Navigating Communication in Nursing Homes During COVID-19: Perspectives From Families, Healthcare Professionals, and Managers in Southern Switzerland—A Qualitative Study

Introduction

The first wave of the Sars-CoV-2 pandemic hit nursing homes (NHs) tremendously. A significant proportion of NH residents tested positive for the virus, with a large number of COVID-19 related deaths registered in NHs worldwide [1]. Given the scale of the impact, strict public health measures were put in place globally, such as visitor restrictions [2–7]. In Switzerland, where this study takes place, public health restrictions were particularly focused on people 65+, who were most affected by the virus [8, 9] and visits inside the NHs were strictly forbidden, except in situations involving end-of-life care [2, 9]. This lead to reduced social contact for residents and their families [2–7]. Research related to the COVID-19 pandemic, confirmed that NHs closure, with residents’ isolation and loss of social connection with family, friends, and peers, had a negative impact on both physical and mental health in residents [7, 10, 11]. Moreover, functional, cognitive, and nutritional decline was found in nursing home residents after the first wave of COVID-19, in both infected and not infected residents. This support the idea that the decline is not related to the infection itself but rather to the experience of social isolation [12]. Physical distancing and the residents’ physical and psychological state have, in turn, a negative psychological impact on family members and friend’s wellbeing [4, 7]. This is exacerbated in cases where the resident has cognitive impairments [3]. Physical distancing also generates frustration and affects the connection between family members and residents, contributing to a sense of anticipatory grief and ambiguous loss [4, 7, 13].

The negative consequences of such isolation sparked a worldwide effort to develop and implement innovative communication strategies such as an increased use of telephone calls and the introduction of video calls [4, 6, 7]. These initiatives came with several initial challenges like the availability of devices, the lack of appropriate IT infrastructure, low digital literacy of both family members and residents resulting in a constant need of staff presence to ensure the correct use of devices. Window visits were also introduced. The challenge in implementing this measure was the lack of space inside some nursing homes. As a following step, outdoor in-person visits have been permitted. Those require an outdoor location where residents can meet their loved ones while maintaining 2 m of physical distance and wearing a face mask. The use of this PPE often caused communication difficulties between residents and visitors [4, 6, 7, 14, 15]. In the Swiss contest, public policies were more strict with NHs: the nursing home closed in early March 2020 [2] and video and telephone calls, as well as window visits, were introduced by the end of March 2020 [16, 17]. It was only in early June 2020 that visits in presence were introduced [18, 19].

To date, little is known about the impact of these strategies in maintaining and facilitating communication between residents and families during the closure of NHs. The few existing studies suggest that a higher frequency of phone calls between residents and families and email exchange between families and staff, is associated with families experiencing less negative emotions and perceiving better emotional state in NHs residents [20]. Families’ satisfaction with communications strategies increased in relation to the number of possibilities to stay in touch with nursing home residents [4] and in presence visits had a positive impact on residents wellbeing [21]. Some studies suggest also barrier to communication, in using measures such videocall with specific population like patient with sensory and/or cognitive impairment [22, 23].

This study aims to explore the effectiveness of these communication strategies to facilitating and maintaining communication between families and NH residents during the first wave of the pandemic, from the perspectives of families, healthcare professionals, and NH managers.

Methods

This qualitative study was conducted in the southern and Italian-speaking regions of Switzerland, specifically Canton Ticino and Moesano, from May to August 2020. We worked in collaboration with the Association of Nursing Home Directors of the Italian-speaking part of Switzerland (ADiCASI) to collect data through qualitative semi-structured interviews.

Study Sample Recruitment

The participant pool included relatives of nursing home residents, healthcare professionals, and nursing home managers. The recruitment took place in close collaboration with one of the authors (VS), training coordinator of ADiCASI. There are 75 nursing homes in southern Switzerland, 72 of which are affiliated with ADiCASI and were approached for participation. We sent letters to all NH managers outlining the study’s purpose and ethical considerations. This letter also extended an invitation to participate to the staff and families of residents. The inclusion and exclusion criteria were defined to ensure representativeness. We specifically sought nursing home managers, doctors, and nurses with either less than 2 years of experience or more than 10 years of experience, as well as family members younger or older than 65 years (with older individuals being more affected by health restrictions). Prospective participants were invited to directly contact the first author (SB) to arrange an interview, independent of the nursing home manager.

