, including the
meeting to obtain consent, explanations of the visit, the
time spent with the end- of- life patient (approximately
30–45 min), immediate support for leaving the room and
accompaniment to the exit of the institution. On average,
the total time was 3 hours including the time the request
was received, the call with the relative to plan the visit and
the postvisit support. The length of the visit was recorded
by the SCF team member accompanying the relative.
These visits were mainly in the hot care units, particularly
internal medicine (n=13) and pulmonology care units
(n=10).
Humanitarian visits for therapeutic purposes
Lastly, the SCF team was entrusted with carrying out
humanitarian visits for therapeutic purposes. These
visits were set up to allow patients in great psychological
distress to have access to a relative for more optimal care
(table 3). Box 1 presents the selection criteria used to
organise humanitarian visits for therapeutic purposes.
In total, 35 patients benefited from a humanitarian
visit for therapeutic purposes between 26 May and 29
June 2020. Fully 80% (n=27) of these visits were carried
out in hot care units (table 3). The average time for a
therapeutic visit for humanitarian purposes was 93 min,
compared with 116 min for an end- of- life visit. This was
due to less need for support after the visit.
Quantitative evaluation of SCF work performed by professionals,
managers and relatives
In total, 53 professionals and managers responded to the
questionnaires (response rate=20.4%). Table 4 presents
the characteristics of the healthcare professionals and
managers who evaluated the SCF team.
A total of 83.1% (n=44) of the healthcare profes-
sionals and managers believed that the work performed
by the SCF team met the needs of families and relatives
(figure 2). One manager felt that the work performed
by the SCF team resulted in a work overload for the
clinical team, and eight (15.1%) people stated that the
Table 2 Clinical selection criteria used to organise a visit to
an end- of- life patient by care unit type
Cold care units*
Warm care units† and
hot care units‡
►Patient receiving level 4 care
to ensure that the patient
is comfortable without
prolonging their life, as
documented in the clinical le.
►Patient receiving palliative
care.
►Patient with a life expectancy
of <2 weeks.
►Patient presenting with
signicant deterioration in their
health condition that could
lead to death in the short term
(<2 weeks).
Predictable situation
►End- of- life patient who
has a life expectancy
of <5 days.
►Conscious patient.
Urgent situation
►Patient showing
sudden deterioration.
►Patient receiving a
painkiller infusion.
►Patient may die during
the day or over the
weekend.
*Patients who tested negative for COVID- 19.
†Patients awaiting results for COVID- 19.
‡Patients infected with COVID- 19.
Table 3 Characteristics and number of interventions for
end- of- life visits and humanitarian visits for therapeutic
purposes
End- of- life
visits
Humanitarian
visits
Total number of visits (cold*/
warm†/hot zone‡)
43 (10/10/23) 35 (4/4/27)
Number of care units
concerned
10 8
Average number of visits per
patient who beneted from
the visit
2.2 1.6
Average time of a visit (min) ≈116 ≈93
*Patients who tested negative for COVID- 19.
†Patients awaiting results for COVID- 19.
‡Patients infected with COVID- 19.
5
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Open access
team should be maintained after the health crisis. The
percentage of 15.1% does not indicate that healthcare
professionals and managers were dissatisfied with the
SCF team; rather, they thought that they would no longer
need this team after the pandemic.
A total of 63 relatives benefited from a visit, and 60
people could be reached by telephone. Among these
people, 85.7% (n=54) agreed to answer the satisfaction
questionnaire. Fully 98.1% (n=53) of them reported that
the visit met their expectations. Regarding the support
received from the SCF facilitator, 88.9% (n=48) felt that
it was very good and 11.1% (n=6) said it was good. A total
of 94.4% of the relatives (n=51) said that the visit(s) had
beneficial effects for them, and 5.6% (n=3) were unsure.
