Abstract

Sam, a middle-aged Black cisgender male (they/them), was admitted for an organ transplant during the first wave of the COVID-19 pandemic. At that time, visitation was heavily restricted: only compassionate exceptions were allowed for patients at the end of life, those whose care required life-altering decisions, or patients with disabilities who required additional assistance. Organ transplant recipients were considered particularly vulnerable because of immunosuppression. Virtual technologies such as smartphones and tablets were used for patients to communicate with their families, but Sam would often decline calls from their spouse, Alex. Several months went by and Sam was still in our care; they had complications of infections and ultimately experienced multisystem organ failure. After the transplant graft failed, it was decided that Sam would be moved to a unit that allowed one designated visitor. When nurses asked Alex whether they would be able to visit, Alex became defensive and began to communicate in a way that some nurses felt was threatening. Alex explained that they needed to continue to work and could not make the long journey to the hospital multiple times each week. Sam continued to deteriorate and on their final day, Alex and Sam’s lifelong friend both came to the bedside. A music therapist and spiritual caregiver provided final services, and the intensive care unit (ICU) nurses experienced the death of another patient for whom they had cared for many months and who had spent their final months isolated from friends and family.Critical care nurses face complex ethical decisions on a daily basis, and these decisions have been magnified by the SARS-CoV-2/COVID-19 pandemic. Ethical considerations are apparent when nurses are involved in life-altering decisions such as withholding or withdrawing life-sustaining treatments, organ transplantation, and surgical candidacy. By contrast, “microethics” captures the ethics of everyday clinical practice and emphasizes the ethical impact of day-to-day interactions and relational considerations.1 Adopting this “view from the inside,” here we focus specifically on new virtual visitation practices and their impact on patients, their loved ones, and nursing care.1 Cuchetti and Grace2 previously argued that nurses should adopt a critical stance and use “intentional authenticity” when using technology to maintain the patient-nurse relationship. Intentional authenticity requires that nurses make authentic and intentional choices regarding the use of technology in specific situations, understanding its potential positive and negative effects on patient care.2 In this article we consider how COVID-19 has brought many microethical issues to the forefront and adopt a critical stance through which to explore the ethical trade-offs nurses face when they choose to use technology for virtual visitation. Using Sam’s case as a basis, we consider the ethical complexities and repercussions of virtual visitation, in particular the way in which technology has both connected loved ones and exacerbated social inequalities throughout the pandemic. At the forefront of the discussion are considerations of equity, safety, trust, and nursing obligations to maintain relationships with and between patients and their loved ones.3The COVID-19 pandemic has required critical care nurses to quickly change many of their practices in order to protect communities within and beyond hospital walls. In many places, visitation was almost entirely restricted, including for patients who were confirmed or likely to have contracted COVID-19.4-6 Nurses and health care systems shifted to offering virtual visitation using smartphones or tablets. The absence of visitors created logistical and ethical challenges for nurses and patients in building and maintaining relationships with loved ones, and, we argue, it also impacted decision-making.Nurses have grown accustomed to frequent changes in practice as technology has advanced, and the recent nursing literature contains discussions about the long-term impact of these changes on nursing care and the healing environment. Treatment modalities such as extracorporeal membrane oxygenation, left ventricular assist devices, and total artificial hearts have created new liminal spaces between life and death.7 Nurses practicing in critical care settings have long been warned about the risks of becoming too distracted by the complex life-sustaining machines such that they risk overlooking the relational needs of the patient. New informational technology used for interfacing with patients creates additional barriers between nurses and patients. Electronic documentation requires nurses to spend hours staring at computer screens in order to chart and receive reminders for upcoming interventions. Exploring the use of smartphones, computers, tablets, and the internet, Cuchetti and Grace2 described how these technologies have the potential to dehumanize patients. Throughout the pandemic, however, we have seen how these technologies have brought people together; rather than serving as a barrier, they have acted as a bridge between patients and loved ones and have enabled health care workers to understand their patients in the absence of in-person visitation.Family presence in the critical care setting is considered an essential component of care and a key element of ICU liberation bundles.8 Provision 1 of the American Nurses Association Code of Ethics for Nurses states that nursing support extends beyond the patient to also include the family.9 For the purposes of this article, we use the term family broadly to include relatives, friends, and other individuals whom the patient considers support persons. For patients, visitation has psychosocial benefits such as reduced anxiety, confusion, and agitation, and physiological benefits including fewer cardiovascular complications and shorter length of ICU stay.10 For loved