Sixteen participants completed the interviews, all preferring remote, web-based formats. The participants included eight physicians and eight nurses, with seven (43.7%) identifying as male (Table 2). Participants had an average ICU experience of 10.6 years, and four (25%) held leadership positions. All participants were recruited from four different healthcare facilities. Collectively, participants reported managing an average of 187 patients with COVID-19 during the study period. Based on the interview results and using thematic analysis, three categories, nine themes, and forty subthemes were developed. Figure 1 presents a diagram illustrating interrelationships among the main themes identified in the analysis. All participants contributed to multiple themes, and no substantial imbalance was observed in the distribution of responses.

Table 2 Demographic profile of participantsFig. 1

Relationships among the main themes

Category 1: Challenges and Adaptations Experienced by HCPsTheme 1. The Implementation of Infection-Control Measures has led to Several Challenges and Complications

HCPs faced significant challenges when caring for patients in COVID-19-designated areas, particularly related to the mandatory use of personal protective equipment (PPE). PPE usage contributed to patient isolation, reduced direct patient-care time, and delayed responses, subsequently increasing patient delirium and staff-related incidents. A participant noted, “Instead of us struggling, I felt the patients were suffering, as PPE makes it hard to read expressions” (D-a-2), highlighting concerns about increased patient anxiety. Adaptations to address these issues included utilizing walkie-talkies for improved communication and installing cameras for enhanced patient monitoring. Moreover, PPE complicated auditory communication, prompting HCPs to speak more loudly and clearly.

Additionally, restrictions preventing direct interaction between HCPs, patients, and families impaired the collaborative discussions crucial for care planning. A participant explained, “Normally, HCPs, patients, and their families can gather at the bedside, but the pandemic interrupted this, making communication uniquely challenging” (N-b-4). Another participant stated, “Even if we communicated via smartphones, it was difficult to foster a sense of togetherness during discussions. The indirect sharing of information felt frustratingly detached” (D-b-1).

Theme 2. HCPs Approached their Practice and Care with a Variety of Emotions

Participants expressed varied emotional responses toward providing COVID-19 care. Initially, they reported little hesitation, viewing their involvement as fulfilling their professional and social responsibilities. Despite their motivation to provide the same quality of care as in non-pandemic times, HCPs faced significant psychological stress and ethical tension, largely due to restrictive infection-control measures enforced by hospital policies and interprofessional disagreements. Additionally, visitation restrictions prevented family members from supporting patients directly, prompting HCPs to adopt supportive roles traditionally fulfilled by families. One participant explained, “With COVID-19, the inability of families to visit meant that there were tasks they could not perform. I aimed to engage with patients as if I was taking that care instead of families, and I believe that sentiment has grown stronger” (D-a-4). Another reflected, “I realized that we, as HCPs, must interact with patients sincerely. While I am not exactly replacing family…” (D-d-1).

HCPs also experienced conflicts and dissatisfaction arising from disagreements among medical professionals, particularly regarding critical treatment decisions. Differences in perspectives between primary physicians and intensivists led to frustration, notably when some physicians hesitated to enter patient rooms due to fears of infection. Participants additionally reported anxiety, stress, and feelings of powerlessness associated with the unprecedented challenges and inadequate preparation for pandemic-specific situations.

Theme 3. Efforts were made to Facilitate Care for Patients with COVID-19

Healthcare facilities adopted multiple strategies to address challenges related to COVID-19 care. Establishing workload-sharing systems among hospitals and developing standardized treatment guidelines substantially alleviated frontline stress. Centralized care and clarified roles between neighboring hospitals improved efficiency, although balancing routine hospital functions with pandemic care remained challenging.

ICU treatment processes were simplified, enabling fewer staff to manage more patients effectively. Several facilities created standardized manuals to facilitate communication with patients’ families. One participant noted,“Recognizing that individual HCPs could not sustain prolonged patient care, we standardized manuals for intubation, extubation, and management before initiating COVID-19 admissions.” (D-b-1). Another stated, “As various HCPs became involved in COVID-19 care, detailed treatment manuals gradually emerged” (D-c-1).

While standardized manuals improved interdepartmental collaboration, communicating protocols to newly assigned support physicians occasionally caused additional stress. Rotating shifts among staff also disrupted consistent relationships with patients’ families. During resource shortages, hospital leadership conferences guided resource allocation decisions.

Theme 4. The Pandemic Reinforced the Critical Role of Interdisciplinary Cooperation

All participants emphasized the importance of interdisciplinary collaboration. Intensivists managed patient care, while attending physicians oversaw key treatment decisions and communicated with families, reflecting effective collaboration across specialties. Specialists regularly exchanged patient information to minimize conflicts and bridge communication gaps. Interdisciplinary conferences were organized to facilitate more effective communication with patients’ families. Additionally, detailed instructions were provided proactively, reducing nurses’ need for repeated clarification and streamlining patient care procedures.