Regarding the beneficial effects for the hospitalised rela-
tive, 81.5% (n=44) reported that the visit(s) had positive
effects on the patient, 16.7% (n=9) were uncertain and
1.9% (n=1) were of the opposite opinion. The written
comments underlined the importance of the patient
being able to receive visits (n=11 people; 20.4%), and
some respondents (n=3; 5.6%) would have liked more
privacy in their time with the patient and not to be accom-
panied in the room by a member of the SCF team.
Qualitative assessment of the SCF team’s contribution
Six main themes emerged from the individual interviews
conducted with SCF team members, professionals and
managers: (1) their motivation to participate in the team’s
activities; (2) the activities performed by team members;
(3) improvements made during implementation; (4)
lessons learnt from the experience; (5) suggestions for
improvements if the implementation process had to be
repeated and (6) maintaining SCF over time.
Motivation to participate in SCF activities
All the SCF team members agreed to participate in this
social and organisational innovation, which was aligned
with their values. Six participants, as many members of
the SCF team (n=5) as professionals from the clinical
teams (n=1) or managers (n=1), believe that this innova-
tion has tried to humanise care.
It was part of my values. Impossible to die alone and
not be able to say goodbye to your loved one. I was
ready to give time to help. (Marie, SCF team member)
At the beginning, when we opened the hot zone
and then we had our first death and the patient was
alone… There was something very discomforting
about that in her practice as a nurse, but also as a
human being. This is difficult for a caregiver to
accept, having an unaccompanied patient who will
end their life locked up in an unfamiliar environment
with strangers. It was difficult. In the beginning, it was
the nurses who supported the families. We decided to
take it upon ourselves and then do it anyway, because
Table 4 Characteristics of the healthcare professionals
and health managers who evaluated the support and
communicate with families team
Characteristics of healthcare
professionals and managers
Number of healthcare
professionals and
managers (%)
Age group (years)
Under 25 3 (5.7)
25–34 13 (24.5)
35–44 15 (28.3)
45–54 15 (28.3)
55–64 7 (13.2)
Over 65 0 (0)
Sex
Female 45 (84.9)
Male 8 (15.1)
Occupation
Physician 4 (7.5)
Nurse 32 (60.4)
Orderly 2 (3.8)
Electrophysiologist 1 (1.9)
Occupational therapist 1 (1.9)
Physiotherapist 3 (5.7)
Psychologist 3 (5.7)
Social service provider 1 (1.9)
Spiritual care provider 2 (3.8)
Administrator 4 (7.5)
Box 1 Clinical selection criteria used to organise a
humanitarian visit for therapeutic purposes, by care unit
type
Cold*, warm† or hot‡ care units
⇒Patient with a disability or disruptive behaviour that requires the
expertise of the relative to help the care team better intervene with
the patient.
⇒Allophone patient whose language barrier hinders continuation of
the care episode and attempts made beforehand have not worked.
⇒Patient who has had a chronic illness for many years, who lives with
family and who presents signicant emotional distress.
⇒Patient with signicant enough psychological and/or emotional dis-
tress to alter their general condition (physical and/or mental).
⇒Patient whose relative demonstrates psychological emotional dis-
tress that is signicant enough to alter their general state (physical
and/or mental).
⇒Patient whose hospitalisation extends >3 weeks and who shows
signs of deterioration in their general condition (physical and/or
mental).
⇒Patient who has been diagnosed with an incurable disease with a
poor prognosis, or with a diagnosis of cancer.
Cold care units only
⇒Patient requiring urgent, high- risk surgery.
*Patients who tested negative for COVID- 19.
†Patients awaiting results for COVID- 19.
‡Patients infected with COVID- 19.
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we just couldn’t watch patients die alone. (Gabriella,
manager)
This sublime project completely thrilled me. It was
part of my values… For me, it isn’t possible that
people could die alone, or even that relatives are not
there to simply say goodbye to a loved one. (Rose,
SCF team member)
There is a real need for families in these difficult
phases. […] Families were bereft, defenceless. (Romy,
SCF team member)
SCF members integrated into clinical activities to support families
For the clinical teams, the SCF team managed to join inter-
disciplinary teams and benefited from privileged access to
physicians, who always collaborated by attending family/
physician meetings. The SCF team was able to be part of
the case discussion and was considered a complementary
therapeutic service. In the case of elderly patients, the
SCF team collaborated with a dedicated team composed
of a physiotherapist, a social worker and a nurse special-
ised in geriatrics.
