key: cord-0995107-o6vnql7v authors: Verbeek, Hilde; Gerritsen, Debby L.; Backhaus, Ramona; de Boer, Bram S.; Koopmans, Raymond TCM.; Hamers, Jan PH. title: Allowing visitors back in the nursing home during the COVID-19 crisis – A Dutch national study into first experiences and impact on well-being date: 2020-06-15 journal: J Am Med Dir Assoc DOI: 10.1016/j.jamda.2020.06.020 sha: e2134a30cb1813e1b662ec1fba93314612395d05 doc_id: 995107 cord_uid: o6vnql7v Abstract Objectives To prevent and control COVID-19 infections, nursing homes across the world have taken very restrictive measures, including a ban for visitors. These restrictive measures have an enormous impact on residents’ well-being and pose dilemmas for staff, although primary data are lacking. A Dutch guideline was developed to cautiously open nursing homes for visitors during the COVID-19 pandemic. This study reports the first findings on how the guideline was applied in the local context, the compliance to local protocols and the impact on well-being of residents, their family caregivers and staff. Design A mixed-methods cross-sectional study was conducted Setting and participants In total, 26 nursing homes were permitted to enlarge their possibilities for allowing visitors in their facility. These nursing homes were proportionally representative of the Netherlands as they were selected by their local Area Health Authority for participation. At each nursing home, a contact person was selected for participation in the current study. Methods A mixed-method cross-sectional study was conducted, consisting of questionnaire, telephone interviews, analyses of documentation (i.e. local visiting protocols) and a WhatsApp group. Results Variation in local protocols was observed, for example related to the use of personal protective equipment, location and supervision of visits. In general, experiences were very positive. All nursing homes recognized the added value of real and personal contact between residents and their loved ones and indicated a positive impact on well-being. Compliance with local guidelines was sufficient to good. No new COVID-19 infections were reported during this time. Conclusions and implications These results indicate the value of family visitation in nursing homes and positive impact of visits. Based on these results, the Dutch government has decided to allow all nursing homes in the Netherlands to cautiously open their homes using the guidelines. More research is needed on impact and long-term compliance. Nursing homes and other long-term care facilities provide care for the most vulnerable people 30 within our society, the majority older people with chronic diseases such as dementia. This 31 group has been highly affected by COVID-19. First estimations indicate that in Europe, 32 between 19% and 72% off all people who died from COVID-19 lived in nursing homes. 1 family, informal caregivers, or friends could visit residents and that residents were not 40 allowed to go outside. Often these restrictive rules also applied to health professionals such as 41 physicians, psychologists, physiotherapists. 4 Furthermore, all group-based and social 42 activities had been cancelled. Throughout the pandemic, guidelines recommended that 43 residents remain in their own rooms for as much as possible. 5 44 45 These restrictive measures have an enormous impact on residents and their well-being and 46 pose dilemmas and challenges for staff, although primary data are lacking. 6 The ban on 47 visitors and restricting their movement is a serious challenge to their autonomy and right to 48 make their own choices, 4, 6 in an era where so much progress was made in eliminating 49 restraints. Despite technological innovations like video calls and creative solutions being 50 tried (e.g., window visits, or separate containers using plexiglass outside the building), 51 residents are socially isolated. Especially people with dementia might benefit more from 52 4 physical closeness (including holding hands, hugging) than from a talk at a distance with 53 relatives. Some residents have to be isolated within their own room, because of COVID-19 54 infections on the unit. Prior research has indicated that loneliness and social isolation have 55 negative consequences for residents' health and well-being, 7 This study reports the first findings on how the national guideline was applied in the local 78 context of the nursing homes, the compliance to local protocols and the impact on well-being 79 of residents, their family caregivers and staff. It used the framework for process evaluation, 10 80 focusing on both first order process data (related to the reach of the guideline and extent of 81 performance in practice) and second order process evaluation data (strategies used for 82 implementation and encountered barriers and facilitators). In total, 26 