Participants noted that the pandemic fostered a stronger collaborative spirit: “It felt like we were starting COVID treatment from scratch together, and I found it easier to consult with different professions during this time” (N-d-3). One participant stressed communication’s significance: “If we don’t prioritize this, it could lead to serious issues” (D-b-1). Before contacting families, HCPs exchanged critical information: “I would always check with the physician about the tone and atmosphere of their explanation since the nurse was not present” (N-b-4).

Many participants described positive experiences from interdisciplinary collaboration, highlighting conferences as essential for aligning team efforts. Family support teams also improved interactions with families: “Since the family support team started attending morning briefings, the exchange of information with patients’ families has significantly increased compared to when we handled it alone” (D-b-1). Additionally, participants recognized that diverse professional perspectives enriched patient care discussions: “The conference provided great insights; it was crucial to gather diverse opinions on a single patient” (N-b-3).

However, participants also reported instances of inadequate collaboration. In some cases, physicians explained patient conditions to families without consulting nurses, and attending physicians rarely visited wards, restricting opportunities for communication. Limited physician engagement in patient care resulted in discrepancies between nurses’ and physicians’ perceptions of patient conditions.

Theme 5. HCPs Faced Unprecedented Challenges during the COVID-19 Pandemic

Participants described encountering unprecedented challenges during the COVID-19 pandemic. As understanding of COVID-19 evolved, clinical management improved, yet emotional and psychological needs intensified. Many patients expressed guilt toward their families for contracting the virus, underscoring the necessity for psychological support that was provided by clinical psychologists and psychiatric nurses.

HCPs reported consistent patient communication despite barriers posed by PPE. Increased nursing staff facilitated effective care delivery. Physicians also highlighted the ethical complexity of treatment decisions, noting the necessity for earlier decision-making and psychological support from clinical psychologists and psychiatric nurses. One participant stated, “Many patients felt guilty toward their families, indicating a critical need for psychological support.”

However, challenges persisted, including restricted communication due to PPE and psychological distress among patients. Additionally, decisions regarding critical care were sometimes made prematurely. Participants reported the importance of psychiatric support to address these issues. Despite these constraints, communication remained consistent, largely due to increased nursing staff, facilitating effective patient care.

Category 2: Interactions Among Patients, Families, and HCPsTheme 6. Understanding the Challenges of Engaging with Patient Families and Taking Action

Visitation restrictions made it challenging for families to clearly understand patients’ conditions and ongoing treatments. Explanations provided remotely by HCPs were often insufficient, leaving families struggling to fully grasp patients’ situations. One participant explained, “Due to visitation restrictions, families unable to see their loved ones have found it difficult to envision the ongoing treatments. In addition, explanations from HCPs via telephone or web communication have often failed to convey the necessary information effectively.” Another participant noted, “The more serious the patient, the harder it is for the family to understand. It was always a struggle. Hearing about the treatment over the telephone made it difficult for families to fully understand the situation.” (D-c-1). A HCP observed that, “regardless of the thoroughness of verbal explanations, families often experienced shock upon seeing the patient’s condition firsthand” (N-d-4). To address these challenges, visual communication methods, including remote video meetings, were implemented to help families better understand the patients’ status, allowing them to see not only the patients but also their surrounding environment, such as respiratory devices. However, this method did not entirely replicate the experience of direct visits. “Viewing a patient on a ventilator through an online platform can be beneficial, but the family may not completely understand the seriousness of the situation” (D-b-2). Additionally, “Online platform communication introduced challenges, including time lags and difficulty perceiving emotional nuances” (N-b-4). Efforts continue to refine these communication approaches to better support emotional engagement between patients, families, and HCPs.

Participants also expressed concern that automated camera adjustments could inaccurately portray patient conditions, complicating families’ understanding. Telephone communication further hindered accurate interpretation, as it limited HCPs’ ability to assess families’ emotional reactions. A participant highlighted, “Communication via telephone complicated the ability to read family members’ expressions, making it difficult to understand their emotional state accurately” (D-b-1). Differences between physicians’ and nurses’ perceptions of families’ emotional states also presented challenges.

Despite these issues, telephone communication was necessary when direct interactions were restricted. Participants noted significant limitations, particularly in scenarios involving multiple family members. One explained, “Telephone communication was especially challenging in group discussions requiring multiple family members’ involvement” (D-b-1). To mitigate these barriers, healthcare teams prioritized direct interactions whenever possible, emphasizing their value in sensitive family discussions.