The SCF team joined to help us with the visits for end-
of- life care and humanitarian visits. It certainly was a
great help, because it permitted a certain standardiza-
tion of practices to allow safety in terms of care, with
respect to visitors and patients. (Gabriella, manager)
The SCF team was well received; it was helpful for the
care units because they came to meet families or pa-
tients who were problematic for the care units. She
came to lend a hand to the nurses when it became
too heavy for us […] when the families called too
much. (Léa, healthcare professional)
I called on them when I had more demanding fam-
ilies. …. I had complaints from nurses telling me,
‘This family is calling us eight times a day’. It took
some pressure off the shoulders of the nurses for end-
of- life visits and humanitarian visits. (Juliette, health-
care professional)
It’s important to take the time to call the families
back. We had calls from doctors, head nurses, and
nurses who told us about families that were experi-
encing the situation in a very dramatic way. So what
we did was communicate regularly with the families.
We called them every day or 2–3 times a week, de-
pending on what they needed in terms of moral sup-
port. (Emilie, SCF team member)
The nurses saw us as an additional support. (Marie,
SCF team member)
For SCF team members, their contribution made it
possible to restore some humanity in the relationships.
The contribution made by professionals on- site, when
we were with relatives, is not a psychological interven-
tion, it is not a spiritual intervention. I would say it’s a
humanitarian intervention more than anything else.
(Mira, manager)
The families, when we bring them back downstairs
so they can go home… If you only knew their look of
gratitude. It was wonderful. Sometimes we were told,
‘You are angels…’ I’m sure that people have died of
loneliness. (Rose, SCF team member)
The relatives were close to us. (Marie, SCF team
member)
Difculties encountered
Participants spoke of various things that could either
promote or harm the SCF intervention. One member of
the SCF team indicated that:
The biggest difficulty we had was at the medical level;
some doctors did not at all respect the procedure for
Figure 2 Perceptions of health professionals and managers of the work performed by the support and communicate with
families team to address the needs of families/relatives.
7
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end- of- life support. He would contact people and say,
‘Come to the hospital’. I felt bad after that. The sort-
ing hadn’t been done, I had to intervene. Sometimes
there could be 3–4 visits offered at the same time, and
I would lose control. (Emilie, SCF team member)
On occasion, doctors have contacted the family
directly without notifying us. When the families
came to see their loved ones we were caught off-
guard, because we hadn't been notified. In fact, it
takes a certain amount of organization on our part
to prepare families to meet their loved ones, and this
type of situation has meant that some families weren’t
been able to see their loved ones when they thought
they could. It’s unfair for the families, and we had
to manage the situations gently. There were times
when I had to mobilize 3 members of my team from
4:00 p.m. to 4:00 a.m. to sort out different situations.
