**Background:** During the COVID-19 pandemic, many Canadian hospitals replaced open family presence policies with restrictive or 'zero visiting' policies to reduce viral transmission. Despite decades of evidence supporting patient- and family-centred care (PFCC), these policies often treated family caregivers as visitors rather than essential partners. This study aimed to understand how these policy changes impacted patients, family caregivers, and frontline healthcare providers (HCPs) in acute care settings across Canada.
**Methods:** A qualitative descriptive design was employed. Between September 2020 and January 2021, 38 in-depth semi-structured interviews were conducted with 8 patients, 18 family caregivers, and 12 HCPs from Alberta (n=15), British Columbia (n=7), Ontario (n=7), New Brunswick (n=6), and Saskatchewan (n=2). COVID-19 patients and their caregivers were excluded. A maximum variation sampling strategy was used to capture diverse perspectives. Interviews explored pre-pandemic caregiver roles, impacts of restrictive policies, and recommendations. Data were analyzed using Braun and Clarke's six-phase thematic analysis with QSR NVivo 12 software, guided by the PFCC framework and the socio-ecological model.
**Key Results:** Five essential caregiver roles were identified: (1) emotional support, love, comfort, and companionship; (2) patient advocacy; (3) supporting two-way communication with the healthcare team; (4) supporting healthcare decision-making; and (5) providing physical care including nutritional support. Restrictive visiting policies interrupted these roles, with impacts falling into four integrated categories:
1. **Emotional and mental health:** Patients experienced anxiety, depression, delirium, and loneliness from separation. Family caregivers reported worry, stress, fear, guilt, and loneliness; some described deteriorating mental health including heightened anxiety and depression. HCPs experienced role strain, burnout/compassion fatigue, and moral distress—some took extended leaves or contemplated resignation. One nurse stated, "a lot of my colleagues are very morally distressed about having to have families split up and not being able to provide, sort of the family-centered care that we really pride ourselves on."
2. **Communication and advocacy:** Family caregivers of patients unable to advocate for themselves (e.g., children with complex needs, severely ill, elderly, cognitively impaired) were particularly affected. Technology-mediated communication (phone, tablet, video) was often inadequate, especially for patients with cognitive/physical disabilities or limited technology literacy. One family caregiver described difficulties connecting with her husband with early-onset Alzheimer's while he was hospitalized.
3. **Safety and quality of care:** Concerns included falls, positioning issues, medication errors (e.g., a patient discharged with another patient's prescription), inadequate personal care (washing, oral care, nutrition/hydration), and inability to attend outpatient appointments. One HCP noted that some patients avoided hospitalization due to visiting restrictions, leading to injuries and complications at home.
4. **PFCC, trust, and future healthcare decisions:** Restrictive policies were described as the "antithesis of PFCC." Some patients and caregivers reported erosion of trust in the healthcare system and fear about accessing hospital care. Some delayed seeking care—for example, one family delayed taking a sibling with complex needs to hospital after a fall, hoping to avoid the restrictive environment.
**Clinical Implications:** The study highlights that restrictive visiting policies caused significant harm across all stakeholder groups. Participants emphasized there is no "one-size-fits-all" policy; flexibility is essential. Recommendations include: balancing infection risk with potential harms of separation; returning to PFCC-supportive policies; ensuring flexibility in defining family presence; supporting safe physical presence (screening, PPE, rapid testing); and fostering consistent, transparent policy implementation. Patients at high risk of harm from caregiver absence include those with cognitive impairment, delirium risk, communication barriers, critical illness, end-of-life needs, and unique sociocultural needs. The findings align with prior research showing that family presence improves safety, reduces medical errors, and enhances patient outcomes. The study also notes that racial disparities and structural racism in Canadian healthcare warrant further research on how these policies differentially affect racialized populations.