Family visits among nursing home residents during the COVID-19 pandemic: a cross-sectional study

Abstract

Background

Loneliness is common among nursing home residents, with decreased social connectedness being linked to an increased risk of mortality. During the COVID-19 pandemic, new modalities for family visits, such as videoconferencing, became available in addition to in-person visits, potentially helping to reduce loneliness. This study aimed to characterize family visits among nursing home residents during the COVID-19 pandemic and investigate their associated factors.

Methods

Data on the visits, including their modalities, were retrospectively collected from facility records for residents of 4 nursing homes over a 3-month period from 2020 to 2022. The types of visits included in-person visits through acrylic boards or windows and video calls. We evaluated the association between resident characteristics and whether they received any visits, regardless of the modality of visit, using a multivariable logistic regression model.

Results

The study included 564 participants (mean age, 84.9 years; female, 70.0%); among them, 33.2% were visited, 72.2% of which had video calls. Participants who used video calls (1.1 ± 0.9 times per month) had significantly higher frequencies of visits than those with in-person visits only (0.6 ± 0.5 times) (p < 0.001). Most visitors used video calls, although older visitors were less likely to use video calls than younger visitors (60.0% vs. 80.7%, p = 0.021). Compared to residents who stayed for less than 1 year, those staying 1–1.9 years were more likely to receive family visits (adjusted odds ratios [aOR] = 2.18, 95% confidence intervals [CI] = 1.38–3.44, p = 0.001), while those staying 2 years or longer were less likely to receive such visits (aOR = 0.53, 95% CI = 0.31–0.91, p = 0.021). None of the other variables, including dementia diagnosis, age, sex, and Barthel Index score, were shown to be associated with family visits.

Conclusion

This study suggests that video calls were widely used for family visits among residents and visitors of nursing homes during the COVID-19 pandemic. For residents with no or infrequent family visits, such as those with shorter or longer lengths of stay, it may be necessary to encourage family engagement and actively incorporate alternative approaches to promote social engagement.

Introduction

Loneliness is an important social issue [1, 2], and its association with mortality has been widely reported [3, 4], with good social connections leading to better health and well-being [5]. Loneliness is prevalent among nursing home residents [6], and greater social connectedness, encompassing social engagement and support, is associated with a lower mortality risk [7, 8]. Interventions aimed at improving social connectedness among older adults in long-term care facilities have proven effective, with family visits serving as a major strategy [9]. Family visits have also been reported to reduce loneliness and depression among nursing home residents [10]. In addition, family involvement has been associated with an improved quality of life among residents [11].

However, the COVID-19 pandemic led to restrictions on visits worldwide, and 99.3% of Japanese nursing homes implemented some restrictions on visits and outings [12]. Consequently, the negative effects of loneliness and social isolation have become more pronounced owing to those restrictions [10]. Access to social technology, therefore, had been proposed to reduce social isolation during the COVID-19 pandemic [13].

Research has shown that applications related to information and communication technology were used to ensure connectedness in addressing social isolation and loneliness in long-term care facilities during the COVID-19 pandemic; for example, online visitation, including video calls, was used as an alternative to in-person visits when visitation restrictions were relaxed [14]. The nursing home residents who received video calls from family members experienced reduced depressive symptoms and loneliness [15]. If the actual status of visiting modalities, such as video calls—which differ from traditional in-person visits—can be systematically described, such modalities could be promoted during pandemics or in situations where family members live far away and find it difficult to visit. This may help increase visit opportunities for residents who typically receive few visits and contribute to reducing loneliness. Therefore, it is important to investigate visit modalities such as video calls.

However, to date, no studies have investigated the actual situation of family visits, including video calls, among nursing home residents in Japan during the COVID-19 pandemic. Furthermore, there is a lack of knowledge on the characteristics of nursing home residents, who are at greater risk of loneliness owing to infrequent visits. Therefore, this study aimed to examine the frequency and modality of family visits among nursing home residents during the COVID-19 pandemic and investigate their associated factors.