I said, ‘Don’t do that anymore, Doctor’. I don’t think
he knew. (Emilie, SCF team member)
We’ve had to deal with situations where, in order to
see their loved ones, families had to see them at night
before they died. Also, if we had to do it again, there
would have to be a day team and a night team. (Rose,
SCF team member)
Improvements made during the project
At the beginning, the project was to relieve some of
the pressure on the nurses, the medical staff who
were being called on by families all the time. In fact, it
was the head nurses or assistants who contacted us to
tell us about this or that family who called a little too
often. These families were worried, because they were
used to seeing their loved ones and then suddenly
could no longer see them. […] In the beginning, this
wasn’t done, so families could call 10 times a day to
get information. […] We were given the last name
and then we called them to see with them what we
could do so that they could be satisfied […] so that
they would call as little as possible. […]. As a result,
we had to hear the expectations from the medical
profession and then hear what the family’s expec-
tations were, and why they did so much. […] Little
by little, it turned into organizing a visit. Some visits
were set up. The families therefore came to see their
hospitalized loved one. (Rose, SCF team member)
With a second mandate, which was to accompany
external relatives to come and visit people inside
[…] There, we began to organize the visits, which
was much more complex because it was necessary to
bring healthy people into COVID rooms. We worked
in partnership with infection prevention. […] For
COVID- negative patients, the challenge was not to
let someone onto the hospital floor or into the room
who could be positive and contaminate the entire
floor. That was an issue. […] and we stayed in the
room to ensure that the person would not become
infected. (Emilie, SCF team member)
We had to make a lot of adaptations. We had to
change some of the ways we did things. We had to see
with the doctors how we were going to manage this,
because we were also throwing off their way of doing
things. (Léa, healthcare professional)
At the beginning, it was the people who were at the
end of their lives, and then it opened up, in the end,
into humanitarianism. But the end- of- life… There are
a lot of questions we had about that. Because, when is
it? Who can say that the person will die tomorrow, in
2 days, in 3 days? This is where [there were] all these
discussions, where sometimes we modified. The first
time I think it was 5 days, when there were 5 days left.
What does that mean? And then also, we realized that
maybe sometimes it would be good for the family to
come and say goodbye, for there to be an exchange
when the person is no longer in an… unconscious
state. Perhaps it would be good, even if the person
dies in a month, for them to have a moment to talk
with several people in their family. So this is when we
made changes. (Rose, SCF team member)
Lessons learnt and suggestions for improvements
SCF team members emphasised the importance of
re- establishing a link between the hospital environment
and the living environment, knowing that some patients
found themselves suddenly hospitalised without being
able to prepare for it:
A lot of people arrived without any personal items.
It’s as if they had suddenly found themselves embark-
ing on this hospital adventure. People are terribly
bored. A lady told me she was counting the tiles on
the ceiling. It’s so obvious that these people are slowly
losing their taste for life, since they no longer have a
life. (Rose, SCF team member)
In my opinion, as soon as someone is hospitalized,
[we should] immediately organize (within 2 to
3 days) a visit from the family to reassure them and
allow personal belongings to be brought in. I had the
reflex to tell people… ‘If you have grandchildren,
don’t hesitate to send your grandmother drawings
and photos… Things that might remind her of her
little family’. (Rose, SCF team member)
If we had to do it again, we said to ourselves that there
would have to be a day shift team and a night shift
team. The problem is that the day shift team can’t do
the night shift. What we really need to understand
about the support is that it was real psychological
support. It was tough. We carried in our arms these
people in distress. There was not only this side of
anxiety at the level of the hospital and the loved one.
It’s also everything that was happening in the life of
the person, who had perhaps lost their job. (Rose,
SCF team member)
It was not equal. We had a lot of requests from several
units. Then, there are other units where we didn’t
8NormandinL, etal. BMJ Open 2024;14:e083948. doi:10.1136/bmjopen-2024-083948
Open access
have any visits at all. … The communications plan,
in my opinion, was not optimal. (Émilie, SCF team
member)
It hurt my heart not to be able to do the night shift.
Many more patients died at night than during the
day. … We tried it at the beginning, but with four
people we were unable to do night shifts. (Émilie,
SCF team member)
Sustainability of the SCF
The participants believe that the SCF interventions
should be maintained over time.
