Strategies Used by Nurses to Maintain Person–Family Communication during the COVID-19 Pandemic: A Scoping Review

Background: The COVID-19 pandemic made nurse–patient–family communication more difficult, reducing the understanding of the patient’s wishes and current care history. COVID-19 challenged healthcare teams to develop strategies to address these changes and provide more integrated care using the technology at their disposal. So, this study aims to map the strategies used by nurses to maintain communication between the person hospitalized with COVID-19 and the family to understand which communication technologies were most used to maintain communication between the person and the family. Methods: A Scoping Review, according to the recommendations of the Joanna Briggs Institute [JBI] with the Preferred Reporting Items for Scoping Review extension (PRISMA-ScR), research conducted between September 2022 and January 2023. The search was conducted in the databases: Latin American and Caribbean Literature in Health Sciences (LILACS); Cumulative Index of Nursing and Allied Health Literature (CINAHL); Scientific Electronic Library Online (SciELO); Medical Literature Analysis and Retrieval System Online (Medline), using the descriptors: family, communication, nurses, hospitals and COVID-19, and the Boolean operators “AND”. The inclusion criteria were: original articles, in Portuguese, English, and Spanish, published from 2020 onwards, with access to full and free text. Results: It was found that most of the communication was unstructured with the family. The technologies most used by nurses were the telephone with video calls from the patients themselves and even from health professionals to maintain communication between the patient and the family. Conclusions: Communication between patients and families became essential during the pandemic, as it became a vital lifeline of human connection that supported the mental health of patients and their families. This study was not registered.


Introduction
The pandemic caused by the coronavirus (COVID-19) has completely changed the concept of visiting health units, particularly in inpatient services with positive COVID-19 patients, introducing substantial communication barriers and abruptly hampering care centered on the patient and family [1]. Restricting family visits to institutions was deemed necessary due to concerns surrounding the transmission of the SARS-CoV-2 virus [1]. Thus, due to the need to maintain complete isolation, COVID-19 has largely changed the way nurses communicate with patients and families in COVID-19 care units. In addition, health professionals themselves were also isolated from their families and had to manage the
The selection of studies strictly followed the recommendations of the PRISMA-ScR, so no former quality assessment was made in the included studies. Our data extraction and analysis focused on a descriptive approach. After selection by title and abstract, the articles were carefully chosen for full-text reading, analyzed by the same reviewers, related to trends, gaps, and patterns in the literature, and afterward summarized and recorded the data collected in standardized evidence sheets organized according to the following items: author(s) year/country, title, design, aim, and results. The completion of these sheets enabled the identification of relevant articles for this Scoping Review, since when compiling the information, articles were also identified that only the full-text reading allowed to verify the presence of reliability conditions related to the exclusion criteria. Finally, in the 5th stage, data of interest were extracted in a summarized form and the results were reported. The search strategy and the different stages of selection, eligibility, and inclusion of articles are shown in Figure 1.
The flowchart of identification, selection, and compilation of articles is presented in Figure 1.

Results
The characterization of the articles included in this review is summarized based on the author(s), year, country of origin, title, base where it was located, study design, objective, and main results, and is presented in Table 1. Table 2 summarizes the main communication strategies and tools used by nurses to maintain person-family communication during COVID-19. The articles were numbered from 1 to 4 for better identification in the text. Participants felt that telehealth was a great help and played an important role in facilitating communication between patients and their families. It was relatively easy and less time-consuming to organize a telehealth meeting than an in-person meeting. Telehealth allowed families to see the faces of their loved ones and what is happening in the ICU, which was especially important during the closure. They again reported that communication was more regular and organized during the pandemic with the use of telehealth. A reservation system was implemented to schedule calls and meetings with family members, healthcare providers, and interpreters. Family liaison nurses were created to facilitate communication between the hospitalized patient and the family. The contact between the family and the health professionals was done mainly through video or telephone calls. An important precondition for contact between patients, their families, and/or healthcare professionals was the availability of telephones and the ability to use them. Most units had unstructured communication with the family, often depending on individual family or bedside nurse actions. In the focus groups, nurses explained that contact with families was much less than before the COVID-19 outbreak. the restricted visitation policy resulted in the absence of family, and (informal) communication stopped.