ones, visitation increases satisfaction, decreases anxiety, promotes understanding of patient care and preferences, and allows more opportunities for education.10 Despite the known benefits of visitation, in order to maintain safety for patients, health care workers, and the broader community and to reduce the spread of SARS-CoV-2, visitation has been heavily restricted.11,12 Such restriction can also be interpreted as supported by the American Nurses Association Code of Ethics: provision 3 states that nurses have an obligation to protect the rights, health, and safety of patients, and provision 5 stipulates that nurses owe the same duties to themselves and others.9In Sam’s case, because of their immunocompromised state, they were completely restricted from seeing their spouse in person for months. Sam, like many other patients, lost the important role their family might have taken to assist with eating and grooming and to provide companionship. The lack of family presence impacts the healing environment that we try to create for patients.13 In an attempt to connect patients and families, many health care organizations used tablets to facilitate visual connections. Considering digital health technologies and relational geography, Peter14 states that “geographers recognize how spaces are created through social interactions and are viewed to be ever-changing, creating ‘social space.’”(p138) By removing visitors from health care settings and instead using virtual technologies, we change the social space of the healing environment.For patients who are able to participate in virtual visitation, the use of technology created ways for them to stay connected to family and friends from the comfort of their hospital room while maintaining safety. Whereas many ICUs previously may have discouraged use of smartphones, they now promoted digital connection to reduce patients’ social isolation. In Sam’s case, despite restricted in-person visitation, they frequently asked the nurse to decline virtual visitation and phone calls, stating that they did not feel up to communicating. Many members of the nursing team felt uncomfortable informing Alex of this, but they also recognized that Sam understood their choice, and so declining virtual visitation promoted Sam’s autonomy. Although connection to family may be important to some patients, nurses need to recognize that not all patients may feel comfortable with virtual visitation.13 Nurses have an ethical obligation to support a patient’s right to self-determination,9 which may include maintaining the patient’s privacy rather than using virtual technology, even if this choice upsets family members.The shift of ethical obligations and priorities during the pandemic has contributed to moral distress. We understand moral distress as psychological distress one experiences in response to a morally challenging event. Morley et al15 describe 5 subtypes of moral distress (see the Table). We have encountered many nurses who have expressed moral-constraint distress when required to facilitate virtual visitation. Whereas many nurses believe that it is their responsibility to connect patients and loved ones, they also have expressed frustration and anger because they have so many competing responsibilities to other acutely ill patients. Nurses continue to struggle with high acuity and understaffing due to colleagues contracting COVID-19 or leaving the profession. The nurses who remain have found themselves responsible for facilitating updates to families through phones or tablets, which is time-consuming. On COVID-19 units, many nurses expressed feeling that the expectation that they would spend more time in patient rooms to facilitate virtual visitation and perform tasks typically performed by persons in other roles, such as emptying trash, was unfair and potentially increased their risk of COVID-19 exposure while consulting services safely worked remotely. This perspective may be countered by arguing that virtual visitation still reduces one’s risk of exposure to COVID-19 when compared with in-person visitation, but nonetheless, many nurses have expressed feeling that they have shouldered a disproportionate burden of responsibility during the pandemic.3In facilities that previously offered 24-hour visitation, families may request continuous video feeds to replace in-person visitation. This request may not seem unreasonable given the lack of access to their loved ones, but it does create ethical questions about both patient and staff privacy and fair allocation of resources, given that most units are not likely to have access to multiple continuous video feeds. We might decide to add video feeds only for the most critical patients so that loved ones can feel more connected, or for patients who might be considered to be particularly vulnerable. Many interventions provided in the ICU, however, can be temporarily painful, and though nurses provide these interventions with the long-term goal of helping the patient to recover or heal, this aim may not be readily apparent to family members watching the video feed. Repositioning and tracheal suctioning may hurt temporarily, but without these interventions the patient may experience complications due to skin breakdown or be unable to breathe. Families can be educated virtually about the clinical indications and risk-benefit trade-offs for an intervention, but the context of care can be lost in a continuous feed. A family might miss a nurse’s comforting touch, reassurance, and coaching through a painful intervention. Nurses may experience moral-uncertainty distress in wanting the family to feel connected but being unsure about whether an incapacitated patient would want to be recorded. Once a video feed is started, families can take photos or make permanent recordings of the video showing the patient or the nurse. Families might also observe an error, and although health care professionals have an