Data Collection and Study Design

Individual semi-structured interviews were conducted in person or via phone between June and August 2020. The interview guide (Supplementary File S1), drafted by one of the authors (SB) and revised by the authors expert in qualitative research (MF and SR), prompted participants to reflect on their experiences during the nursing home closures between March and June 2020. The guide encompassed five sections: ice-breaker questions, attitudes about closure, experiences of closure, communication strategies adopted, and an open comment section. For this study, we concentrated primarily on data from the sections regarding the experiences during the closure and communication strategies adopted.

Data Analysis

Interviews were transcribed verbatim, and these transcripts were analyzed using an inductive-deductive thematic approach. After a first phase of familiarization with the daty, we reviewed them inductively to identify emergent themes until theoretical saturation was reached. The themes were meticulously identified and organized, leading to the development of a list of codes. These codes were then used deductively to analyze the remaining interviews. Codes were later categorized into broader macro-codes. During the analysis, two researchers (SB and MF) regularly compared notes to ensure the accuracy of the results.

Results

13 NHs joined the study, 8 NHs managers participated (1 woman and 7 men) together with 20 NHs residents’ family members and 16 NHs healthcare professionals (Table 1). Among them, 5 were doctors (women with more that 10 years of experience), 9 nurses (3 of them were man with more that 10 years of experience), and 2 were animators. Between the 20 NHs residents’ family members, 16 were woman, 4 of them were over 65 years old, and 3 of 4 man were below 65 (see Table 1).

Table 1. Actual sample of a study on communication in nursing homes during COVID-19, Bellinzona, Switzerland. 2020.

Of the 13 NHs, 8 were in an urban area and the 5 others in a rural one. The 13 NHs had a different experience of infection from COVID-19 in term of numbers of COVID-19 positives residents and deaths. The interviews duration was minimum 30 and a maximum 50 min.

To compare the internal perspectives of nursing home directors and nurses with the external perspectives of family members on communication measures, the results will be presented in a way that emphasizes both the similarities and differences between these two viewpoints.

Communication Strategies Adopted During the Pandemic

Both the internal perspective (from directors and nurses) and the external perspective (from family members) identified the same communication strategies between residents and their families. These strategies were implemented in two consecutive phases, aligned with public health policy recommendations and the evolving permissions for visitors to enter nursing homes.

Initial Phase

In the early phase of public closures of NHs in Canton Ticino (from early March to early June 2020), on-site visits were strictly restricted. As per participant responses, strategies such as video calls, phone calls, exceptional in-person visits, spontaneous long-distance visits, letter and gift exchanges, and window visits were deployed for resident-family communication, as outlined in Table 2.

Table 2. Direct quotes on strategies of communication between resident and family member, from a study on communication in nursing homes during COVID-19, Bellinzona, Switzerland. 2020.

Video calls emerged as one of the earliest newly-introduced communication means. Initially, caregivers utilized their personal mobile devices for this purpose, which was later replaced by facility-provided tablets (Table 2, Quotes S1 and S2).

Phone calls between residents and family members were another commonly used form of communication from the onset of the NHs' closure. This mode of communication, typically used by residents with personal mobile phones before the pandemic, was extended to all residents, facilitated often by caregivers (e.g., physiotherapist, animator) whose regular duties were disrupted due to preventive measures (Table 2, Quotes S3 and S4).

During the closure NHs allowed exceptional in-person visits for critically ill residents nearing end-of-life (Table 2, Quotes S5 and S6), and for those who were significantly struggling with isolation (Table 2, Quotes S7 and S8).

In an attempt to maintain contact, family members also arranged spontaneous long-distance visits, leveraging NH architectural features and outdoor areas such as balconies and gardens (Table 2, Quotes S9 and S10).