Methods

Study design, setting, and participants

This cross-sectional study included residents aged 65 years or older from 4 nursing homes who were present at the start of the study (May or June 2020, depending on the facility), as well as those admitted between the study’s onset and September 2022. Participants were excluded from the study if they fell into any of the following categories: being younger than 65 years, having level 1 or 2 care needs (generally those with level 3 care needs or greater were eligible for admission to nursing homes), being hospitalized for more than 30 days during the 3-month assessment period, and being discharged from nursing homes before the end of the assessment period. Of the 666 initial participants, 564 (84.7%) were included.

Measurement

From the electronic records, we collected baseline data on age, sex, care needs level, Barthel Index of Activities of Daily Living (BI) score, diagnoses, length of stay, and dates of admission and discharge. The assessment period for visits between May 1, 2020, and September 30, 2022, was 3 months from the study’s start date or the participant’s admission date. We chose a relatively short assessment period to avoid marked changes in the residents’ health conditions and exclusion from the study owing to hospitalization or discharge. The number and modality of visits, as well as the relationship between visitors and residents, were collected from paper visitation books in each facility. The modality of visits was categorized as in-person visits and video calls (using the smartphone application Google Meet). Residents who received both in-person visits and video calls during the study period were categorized in the video calls group, while those who received only in-person visits were categorized accordingly. Visitors were categorized based on their assumed age: older (spouse and siblings) or younger (children, grandchildren, spouses of children, etc.).

Statistical analysis

The participants’ characteristics were analyzed using descriptive statistics. The chi-square test or Fisher’s exact test were adopted to compare the proportions of categorical variables, while the Mann-Whitney U test was used to compare continuous variables. Logistic regression analysis was performed to evaluate the association between residents’ characteristics and family visits, regardless of the visit modality. The independent variables were age (65–79, 80–89, and ≥ 90 years), sex, BI (0–20, 25–60, and 65–100), a diagnosis of dementia, and length of stay (< 1, 1–1.9, and ≥ 2 years). Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were calculated. Statistical significance was defined as p < 0.05. Statistical analyses were performed using Stata/MP 16.1 Windows.

Results

Characteristics of participants

Of the 666 initial participants, 11 were younger than 65 years, 21 had lower care needs levels (1 or 2), 49 were hospitalized for more than 30 days during the assessment period, 18 were discharged from nursing homes within the assessment period, and 3 had missing data for the BI score or other variables. A total of 564 (84.7%) participants were included in the analysis.

Participants’ characteristics are presented in Table 1. The mean age was 84.9 years, 70.0% were female, 62.9% were diagnosed with dementia, and the mean BI score was 41.9. In total, 187 (33.2%) of participants received visits, and there were no differences in the characteristics between residents who received visits and those who did not, except for the BI score and length of stay.

Table 1.

Demographic characteristics of residents (n = 564)

	Total (n = 564)	Visits (n = 187)	No visits (n = 377)
	n (%) or Mean ± SD	n (%) or Mean ± SD	n (%) or Mean ± SD	P value
Age	84.9 ± 6.9	85.1 ± 6.6	84.8 ± 7.0
65–79	112 (19.9)	32 (17.1)	80 (21.2)	0.47
80–89	306 (54.3)	107 (57.2)	199 (52.8)
≥ 90	146 (25.9)	48 (25.7)	98 (26.0)
Sex
Male	169 (30.0)	54 (28.9)	115 (30.5)	0.69
Female	395 (70.0)	133 (71.1)	262 (69.5)
Care needs level
Care needs level 3	175 (31.0)	57 (30.5)	118 (31.3)	0.65
Care needs level 4	225 (39.9)	71 (38.0)	154 (40.9)
Care needs level 5	164 (29.1)	59 (31.6)	105 (27.9)
Barthel Index	41.9 ± 27.4	42.1 ± 26.0	41.8 ± 28.1
0–20: Total dependence	169 (30.0)	50 (26.7)	119 (31.6)	0.037
25–60: Severe dependence	250 (44.3)	97 (51.9)	153 (40.6)
65–100: Moderate dependence	145 (25.7)	40 (21.4)	105 (27.9)
Diagnoses of selected diseases
Progressive neurological disease	192 (34.0)	63 (33.7)	129 (34.2)	0.90
Depression	26 (4.6)	8 (4.3)	18 (4.8)	0.79
Dementia	355 (62.9)	116 (62.0)	239 (63.4)	0.75
Cancer	82 (14.5)	27 (14.4)	55 (14.6)	0.96
Charlson Comorbidity Index
0: No comorbidities	115 (20.4)	35 (18.7)	80 (21.2)	0.91
1–2: Mild comorbidities	350 (62.1)	119 (63.6)	231 (61.3)
3–4: Moderate comorbidities	85 (15.1)	28 (15.0)	57 (15.1)
≥ 5: Severe comorbidities	14 (2.5)	5 (2.7)	9 (2.4)
Length of stay (years)
< 1	355 (62.9)	115 (61.5)	240 (63.7)	< 0.001
1–1.9	101 (17.9)	50 (26.7)	51 (13.5)
≥ 2	108 (19.2)	22 (11.8)	86 (22.8)
Hospitalization during exposure period	62 (11.0)	20 (10.7)	42 (11.1)	0.87