Before COVID we were already asking ourselves how
we could support families in difficult situations. What
we have experienced with the SCF team makes me
want to continue and go further in our ability to in-
tegrate families into complex care systems, thanks
to the support that loved ones can receive from an
entity like the SCF team. I am therefore in favour of
maintaining it over time. (Gabriella, manager)
DISCUSSION AND LIMITATIONS
During the first wave of the COVID- 19 pandemic, interna-
tional regulations prohibited relatives from being physi-
cally present with hospitalised patients due to the risks of
transmission in the absence of an effective vaccine.4 22–24
Although this served a need for both patients and their
relatives, the pandemic interrupted essential human
contact.23 24
This situation provoked the emergence of social and
technological innovations all over the world. In Québec
and, more particularly, at CHUM, the TCP programme
was implemented and included the creation of the SCF
team to support families and clinical teams during a
difficult period when clinical members did not have the
time needed to meet families’ needs.89 The SCF team
was therefore able to offer three types of support to fami-
lies: telephone support, end- of- life visits and visits for
humanitarian reasons. The goal was to limit the isola-
tion of patients and their families and to free up time for
healthcare professionals overwhelmed by the requests of
relatives. Telephone support made it possible to support
clinical teams and show empathy towards patients and
relatives. However, this proved to be insufficient, which
motivated the SCF team to offer two other face- to- face
arrangements to support complex care situations and end-
of- life patients. These results are aligned with those from
a study carried out in the Netherlands, which showed the
importance of empathetic support from healthcare teams
and of maintaining family visits to promote the dignity
of end- of- life patients and that of their relatives during a
pandemic25 as well as in normal times.26
During the health crisis, CHUM deployed complex
measures by mobilising a culture that promotes flexibility
and adaptability.27 The results highlight the fact that the
SCF team’s interventions made a difference by providing
an environment that was respectful of relational needs in
a context of extreme vulnerability. Members of the clinical
team were able to support relatives and patients during
difficult and emotionally charged times. According
to Aubry,28 health containment measures intended to
prevent relatives from accompanying their loved ones
during the final phase of life could lead to post- traumatic
syndromes in the following months.29 Moreover, having
the family at the patient’s bedside so that the patient does
not die alone is recognised as one of the quality indicators
of end- of- life care.30
Furthermore, the SCF team is a fairly unique inter-
vention model in the literature, by virtue of the fact that
it facilitates face- to- face visits and has an impact on an
entire institution. This intervention complemented the
deployment of tablets and smartphones to less seriously
ill patients,24 courtesy telephone calls made by volun-
teers31 and even home monitoring using a mobile appli-
cation.32 Such initiatives have also been carried out in
other countries. In France, in the intensive care unit of
the Pitié-Salpêtrière Hospital, the neurology team called
relatives daily to give them news and offer them visits to
maintain connections with patients.33 Other initiatives
that leverage technology have also been implemented,
such as in Italy, where an intensive care team used video
calls to allow relatives to say goodbye to their loved ones.
An assessment carried out 2 weeks after the patient’s
death highlighted the importance for relatives of being
able to have this final contact.34 In Spain, from the start
of the COVID- 19 pandemic, several measures were imple-
mented to improve communication between seriously
ill patients in isolation and their relatives in a university
hospital.7 Through videoconferencing conducted at the
patient’s bedside, healthcare professionals provided daily
clinical information to relatives who could interact with
patients through the screen.7 In the UK, from April 2020,
the National Health System recommended the use of
digital tools to offset visiting restrictions.35 Nearly half of
the hospitals with intensive care units established a team
dedicated to communicating with families during the
pandemic.36 37 Like the SCF team, these teams of care-
givers were responsible for informing families about the
state of health of patients hospitalised in intensive care.
However, the visits offered were carried out on a virtual
basis rather than in person. Canadian teams have also
chosen to use videoconferencing to maintain connections
between relatives and end- of- life patients.38 However,
these experiences suffered from limited access to tech-
nology and a lack of direct contact between relatives and
patients.36–38 Furthermore, these studies rarely measure
the effects of these interventions on patients, relatives
and healthcare professionals.