Further, caregivers and family members kept contact through the exchange of letters and gifts (Table 2, Quote S11). Family members mainly mentioned exchanges of letters and cards with residents, while caregivers also mentioned the exchange of gifts and food (Table 2, Quote S12).

NHs established designated meeting stations within the facilities where residents and family members were separated by a plexiglass wall, often with a phone present to facilitate conversation (Table 2, Quotes S13 and S14).

Alternatively, meetings could be held with glass windows separating residents inside the building from family members outside, with telephones supporting the conversation in these instances as well (Table 2, Quotes S15 and S16).

Subsequent Phase

After the initial phase, the government allowed the gradual resumption of in-person visits to nursing homes starting on June 8, 2020 [18]. In this updated scenario, meetings with residents outside the nursing homes were permitted, with mandatory social distancing in place. Alternatively, closer proximity was allowed under strict hygiene protocols, such as wearing masks and gowns. This adjustment even made physical contact permissible, provided that strict hygiene measures were followed (Table 2, Quotes S17 and S18).

Assessment of Communication Measures

Family members, directors, and nurses generally found the aforementioned communication strategies to be beneficial for maintaining dialogue between residents and their families, despite encountering some challenges (refer to Tables 3–5).

Table 3. Direct quotes on facilitators to communication between resident and family member, from a study on communication in nursing homes during COVID-19, Bellinzona, Switzerland. 2020

Table 4. Direct quotes on obstacles to communication between resident and family member, from a study on communication in nursing homes during COVID-19, Bellinzona, Switzerland. 2020.

Table 5. Assesment of facilitator and obstacles to communication by internal and external viewpoint, from a study on communication in nursing homes during COVID-19, Bellinzona, Switzerland. 2020.

Communication Enhancements (or Facilitators)

From an internal viewpoint, strategies such as video calls and indoor visits, facilitated by plexiglass or glass windows, enabled continuous contact between residents and their families despite the closure of NHs. Both managers and caregivers perceived that these communication methods were well-received by family members (Table 3, Quotes F1 and F2).

Family members greatly valued the outdoor visitation areas, which allowed them to personally meet with the residents, touch them, and engage in activities other than conversation. This was particularly important for family members of residents suffering from cognitive decline or hearing impairment (Table 3, Quote F3).

There was a consensus between the internal and external perspectives that the use of video calls provided reassurance to family members. They were able to see their loved ones, observe their physical and emotional wellbeing, and assess the quality of care being provided to the elderly individuals (Table 3, Quotes F4 and F5).

Participants also pointed out that telephone calls and video calls helped reassuring the residents that they were not forgotten by their family members, despite the lack of visits (Table 3, Quotes F6 and F7).

Family members greatly appreciated the opportunity for exceptional visits. These instances allowed them to accompany the resident through their end-of-life stages (Table 3, Quotes F8 and F9).

Obstacles to Communication

Both managers and family members expressed concerns about the technical and organizational challenges associated with implementing communication measures. Issues included the limited availability of devices within the facility, which reduced the frequency of meetings, and the initial absence of a Wi-Fi network, which took time to activate (Table 4, Quotes B1 and B2).

Both external and internal perspectives highlighted an issue with the limitations on the frequency and duration of video calls, indoor visits with plexiglass or glass windows, and outdoor in-person visits. Video calling wasn't feasible every day and was time-restricted, as were the indoor visits with plexiglass.

Some NHs only allowed outdoor visits on weekdays for 30–45 min with only 1 or 2 persons at a time. This proved challenging for family members who worked during the week and for those who visited residents frequently.

All participants identified time restrictions as a source of dissatisfaction for family members (Table 4, Quotes B3 and B4).

While video calls provided some reassurance to family members (as discussed below), maintaining a conversation with the resident through a device was often difficult, especially when the resident had cognitive decline or sensory impairment (Table 4, Quotes B5 and B6).

As noted by the external perspective, telephone communication also proved challenging for residents with hearing loss and cognitive impairment (Table 4, Quotes B7 and B8).

Indoor visits with plexiglass and phones, and outdoor visits with enhanced hygiene measures (distance, mask, gown), impeded nonverbal communication, especially for residents with cognitive decline (who found it challenging to recognize family members) or hearing loss (who found hearing and lip-reading difficult) (Table 4, Quotes B9 and B10).

