It’s been a hard year for all of us in Covid Time. But it’s been an especially hard year for people living in nursing homes. Not only was COVID-19 particularly deadly for nursing home residents, but also the virus provoked the imposition of severe social restrictions to protect residents’ physical health—all too often, at the expense of their emotional and mental well-being.
In fact, everything that makes a nursing home feel more like home has been limited or even off-limits for many months. According to a pre-pandemic, 2018 survey in JAMDA of 255 elders living in 28 Philadelphia nursing homes, here are the top five comforts that residents valued most:
- Regular contact with family
- Choosing what to eat
- Tie: Listening to favorite music; staying in contact with friends
- Watching TV
- Privacy
Who knew that listening to favorite music would beat TV and privacy, and tie with keeping contact with friends? However, both the top and tied-for-third priorities were severely affected by Covid restrictions. What has the pandemic taught us about these essential elements? And how can we apply those lessons to improve quality of life in nursing homes going forward, post-pandemic?
Regular Contact with Family
The biggest loss this past year was the very thing of greatest value for nursing home residents— regular contact with family. With in-person visits suspended, phone and video calls (if available) filled the gap. But the experience was far from equivalent. Residents’ mental health suffered. Those with Alzheimer’s declined more quickly. Room isolation limited motor activity and accelerated physical decline. Anxiety and depression intensified for residents, families, and staff.
One answer, using digital tablets for remote video visits, seemed like a good idea. But staff were overwhelmed. I had to wait many weeks to set up a video call with my 93-year-old mother, let alone a regular call. To top it off, many people with dementia did not recognize family members through windows or on screens.
Video visits are still a good idea, particularly when in-person visits must be limited for whatever reason. But we need better planning for video calls as part of everyday routine in nursing homes, so that high demand during a public health emergency doesn’t constrain meaningful contact. Dropping off a tablet for a loved one doesn’t help if staff don’t have the bandwidth to schedule a video call, set it up, and make sure things go well. The pandemic has highlighted the need for every room to be equipped with a video-call device. Smart speakers now come with video options. Make them standard issue, and train staff, aides, family, and, when able, residents how to use them.
Choosing What to Eat
While residents were still able to select their food preferences, mealtime was not the same. In nursing homes and assisted living, residents had to eat alone in their rooms. With the return to congregant dining, now that most residents have been vaccinated, people are still separated by plexiglass and unable to socialize easily at mealtime. Once the plexiglass comes down, this important communal activity should help to improve social interactions and reduce loneliness. Should there ever be a need to reimpose such restrictions for meals, however, perhaps a good system with tablets could provide a way for individuals to still socialize, virtually, over dinner.
Listening to Favorite Music
Before the pandemic, communal music was everyone’s favorite form of recreation. Popular activities included group singing, karaoke, music making, and guest musicians. But when the pandemic hit, all that shared music was silenced, with no backup plan.
Less affected by the music “blackout” were the three percent of residents who had their own digital music players, pre-set with their favorite music. How often did the rest of us listen to the music we love during the pandemic? I know I did, every day. Pandemic be damned, we had full control over what music we enjoyed and when, a huge stress reliever.
Congratulations to the care home staff and families who set up their loved ones pre-Covid (or even during Covid) so that they could be more engaged, in a better mood, experience less anxiety, and feel more alert and connected with themselves and others. Lesson learned: access to personal music is essential for all of us, especially during times of high stress, and especially in a nursing home or assisted living at any time.
Staying in Contact with Friends
Connections with friends suffered a pandemic body blow, as well. Because nursing homes were only able to handle relatively few video calls, and placed a priority on family members, many friends lost out. Often, they did not know whom to contact to set one up. And even if they did, staff were overwhelmed with just the primary family members. Again, the pandemic lesson is to establish a system that includes appropriate video-call devices in every room and staff support, to make video visits a part of everyday nursing home routine.
Watching TV
Pre-pandemic, TV seemed like an afterthought. Every room has one, but staff pay little attention to its use, as residents are pretty much “on their own.” But as COVID-19 pervaded facilities and residents were restricted to their rooms, the TV became a lifeline, both to inform and entertain. My mother constantly watched the news, which, frankly, kept her engaged.
Not so, however, for those with some cognitive decline or depression, who might be disinclined or unable to discover TV programs they would really enjoy. Were staff or family helping them? Hard to do remotely. Did they know which programs their loved ones enjoyed and make an effort to remind them or set them up with programs to their liking?
During the pandemic, when family couldn’t visit, there was another roadblock: with more than half of resident populations living with hearing impairments, who was responsible or cared enough to see if they could hear the TV well enough in the first place? Just before the pandemic, I discovered that my mother could only recognize one in three words spoken on TV. I purchased her a wireless headphone that enabled her to hear clearly. That eureka moment reinforced for me to the need for thinking holistically about all the ways that nursing home residents interact with technology—and how to make that a priority for staff.
Privacy
Privacy (embodied by HIPAA guidelines in the U.S.) gets serious attention. And for good reason. We all crave space and time to call our own, and a right to protect the personal details of our lives. But given the priorities of nursing home residents in the Philadelphia survey, shouldn’t we be paying at least as much, if not more attention, to what is most important to the residents themselves? When a desire for privacy comes in fifth, what does that say about how well we are aligning our policies and priorities in long term care with the preferences of those we care for and serve?
Everyone has a right to music, just as they have a right to see their families, choose their food, and visit with friends. They have a right to access the same valued comforts of their former living situations when they move into a nursing home or assisted living. If long-term care is to be truly person-centered or person-directed, we need to re-examine just what that means and ensure that residents’ priorities are honored by the systems, policies, requirements, and funding we have in place. If we can do that, then at some point we may all look forward to the day we are being cared for by others with our best interests and preferences in mind.
Image: Georg Arthur Pflueger