nursing homes were allowed to enlarge their possibilities for allowing visitors in 91 their facility. See Table 1 In each nursing home, one individual was selected to fill out an electronic questionnaire and 99 participate in a telephone interview. Nursing homes selected the person they considered to 100 have the most information on the policy and local protocol for the facility and who was 101 involved in the development of the local guidelines. The contact persons were nursing home 102 6 managers (n=16), local quality or policy officers (n=8) or registered nurses (n=2). All contact 103 persons were invited to join a WhatsApp group in which participants could share experiences 104 on the application of their local protocols in practice. They could also invite their colleagues 105 to join the group. 106 107 Data collection 108 Table 2 The results showed a variation in how the national guideline was applied in the local context 182 of nursing homes, especially regarding the use of personal protective equipment and the 183 supervision of visits (see Table 3 ). In some nursing homes all staff and visitors were obliged 184 to wear a protective mouth mask (n=11), whereas in others protective mouth masks were only 185 obliged for visitors of residents with dementia. All visitors were screened on active COVID-186 19 symptoms, although in 2 nursing homes this did not happen at the visit but only 24 hours 187 before the visit via telephone. The vast majority also took the temperature at the visit (n=22). 188 In 10 nursing homes the visits were unsupervised. Visits were in the residents' own room and 189 nursing homes explained they wanted to respect the privacy of the residents. For example, visitors did not use protective measures during the whole visit. Especially the 203 protective mouth masks were perceived as difficult to comply with in certain circumstances. 204 A common situation was sharing coffee or food, which was permitted in some nursing 205 homes, and for which case wearing a mask was impractical. Furthermore, a small minority of 206 homes did allow more than 1 designated visitor, when confronted with more than 1 visitor. 207 Finally, physical contact did occur according to some respondents (including giving hugs) 208 and they did allow this. Residents experienced joy, as well as staff, who although some stated that it was difficult for 239 residents and family that they were not able to touch each other and have physical contact. The Dutch government has decided as of May 25 th that all nursing homes in the Netherlands 316 are allowed to have visitors using this national guideline. Results of the current study have 317 been used to formulate this advice. An adapted version of the guideline was developed, in 318 which the need for expansion of the regulations was requested, including the need for 319 residents to go outside with their visitors. At the moment, it is unclear whether nursing homes 320 will apply this in their local context whether the decreasing trend will remain. Other countries 321 are currently also piloting allowing visitors back in the nursing home. More research is 322 needed on long-term effects, including insight in infection rates and in-depth experiences of 323 family, residents and staff. 324 We declare no conflict of interest. 327 Article in LTCcovid.org, 331 International Long-Term Care Policy Network Update registratie verpleeghuizen 2 juni Dementia care during COVID-19 COVID-19: it is time to 338 balance infection management and person-centered care to maintain mental health 339 of people living in German nursing homes Managing the COVID-19 pandemic in care homes for older 342 people. Good Practice Guide Commentary: COVID in care homes-345 challenges and dilemmas in healthcare delivery Social isolation, loneliness and health in old age: a scoping 348 review COVID-19 and the consequences of isolating the elderly Handreiking voor bezoekbeleid in 352 verpleeghuizen in corona tijd Process evaluation to explore 355 internal and external validity of the Update registratie verpleeghuizen 12 mei 361 12. Verenso. Update registratie verpleeghuizen 19 mei 364 13. Verenso. Update registratie verpleeghuizen 26 mei Associated With Quality of Life of People With Dementia in Long-Term Care 371 Facilities: A Systematic Review Loneliness as a public health issue: the impact of 374 loneliness on health care utilization among older adults Gerritsen DL & Oude Voshaar RC. The effects of the COVID-19 virus on mental 377 healthcare for older people in The Netherlands, Int Psychoger Essential Family Caregivers in Long-term Care during the COVID-19 We would like to thank all nursing homes for their participation. In addition, we would like to thank Erica de Vries, Judith Urlings, Johanna Rutten and Eveline van Velthuijsen for their valuable contribution in data collection and analyses.