Participants mentioned struggles in maintaining dialogue with residents, particularly those with cognitive decline, during indoor and outdoor visits, and expressed difficulties in communication due to the lack of touch and physical proximity or engagement in non-verbal activities (Table 4, Quotes B11 and B12).

For residents unaccustomed to the use of such technologies, handling tablets and phones for video calls proved challenging, resulting in less spontaneous interactions between them and their families (Table 4, Quotes B13 and B14).

Family members pointed out three issues that were not raised by caregivers and managers. Firstly, they mentioned issues of privacy stemming from the presence of an operator during video calls, giving the impression that their conversations with the residents weren’t private. The use of shared spaces for indoor visits with plexiglass also led to communication difficulties due to noise from other visitors and a lack of intimacy (Table 4, Quote B15).

Secondly, family members who were accustomed to exchanging food and gifts with residents found that these exchanges were prohibited due to mandatory quarantine for items entering the facility, making the exchange of fresh food and flowers challenging (Table 4, Quote B16).

Lastly, from the external perspective, it was noted that older adults found it difficult to meet their family members in unfamiliar settings, such as outdoor visitation areas or indoor areas with plexiglass. These environments added to their disorientation (Table 4, Quote B17).

Lessons Learned

The preceding section highlighted areas for improvement. Consequently, participants were asked to propose ways that NH could better address the challenges in maintaining communication between family members and residents. While some suggestions were specific to the lockdown and COVID-19 measures and not universally agreed upon, there was a consensus on the need for NH to enhance their resources, both in terms of technology and staffing. Participants suggested the inclusion of a dedicated person, such as a volunteer (civilian or military) or an activity coordinator, who could focus solely on facilitating communication, thereby reducing the burden on caregivers (Table 6, Quotes L1 and L2).

Table 6. Direct quotes on lessons learned, from a study on communication in nursing homes during COVID-19, Bellinzona, Switzerland. 2020.

The need for improved technology for remote communication was also underscored, such as the provision of additional tablets. This could enable more frequent interactions between family members and residents (Table 6, Quotes L3 and L4).

Discussion

This study aimed to examine the perceived effectiveness of communication strategies used to maintain interactions between families and nursing home (NH) residents during the first wave of the COVID-19 pandemic. We took into account the perspectives of families, healthcare professionals, and NH managers. Our findings indicated that the unique circumstances necessitated flexible implementation of both conventional and novel communication methods. There was an uptick in phone calls and exchanges of letters and gifts, while video calls, window visits, and outdoor meetings with enhanced hygiene measures were newly introduced. NHs ensured special visitations for residents nearing end-of-life, and families took the initiative to arrange unplanned, long-distance visits. All participants agreed that, despite some challenges, these measures helped maintain contact, provide reassurance to all parties, and facilitated end-of-life support.

Firstly, the use of telephone calls, video calls, and increased hygiene measures (such as physical distancing and facial masks) proved a communication barrier for those suffering from sensory and/or cognitive decline—a challenge well-documented in existing literature [22, 24]. Consequently, electronic devices like tablets were not independently usable by older adults. This required the presence of nursing home staff, which affected residents’ and families’ privacy and increased the caregivers’ workload.

Secondly, NH staff faced difficulties in ensuring regular meetings, with time and frequency limitations posing an issue. Lastly, technical and structural resources were problematic. The initial absence of Wi-Fi and electronic devices delayed video call implementation, while meeting spaces inside NHs failed to provide necessary privacy and were unsuitable for disoriented older adults.

Despite acknowledging the benefits and challenges of the measures undertaken, family members were more critical, highlighting further issues. Prior studies suggest an alignment between family members and NH staff on assessing residents' needs, but they also observed that nurses often perceive residents’ problems as less problematic than family members do [25].