This study has some limitations. First, the 20.4%
participation rate for healthcare professionals is lower
than what is normally found in the literature.39–41
Furthermore, although the relatives of hospitalised
patients were contacted by a member of the SCF
team to complete a satisfaction questionnaire, no
9
NormandinL, etal. BMJ Open 2024;14:e083948. doi:10.1136/bmjopen-2024-083948
Open access
individual interviews were carried out by the research
team to assess the perceptions of relatives concerning
the support received from SCF team members and
whether the visit had any beneficial effects. Finally,
the individual interviews carried out with two health-
care professionals and two managers to gather their
perceptions of the SCF team’s activities did not enable
us to achieve data saturation. This can be explained
by the difficulties encountered interviewing health-
care professionals who were under considerable pres-
sure and overworked. It is therefore possible that the
lack of data saturation has prevented us from high-
lighting other, more negative points about the SCF
initiative. Although we cannot be certain that we have
reached data saturation, a recent systematic review of
sample sizes for achieving data saturation in qualita-
tive research shows that it can be achieved with a small
number of interviews, ranging from 9 to 17, particu-
larly in studies with homogeneous populations.42
CONCLUSION
COVID- 19 brought about unprecedented changes in
the way patients and families experience illness and
death. To limit the spread of the virus in the commu-
nity, hospitals were required to prohibit all visitors.
However, CHUM was convinced that no one should
die without being able to say goodbye to their rela-
tives. As a result, the hospital implemented a social
innovation to maintain lines of communication with
families or with accompanying relatives of end- of- life
patients. This is how a liaison team was created for
family support and communication with end- of- life
patients. These results have led us to recommend
the creation of teams of healthcare professionals
dedicated to communicating with relatives and main-
taining physical contact between relatives and hospi-
talised patients with specific health conditions. The
intent behind this innovation was to support the
complexity of highly emotional situations experi-
enced by families during the COVID- 19 pandemic.
Author afliations
1Centre Hospitalier de l'Université de Montréal Centre de Recherche, Montreal,
Québec, Canada
2Université de Montréal, Montreal, Québec, Canada
3Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
4Université Claude Bernard Lyon 1, Villeurbanne, France
5General Directorate, Centre Hospitalier de l'Université de Montréal, Montreal,
Québec, Canada
6Centre d'excellence sur le partenariat avec les patients et le public, Montréal,
Québec, Canada
7Department of Health Management, Evaluation, and Policy, Université de Montréal,
Montreal, Québec, Canada
Acknowledgements We are grateful to all the healthcare professionals who
participated in this study, the relatives of hospitalised patients who completed the
satisfaction questionnaire and the families that encouraged CHUM’s leadership to
launch this programme.
Contributors KM, CW, FB and M- PP contributed to the design of the study.
Interviews were conducted by CV, IG and M- PP. Analysis was done by LN and IG.
Quotes were selected by LN and M- PP. LN and M- PP drafted the manuscript. CV, IG,
JS, DF, KM, CW and FB provided critical comments on drafts of the manuscripts and
approved the nal manuscript. M- PP acts as a guarantor.
Funding This study was supported by the Canadian Institutes of Health Research
(VR4—172769). M- PP has received a Senior Career Award from the Quebec Health
Research Fund (FRQS) (322746/322747), the Centre de recherche du Centre
hospitalier de l’Université de Montréal and the Ministère de la Santé et des Services
Sociaux du Québec.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in
the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not applicable.
Ethics approval This study received ethical approval from the Research Ethics
Committee of the CHUM Research Center (CRCHUM), approval number 20.040. All
study participants signed an information and consent form. This information and
consent form, approved by the Ethics Committee, was presented to participants
in one of two ways: in paper format prior to the interview or at the start of the
electronic questionnaire.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available on reasonable request.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non- commercial. See:http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iD
Marie- PascalePomey http://orcid.org/0000-0001-5180-8139
REFERENCES
1 Tremblay É. Première vague de la pandémie de covid- 19 au
québec: regard sur les facteurs associés aux hospitalisations et aux
décès: état des pratiques. In: Québec (Québec): Institut national
d’excellence en santé et en services sociaux. 2020.