Communication Strategies
Creation of a group of managers to carry out the communication: 1; 4.
Draft and share consensus statements to enable the healthcare team to provide an optimal level of communication with patients' families in circumstances of total isolation: 1.
Phone calls to try to meet the expectations of families: 1; 2; 3; 4.
Organizar visitas de telehealth foi uma grande ajuda e desempenhou um papel importante na facilitação da comunicação entre doentes e familiares: 3. Implementing a reservation system to schedule calls and meetings with family members, healthcare providers, and interpreters: 3.
Family liaison nurses were created to facilitate communication between the hospitalized patient and the family: 3.
Phone calls with unstructured communication with the family, often depending on individual actions by the family or the nurse responsible for the patient: 1; 2; 3; 4.
Evidence increasingly supports the impact of family presence on improving patient care experiences and outcomes and on the mental and physical well-being of patients, families, and healthcare professionals [15][16][17][18]. Results highlighted that communication with the patient and family of the hospitalized patient is extremely important, as it is crucial to reduce anxiety and anguish (both in families and hospitalized patients) [14,15]. These findings are in line with current research that supports the central role of assertive communication in healthcare and clinical decision making [14][15][16][17]. In addition, our findings reveal that virtual visits offered an alternative way to [1] restore family unity, [2] facilitate family involvement, and [3] allow for the expression of the family's feelings.
Virtual visits made it possible for multiple family members to simultaneously communicate and interact with the hospitalized relative and restored a sense of family unity [12,16,17]. Also, the family involvement level in end-of-life presence and the communication guidance activities, highlighted how the virtual visit could contribute to effective family-centered care [7,16]. Additionally, virtual visits were emotionally challenging for many family members, but also cathartic in helping them understand their own emotions and experiences, visualizing their hospitalized family members [7,16].
Several studies report that at the beginning of the COVID-19 outbreak, families felt that they were losing vital information, so communication with the health team was very important for them. They also felt some anguish since this information was not standardized or structured, depending on the different nurses in charge [5,7,[16][17][18][19]. Some family members took the opportunity to be updated on their patient clinical status during phone call contact with healthcare professionals and some studies described these experiences as "disappointing", "excellent" or "impersonal", and express that communication with nurses was generally more consistent than communication with physicians [5,12,19].
Study results show that the technologies most used by nurses to maintain communication between the person and the family were phone calls with video, made by the patients themselves, or made by healthcare professionals. Some studies describe ambiguous feelings reported by family members about phone or video calls. Families often describe mixed feelings, both as "very satisfied" as well as "disturbing" and "traumatic" [5,7,13]. For health professionals, it was also a great challenge, adding this procedure to the many stressful routines in the ward units' daily COVID-19 care. Many nurses had to deal with families' constant phone calls to ask for updates on the health status of patients, and in the vast majority of hospitals, there was no management group to make daily updates to families [5,7,9,13].
Results show that several family members called the units several times a day to speak with the nurse in charge of their relative acre; however, others waited for the nurse to call them back to update the patient's condition [5,13,16]. In the second example, the anxiety and fear reported by these families were particularly high, with many family members reporting that waiting for this phone call was like "torture" [5].
Additionally, it was found that using telehealth was another strategy used to maintain communication between the person and the family, especially when the family was conscious [4,5,18]. There are reports in some family studies that seeing family members via telehealth was good; however, for other families, it was a less positive disturbing experience [4,5,13]. The platforms most used to carry out communication were TouchAway, developed by the LifeLines team, followed by Skype and FaceTime. Despite these platforms not being the ideal way to maintain essential communication between the patient and the family, during the COVID-19 pandemic, they were the vital lifeline of human connection that supported the mental health of patients and their families [17]. In this context, some studies reported that these platforms and new technologies developed a key role promoted meaningful connections with their families and allowing them to feel present during the person's hospitalization [4,9,17].
In this sense, some participants mentioned directly observing the negative impact of social isolation on the patient's well-being and recovery during the period of visitation restrictions, saying that they could see that their loved one "did not want to live like this". Ultimately, patients and families perceived that new technologies were a patient and family-centered innovation that can facilitate regular connection between them, not just during the COVID-19 pandemic situation, but at any time the patient needs care and comfort from and a connection with their family [9,16].

Conclusions
The analysis of the studies included in this review showed that the main strategies used by nurses to maintain communication between patients and families during the COVID-19 outbreak were phone calls. Performing a virtual visit played an important role in facilitating emotional support; however, these strategies wore unstructured, depending on the individual actions of the family or the nurse in charge of the patient. The technologies most used by nurses were the telephone-video calls, made by the patients themselves or by health professionals.
Maintaining communication between the patient and family played a central role during the COVID-19 pandemic, as it become a vital lifeline of human connection and promoting the mental health of the patient and family. This study also highlights the potential of new technologies as resources for nursing care, in a critical period for humanity, namely lessening the negative effects of isolation and/or limitation of significant relatives with patient contact. Finally, this study highlighted that nursing teams working during the COVID-19 context were able to find pioneering strategies to maintain and strengthen nurse-patient-family communication, considering it an essential guarantee in the provision of care.