Our findings highlight the crucial role that both NH staff and family members played in implementing various communication methods, as well as the adaptability of NH workers. While existing literature emphasizes the central role of NH managers and staff, the contributions of family members in suggesting new communication modalities are still largely unexplored. Often, NHs purchased tablets to facilitate video calls [26]. Care and activity teams collaborated to support communication between families and residents, with NH care staff assisting with device usage and activity teams aiding in writing letters [26, 27].

Additionally, NH managers and staff regulated exceptional visits [28] and regularly updated families on residents' wellbeing [29]. This added to NH staff’s workload [21, 28, 30], already burdened with infection control and emotional stress due to residents' loneliness, illness, and death [10, 31]. Our results suggest that re-evaluating technical, human, and structural resources in nursing homes is essential for effectively managing future crises, reinforcing findings from previous studies [6].

Communication is inherently linked to quality of life (QoL) not only for family members [3] but also for NH staff [31] and, most importantly, for the residents themselves [32]. Enhancing technical and human resources can maintain relationships outside NHs [6] and facilitate staff-resident interactions and physical activities [33]. Moreover, architectural considerations can enhance both internal and external communication, resident privacy, and social activities, all contributing to QoL [34]. The scarcity of human resources is a known ethical challenge in NHs [35], relating to principles of non-maleficence and distributive justice [36], and the concept of dignity [37]. Thus, our findings, albeit limited to the COVID-19 period, underscore an existing need for NHs to increase human, structural, and technical resources in order to ensure meaningful change in communication within nursing homes. We argue the need to place communication at the center of care practices to create an ethical care environment [36], ensuring that all parties are actively involved and held accountable [38, 39].

Limitations

Our research faces four primary constraints. The first is linked to the study design, which doesn’t encompass a longitudinal view or quantitative data. A more in-depth exploration of how communication measures developed during the pandemic, along with potential additional difficulties or solutions, could be insightful. Incorporating quantitative data could have offered a more comprehensive understanding of the effectiveness of communication strategies. Yet, this investigation aimed to initially inform regional public health policies about challenges faced during the initial implementation of communication measures (press conference in December 2020), prioritizing an examination of the prevailing circumstances.

Secondly, our study is geographically limited to the southern, Italian-speaking region of Switzerland, which may restrict the applicability of our findings to other cultural contexts. Nevertheless, research conducted in various countries corroborates a similar progression of events, communication measures enacted, and associated challenges. Given that the area we examined was severely affected by the pandemic, we argue that our findings could be relevant in other contexts.

A third limitation may be the reliance on nursing home managers for participant recruitment. However, participants were encouraged to contact one of the authors (SB) directly, which helped ensure their anonymity.

The last limitation is the omission of resident’s viewpoints on the implemented communication measures. As of now, however, no study has compared internal and external perspectives on residents’ relational wellbeing and communication during the COVID-19 pandemic.

Conclusion

This study illuminates the critical role that communication plays in the care of nursing home residents, particularly under the stressors imposed by the COVID-19 pandemic. Our findings underscore the benefits of various communication measures in maintaining connections between residents and their families while also outlining the difficulties experienced in their implementation. Significantly, these findings highlight the necessity for nursing homes to augment both human and technological resources to facilitate smoother communication. Despite the limitations inherent in its geographic focus and study design, the study provides valuable insights that extend beyond the specific context of the COVID-19 pandemic. Ultimately, it underscores the fundamental need for nurturing human connections in care environments and the critical role of adaptability in overcoming unprecedented challenges. It is a call to action for ongoing investment and innovation in the domain of nursing home communication, ensuring a high quality of life for residents, their families, and the staff who care for them.

Ethics Statement

The studies involving humans were approved by scientific Ethics Committee of Canton Ticino, Switzerland (Comitato etico Cantonale, Repubblica e Canton Ticino). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author Contributions

Study conceptualization: SB, GM, and RM; participant recruitment: VS, methodology, MF and SR; collected data SB; analyzed data SB and MF; writing–original draft, SB; writing–review and editing SB, MF, and SR. All authors contributed to the article and approved the submitted version.

Funding

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Conflict of Interest

The authors declare that they do not have any conflicts of interest.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.ssph-journal.org/articles/10.3389/ijph.2024.1606583/full#supplementary-material

References