2 World Health Organization. Timelline: WHO’s COVID- 19 response,
2023. Available: https://www.who.int/emergencies/diseases/novel-
coronavirus-2019/interactive-timeline#event-88
3 Gouvernement du Québec. Loi sur la santé publique - Chapitre
S- 2.2, 2020. Available: https://www.legisquebec.gouv.qc.ca/fr/
document/lc/s-2.2
4 Wakam GK, Montgomery JR, Biesterveld BE, etal. Not Dying Alone
— Modern Compassionate Care in the Covid- 19 Pandemic. N Engl J
Med 2020;382.
5 Morris SE, Moment A, Thomas J deLima. Caring for Bereaved Family
Members During the COVID- 19 Pandemic: Before and After the
Death of a Patient. J Pain Symptom Manage 2020;60:e70–4.
6 Downar J, Kekewich M. Improving family access to dying patients
during the COVID- 19 pandemic. Lancet Respir Med 2021;9:335–7.
7 Estella Á. Compassionate Communication and End- of- Life Care
for Critically Ill Patients with SARS- CoV- 2 Infection. J Clin Ethics
2020;31:191–3.
8 Pomey MP, Malas K, Petitgrand C, etal. CHUM and MUHC innovate
with Techno- COVID Partnership program. C H T 2020;25:4.
9 Programme Techno- Covid- Partenariat. n.d. Un programme de
recherche en soutien aux développements des technologies et du
partenariat au CHUM et au CUSM dans le contexte de la COVID- 19.
10 Yin RK. Case study research: design and methods. SAGE
Publications, 2009.
11 Creswell J. Research design: qualitative, quantitative, and mixed
methods approaches, 4th Edn. Thousand Oaks, CA: Sage, 2013:304.
12 Centre intégré universitaire de santé et de services sociaux de l’Est-
de- l’Île- de- montréal. 2020. Available: https://ciusss-estmtl.gouv.qc.
ca/portail-employe/zone-daccueil/les-zones
13 Boulenger S, Motulsky A, Paré G. Frequency, nature and impact of
the consultations provided by community pharmacists in Quebec.
CIRANO (CIRANO Project Reports 2018 Rp- 17). 2018.
14 Harris PA, Taylor R, Thielke R, etal. Research electronic data capture
(REDCap)--a metadata- driven methodology and workow process
for providing translational research informatics support. J Biomed
Inform 2009;42:377–81.
10 NormandinL, etal. BMJ Open 2024;14:e083948. doi:10.1136/bmjopen-2024-083948
Open access
15 Braun V, Clarke V. Thematic analysis. In: Cooper H, Camic PM,
Long DL, etal, eds. APA handbook of research methods in
psychology, Vol. 2. Research designs: Quantitative, qualitative,
neuropsychological, and biological. American Psychological
Association, 2012: 57–71. Available: http://content.apa.org/books/
13620-004
16 Kiger ME, Varpio L. Thematic analysis of qualitative data: AMEE
Guide No. 131. Med Teach 2020;42:846–54.
17 Provalis research. QDA Miner software. Montreal, Quebec, 2020.
Available: https://provalisresearch.com/products/qualitative-data-
analysis-software/
18 Pomey M, Forest P, Sanmartin C, etal. Determinants of waiting time
management for health services. Montreal, Quebec: Université de
Montréal, 2009.
19 Brislin RW. Back- Translation for Cross- Cultural Research. J Cross
Cult Psychol 1970;1:185–216.
20 Sperber AD, Devellis RF, Boehlecke B. Cross- Cultural Translation:
Methodology and Validation. J Cross Cult Psychol 1994;25:501–24.
21 Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting
qualitative research (COREQ): a 32- item checklist for interviews and
focus groups. Int J Qual Health Care 2007;19:349–57.
22 Moss SJ, Krewulak KD, Stelfox HT, etal. Restricted visitation policies
in acute care settings during the COVID- 19 pandemic: a scoping
review. Crit Care 2021;25:347.
23 Strang P, Bergström J, Martinsson L, etal. Dying From COVID- 19:
Loneliness, End- of- Life Discussions, and Support for Patients and
Their Families in Nursing Homes and Hospitals. A National Register
Study. J Pain Symptom Manage 2020;60:e2–13.