obligation to disclose errors, information could be misinterpreted, or family access to information about who was responsible could jeopardize therapeutic alliances and undermine patient care.In Sam’s case, Sam had the capacity to make decisions and could agree to, or indeed decline, virtual visitation. Many patients, however, are unable to provide permission and discover upon their recovery that they have been included in video calls. In a study of health care professionals from the United Kingdom, survey respondents reported the perceived distress this caused to families when practices varied between units and hospitals. Some units would facilitate virtual visitation without patient consent, whereas others required such consent.5 This variation in practice highlights the need for institutions to develop standard protocols and procedures.Disputes with patients or their surrogates about visitation can create moral-conflict distress for the nursing team. Sam would frequently decline phone calls and offers of virtual visitation through a tablet, which created conflict between Alex and the health care team. The health care team believed that they were frequently giving Alex updates, but Alex expressed frustration and accused the team of “not letting me talk to Sam”; Alex also often expressed feeling that they did not have sufficient information to serve as Sam’s surrogate decision-maker. The pandemic has probably exacerbated workplace violence as a result of higher stress and anxiety among patients, families, and health care workers, leading to an increase in verbal threats.16 Verbal threats are less likely to be reported than physical violence, which suggests that health care organizations may not be robustly capturing this negative impact of the pandemic. In Sam’s case, many nurses expressed feeling that Alex spoke in a threatening tone. Although nurses should not be subjected to verbal or physical abuse in the workplace, we have noted times when health care workers’ own racial or socioeconomic biases seem to affect their perception of an individual or a situation. A balance must be struck between supporting nurses who perceive that they are experiencing verbal abuse and addressing biases. Nursing ethics has a long history of commitment to social justice, and working to address unjust systems must be balanced with a nurse’s duty to themselves and no tolerance for verbal abuse.9,17 We found it helpful to encourage the nursing team to engage in perspective-taking and consider why Sam’s partner might express anger. For example, Alex might have felt guilty that they were unable to visit and frustrated that Sam kept declining their attempts to communicate virtually. During times when in-person visitation was not restricted, Alex might have felt angry that they were unable to take time away from work to visit, or indeed, they might have been angry about ongoing structural injustices that have meant that COVID-19 has disproportionately affected Black communities and other people of color.18Nurses are frequently told that their health care institutions take a zero-tolerance approach to workplace violence, but in reality, complex dynamics frequently mean that allowances are made for patients or visitors who are verbally abusive or violent. For example, consider patients who lack decision-making capacity and are violent, or visitors who have extreme emotional reactions but are able to return for compassionate reasons such as end-of-life visitation. Even with virtual options available, many family members understandably felt strongly that they should be able to see their loved ones despite the necessity of visitation restrictions. The responsibility for consistently enforcing and reinforcing institutionally mandated visitation policies and restrictions often falls to clinical nurses at many health care organizations. Such institutional changes can result in moral-constraint distress, as nurses are required to shift from focusing on caring relationships to reinforcing institutional rules that they might not agree with. This shift potentially risks the therapeutic and collaborative relationships that nurses in an ICU work to build with patients’ loved ones.Many nurse managers and leaders stepped in to support clinical nurses and found themselves in the position of interpreting hospital policies that necessarily allowed for compassionate exceptions. Nurse managers experienced moral-conflict distress as they tried to balance these ethically laden considerations. Reflecting after a severe acute respiratory syndrome outbreak in the early 2000s, Rogers19 highlighted the need to examine ethical repercussions of visitation restrictions for future health emergencies. Rogers concluded that because health care workers have a duty to care for patients and families, organizations must accept responsibility for both making and enforcing visitation restrictions. Many health care institutions, however, found that they were not prepared for the COVID-19 pandemic, and fielding the frustration and anger of families experiencing restrictions fell to bedside clinicians.19Many organizations made exceptions to allow for in-person visitation, but disparities may be exacerbated if exceptions are made solely by individuals. Importantly, exceptions might be made more often for patients who do not have COVID-19 in order to preserve personal protective equipment and the perception of a lower risk of spread, meaning that patients with confirmed COVID-19 are less likely to receive visitation exceptions.18 As we mentioned, the COVID-19 pandemic has disproportionately affected people of color, further amplifying racial injustice.Issues related to access that create microethical complexities must also be considered when using virtual technologies. Patients who do not have their own device or are unable to hold a device must rely on the availability of hospital equipment and an employee to assist them. Patients