To better address these communication challenges, many facilities introduced family support teams dedicated to providing emotional support and updates. This intervention facilitated clearer, more consistent communication with families unable to visit in person, improving mutual understanding of the patient’s condition and treatment plan. Furthermore, “A physician noted the limitations of telephone communication, particularly in group settings where multiple family members needed to be involved” (D-b-1). Consequently, it was reported that key discussions with families were conducted through direct interaction whenever possible.

Theme 7. Creating Initiatives to Encourage Visits that Strengthen Relationships between Patients and their Families

Owing to infection-control measures, hospital visitation was highly restricted, creating emotional distress among patients and families. One participant reflected, “I wanted to find ways for families to visit, but continuously making exceptions felt inappropriate for the organization” (D-a-2). Differences also emerged among HCPs; while physicians tended to favor restrictions due to infection risks, nurses were more inclined to advocate for family presence. Discrepancies in visitation policies between hospitals further complicated the issue.

Remote visits were implemented to maintain patient-family connections. Initially, privacy concerns and the need for clear guidelines created barriers. Additionally, some families avoided in-person visits due to fear of infection. Despite these obstacles, families expressed a strong desire to visit patients during critical situations, highlighting the emotional importance of direct interaction. As one participant noted, “When significant circumstances arise, the disconnect in time and space is unsettling. While not everyone needs physical contact, for some, seeing and touching can make a difference” (D-b-1).

As direct visits resumed, feedback from families indicated relief from being able to see the patients directly. Despite the challenges posed by the pandemic, in-person visits, whether through windows or directly, were preferable to online meetings. Efforts have been made to facilitate these encounters, such as allowing families into negative-pressure rooms or, in end-of-life situations, having family members donate PPE for direct visits with consent. Retrospectively, there is a sense of regret about not swiftly establishing visitation protocols. One participant remarked, “If we could have devised a system more quickly or found innovative methods for visits, we could have created more opportunities for patients and families to connect” (N-b-4).

Theme 8. Nurses played a Significant Role in Supporting Patients and their Families

Nurses played a central role in supporting families throughout the COVID-19 pandemic. Before the pandemic, nurses participated in family briefings alongside physicians, helping families understand patients’ conditions and encouraging emotional expression. Although direct family visits were suspended during the pandemic, nurses continued to engage families separately from physicians, allowing families to voice concerns they might hesitate to share directly with physicians. Nurses validated these anxieties and served as critical intermediaries, linking families with multidisciplinary support teams.

Participants emphasized nurses’ critical role in connecting HCPs with families. One nurse explained, “Establishing communication with families is essential. It’s our responsibility to interpret their emotional states and perceptions, conveying these to physicians and specialists. When specialists are available, we connect families to them” (N-b-4). Another participant highlighted nurses’ growing importance in team-based care, noting, “Facilitating these connections has become a key nursing responsibility” (N-b-4).

Category 3: Lessons Learned from the Pandemic ExperienceTheme 9. The Pandemic’s Contribution to Enhancing Healthcare and Patient Care

The pandemic experience significantly raised awareness of interdisciplinary collaboration. Opportunities for interdisciplinary discussions regarding patient-centered goals increased, shifting focus from solely medical management toward care aligned with patient values. Enhanced communication systems facilitated these interactions, notably between physical therapists and nurses. As one participant remarked, “We increasingly discuss what we can do to support patients in reaching their goals” (N-a-4). Another emphasized the educational impact, stating, “The pandemic compelled HCPs to consider medical care necessary to help patients live the lives they desire” (D-b-1). Structured ethical consultations clarified previously vague concepts related to prognosis and patient values.

The onset of COVID-19 coincided with the hospital’s efforts to integrate ethical practices into routine operations. Following years of establishing an ethics consultation team and training staff in ethical decision-making, the hospital was well-prepared when the pandemic began (b-1).

Additionally, attitudes toward patients and families evolved, promoting a more patient-centered approach. Participants emphasized that the enhanced focus on individual patient needs during COVID-19 positively influenced routine emergency care beyond the pandemic. One nurse noted, “It may have been a valuable opportunity to reevaluate routine nursing practices” (N-b-4).

New insights emerged regarding routine medical care. Face-to-face bedside meetings between patients and families demonstrated the importance of physical presence for effectively understanding patient conditions. Participants recognized that traditional ICU settings often lacked opportunities for meaningful family interactions, prompting a reassessment of visitation policies. As one participant reflected, “COVID-19 prompted deeper reflections on how and when families could best visit loved ones” (N-d-4). “Looking back, it may have been a valuable opportunity to reevaluate routine nursing practices” (N-b-4).