24 Wei E, Segall J, Villanueva Y, etal. Coping With Trauma, Celebrating
Life: Reinventing Patient And Staff Support During The COVID- 19
Pandemic. Health Aff (Millwood) 2020;39:1597–600.
25 Becqué YN, van der Geugten W, van der Heide A, etal. Dignity
reections based on experiences of end- of- life care during the
rst wave of the COVID- 19 pandemic: A qualitative inquiry among
bereaved relatives in the Netherlands (the CO- LIVE study). Scand J
Caring Sci 2022;36:769–81.
26 Caswell G, Pollock K, Harwood R, etal. Communication between
family carers and health professionals about end- of- life care for older
people in the acute hospital setting: a qualitative study. BMC Palliat
Care 2015;14:35.
27 Brunet F, Malas K, Fleury D. A model of an agile organization
designed to better manage the COVID- 19 crisis. Healthc Manage
Forum 2021;34:115–8.
28 Aubry R. What are the ethical issues raised by the COVID 19
epidemic? Eth Sante 2020;17:155–9.
29 Kentish- Barnes N, Chaize M, Seegers V, etal. Complicated grief
after death of a relative in the intensive care unit. Eur Respir J
2015;45:1341–52.
30 Ministère de la Santé et des Services sociaux. Directives sur les
soins palliatifs et de n de vie, 2021. Available: https://publications.
msss.gouv.qc.ca/msss/chiers/directives-covid/archives/dgaumip-
014-rev3.pdf
31 Normandin L, Wong C, Dumez V, etal. Reducing social isolation
during the COVID- 19 pandemic: Assessing the contribution of
courtesy phone calls by volunteers. PLoS One 2022;17:e0266328.
32 Bouabida K, Malas K, Talbot A, etal. Healthcare Professional
Perspectives on the Use of Remote Patient- Monitoring Platforms
during the COVID- 19 Pandemic: A Cross- Sectional Study. J Pers
Med 2022;12:529.
33 Bourmaleau J, Maillard S. Nurses in multi- disciplinary team to face
Sars- CoV- 2 in intensive care. Rev Inrm 2020;69:18–9.
34 Galazzi A, Brioni M, Mistraletti G, etal. End of life in the time of
COVID- 19: the last farewell by video call. Minerva Anestesiol
2020;86:1254–5.
35 National Health Service. Visitor guidance. London, UK, 2020.
Available: https://www.yhscn.nhs.uk/media/PDFs/mhdn/
Dementia/Covid%2019/C0030_Visitor-Guidance_8-April-2020.
pdf
36 Rose L, Yu L, Casey J, etal. Communication and Virtual Visiting
for Families of Patients in Intensive Care during the COVID- 19
Pandemic: A UK National Survey. Ann Am Thorac Soc
2021;18:1685–92.
37 Boulton AJ, Jordan H, Adams CE, etal. Intensive care unit visiting
and family communication during the COVID- 19 pandemic: A UK
survey. J Intensive Care Soc 2022;23:293–6.
38 Elma A, Cook D, Howard M, etal. Use of Video Technology in
End- of- Life Care for Hospitalized Patients During the COVID- 19
Pandemic. Am J Crit Care 2022;31:240–8.
39 Braithwaite D, Emery J, De Lusignan S, etal. Using the Internet to
conduct surveys of health professionals: a valid alternative? Fam
Pract 2003;20:545–51.
40 Cunningham CT, Quan H, Hemmelgarn B, etal. Exploring physician
specialist response rates to web- based surveys. BMC Med Res
Methodol 2015;15:32.
41 Meyer VM, Benjamens S, Moumni ME, etal. Global Overview of
Response Rates in Patient and Health Care Professional Surveys
in Surgery: A Systematic Review. Ann Surg 2022;275:e75–81.
42 Hennink M, Kaiser BN. Sample sizes for saturation in qualitative
research: A systematic review of empirical tests. Social Science &
Medicine 2022;292:114523.