with visual or hearing impairments may not be able to use the technology effectively, raising the question of whether visitation policies should allow exemptions for this patient population. Families may not have access to the technology required for virtual visitation, such as a high-speed internet connection and a phone or computer with a camera, and many resources that were previously available, such as libraries and community centers, have been closed. Older adults and other individuals may not feel comfortable using the technology. Because of the unprecedented nature of COVID-19, rapid changes were required to ensure that patients and families were not entirely isolated. Moving forward, health care institutions and services should consider ways they can bridge the “digital divide” and ensure equitable access to devices in order to facilitate virtual visitation.Families are often overwhelmed the first time they come into an ICU. As they sit by the patient’s bed each day, they may observe the patient deteriorating and see subtle changes in the patient’s condition. When these visits happen at a distance, the family may visualize their loved one for only a few minutes a day, if at all, and rely on complex information from a team with whom they have had less opportunity to build a relationship. When Sam was acutely ill and lacked decision-making capacity, the health care team often had to call several times in order to reach Alex to discuss the risks and benefits of recommended interventions and obtain informed consent. Alex frequently did not answer the phone and requested more time to make decisions. This raised questions for many members of the health care team about Alex’s reliability and understanding of the situation. Health care teams depend on families to act as surrogate decision-makers and ask them to make decisions on the basis of substituted judgment or best interests.20 Such decisions require knowledge of complex medical information, an understanding of the patient’s values and preferences, and a trusting relationship with the health care team. Exchanging information and building trust can be made more difficult when using virtual means. A systematic review published before the pandemic indicated that surrogates failed to predict accurately patients’ end-of-life treatment preferences in one-third of cases.20 Surrogates who are not able to be present at the bedside may find it even more difficult to make complex decisions. The health care team and the family may experience moral-dilemma distress as they attempt to negotiate these difficult decisions.In many health care organizations, visitation exceptions included end-of-life situations. After months in the ICU, Sam began to deteriorate clinically. Supported by institutional policy, the health care team made exceptions to allow both Alex and Sam’s friend to come into the ICU. After arriving, they fondly shared stories of Sam at the bedside. Care teams that had supported Sam throughout their stay came to pay their final respects. In the days after Sam’s death, many nurses shared feelings of sadness and loss.Although Sam had shown signs of clinical deterioration that allowed family to be called in before their death, there is not always advanced warning of deterioration. Studies continue to indicate that most adult patients want family members present during emergency procedures and at the end of life, and that families feel that it is their duty to be present during resuscitations and invasive procedures.21 Benefits for the family include lower reports of posttraumatic stress disorder and traumatic grief.21 Families who may previously have been unable to make it to the hospital can now be offered the option of being present virtually; however, we do not know whether those same benefits translate to virtual presence. In these cases, one nurse can hold the tablet while another explains everything that is happening and observes for cues that the family may want to end the virtual visit. During in-person visitation, a nurse would continue to comfort the family and bring in spiritual care supports. These microethical decisions about whether to sit with the family or hold their hand are crucial elements of a holistic approach. During virtual visits, after a patient dies, a nurse can offer condolences and disconnect the call, but this may feel both incomplete and inadequate for a grieving family and limits the nurse’s ability to care for the family.Perceptions of a “good death” may depend on one’s culture, but nurses in the United States perceive as a common value the desire to be connected with a loved one at the end of life.22 They feel a moral obligation to provide this aspect of a good death to the patients in their care. Nurses have always been witnesses to the process of dying, but the impact of holding a tablet and trying to ensure that the patient feels that presence at the end of their life is daunting. Many nurses and other health care workers may experience moral-constraint distress because they feel constrained by their ability to provide only this virtual connection and thereby seemingly abandon a core moral commitment. Nurses may act as a surrogate family, which increases their psychological burden and emotional labor, and many report an emotional toll in hearing the last intimate words of families to their loved ones.22,23During the COVID-19 pandemic, technology began to be used in order to preserve therapeutic and valued relationships for patients. The use of virtual technology has had both positive and negative ethical repercussions, and, as we have discussed, it has created microethical problems for critical care nurses. In a survey administered by Rose et al,5 health care professionals perceived benefits to patients of virtual technology, such as reduced psychological distress (78%), the ability to reorient delirious patients (47%), and patient engagement with physical therapy (44%). Staff also reported an increased sense of morale from seeing their patients connect with loved ones (68%). They did, however, highlight multiple barriers to virtual visitation, such as a lack of staff to facilitate visits, a lack of family access or families lacking ability to use devices, and privacy concerns.5 As the pandemic plateaus, we must continue to consider the ethical issues technology has raised, such as equitable access to technology, safety, patient/family expectations, moral distress, and increased nursing workloads.For those who have access to the necessary technology, virtual means may have helped overcome some of the financial barriers and risks to visitation. Black and Hispanic individuals have had higher rates of unemployment during the pandemic,24 which impact the ability to afford transportation to visit hospitalized loved ones. Black and Hispanic individuals living in urban areas also are more likely to rely on public transportation,25 which presents a risk of exposure to COVID-19. Although virtual visitation may provide protection from harm, it is not an option for everyone. As Cuchetti and Grace2 suggest, nurses need to take a critical stance when considering the use of virtual technology in various situations.Nurses have undoubtedly experienced moral-dilemma distress as they have tried to balance their obligation to care for patients and to maintain their own personal safety throughout the pandemic. Facilitating virtual visits is time-consuming; optimally, nurses would set up the tablet, provide an update, answer questions, and then leave the tablet with the patient so that they can continue with other care needs. As we continue to provide virtual visitation, nurses should be offered training on the technology and be given the opportunity to ask questions related to its use. Nurses would probably benefit from education about how to communicate clearly, honestly, and transparently with patients and families about possible constraints to visitation.Hospitals need to provide guidance on how to address staff’s ethical concerns, such as resource limitations affecting the use of technology and policies regarding requests around unlimited access (eg, continuous 24-hour video). Many hospitals in the United States have released ethical guidance for clinicians during the pandemic, but this guidance does not include the ethical use of virtual technology in the inpatient setting.26-28 Rose et al5 noted that many UK hospitals relied on guidance from the United Kingdom Intensive Care Society on the appropriateness of virtual visitation, but local interpretation varied regarding what was in a patient’s best interest. Virtual visitation may support relationships between patients and their families, but it also increases emotional labor and workload for nurses. It is important to recognize that switching to virtual formats for visitation, especially for patients who are at the end of life, may have a profound impact on nurses, who may experience posttraumatic stress disorder, grief, and different types of moral distress. Hospitals should provide resources to address both psychological and moral distress among health care workers and actively mitigate avoidable causes. The pandemic has presented new ethical challenges and exacerbated others, and resources should be available to address moral distress, such as consultative ethics services for decision-making at an individual and a system level,29,30 and group moral distress debriefing.31To provide patient-centered nursing care, we must be critical and thoughtful about the ways in which we use technology. The COVID-19 pandemic has required changes to be implemented quickly. We suggest that, moving forward, it will be important to implement technology with a plan for ongoing assessment of a technology’s effectiveness and its impact on the patient, the family, the inter-professional team, and the practice environment. The pandemic has required processes in which communication and medical decision making do not occur at the bedside. In order to limit provider exposure, rounds may be done virtually, with team members in remote locations. Virtual updates to families may occur during these remote rounds. Without careful planning, both of these processes risk excluding bedside nurses and potentially patients. Because nurses are present with patients 24/7 and often act as the primary communicator with the patient and the family, hospitals must implement processes to ensure nurses are included in the decision-making processes, as their exclusion would exacerbate epistemic injustice.32 Epistemic injustice is a type of injustice that occurs against individuals as knowers and can occur when nurses are not incorporated into decision-making.32,33 Ulrich at al30 recently suggested that in ethical practice environments, nurses must be heard, interprofessional teams must work together, leaders must support staff, appropriate resources should be obtained, and policies must be adopted that protect staff.Before we adapted to life with COVID-19, we feared that virtual technology would facilitate and exacerbate a “disembodied presence” between nurses and patients.2 We have seen throughout the pandemic how technology can bring great benefit to some patients and loved ones, mitigating isolation and strengthening relationships. As with many other aspects of this global pandemic, however, use of such technology in the ICU setting raises issues of justice, fairness, and access. While Sam, in their immunocompromised state, remained protected and was able to exercise their autonomy in selecting when to have virtual visitors, virtual visitation remained imperfect and did not replace in-person interaction. Still, where these technologies are available, they have served to strengthen nurses’ understanding of patients and to humanize, rather than dehumanize, the patients for whom we care.

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