Description of family visits

Among those who received visits, 135 (72.2%) had video calls (including 24 residents who had both video calls and in-person visits), and 52 (27.8%) had in-person visits only. Participants who used video calls (1.1 ± 0.9 times per month) had significantly higher frequencies of visits than those with in-person visits only (0.6 ± 0.5 times) (p < 0.001).

The most frequent visitors were children (67.0%), followed by participants’ spouses (14.5%) (Table 2). Most visitors used video calls, although the older ones were less likely to do so than the younger ones (60.0% vs. 80.7%, p = 0.021).

Table 2.

Types of visitors by type of visits

	Visits (n = 187)	Video calls (n = 135)	In-person visits only (n = 52)
	n	n (%)	n (%)
Visitors	221	160 (72.4)	61 (27.6)
Older visitors	40	24 (60.0)	16 (40.0)
Spouses	32	20 (62.5)	12 (37.5)
Siblings	8	4 (50.0)	4 (50.0)
Younger visitors	181	146 (80.7)	35 (19.3)
Children	148	110 (74.3)	38 (25.7)
Grandchildren	11	10 (90.9)	1 (9.1)
Spouses of the children	11	7 (63.6)	4 (36.4)
Others	11	9 (81.8)	2 (18.2)

Factors associated with family visits

Compared to residents who stayed for less than 1 year, those staying 1–1.9 years were more likely to receive family visits (aOR = 2.18, 95% CI = 1.38–3.44, p = 0.001), while those staying 2 years or longer were significantly less likely to receive such visits (aOR = 0.53, 95% CI = 0.31–0.91, p = 0.021). None of the other variables analyzed were associated with family visits (Table 3).

Table 3.

Factors associated with family visits

Variables	aOR (95% CI)	P value
Age
65–79	Reference
80–89	1.45 (0.89–2.37)	0.14
≥ 90	1.36 (0.78–2.38)	0.28
Sex
Male	Reference
Female	1.22 (0.81–1.84)	0.35
Barthel Index
0–20: Total dependence	Reference
25–60: Severe dependence	1.38 (0.89–2.14)	0.16
65–100: Moderate dependence	0.75 (0.45–1.25)	0.27
Dementia	0.84 (0.57–1.24)	0.38
Length of stay (years)
< 1	Reference
1–1.9	2.18 (1.38–3.44)	0.001
≥ 2	0.53 (0.31–0.91)	0.021

aOR Adjusted odds ratio, CI Confidence intervals

When comparing resident characteristics across length of stay categories, no statistically significant differences were observed in age, sex, BI score, or diagnosed with dementia (Table 4). However, residents with longer stays tended to have lower BI scores.

Table 4.

Resident characteristics by length of stay (years) (n = 187)

	< 1 (n = 115)	1–1.9 (n = 50)	≥ 2 (n = 22)
	n (%) or Mean ± SD	n (%) or Mean ± SD	n (%) or Mean ± SD	P value
Age	85.2 ± 6.4	84.7 ± 7.5	85.0 ± 5.8
65–79	16 (13.9)	13 (26.0)	3 (13.6)	0.32
80–89	70 (60.9)	23 (46.0)	14 (63.6)
≥ 90	29 (25.2)	14 (28.0)	5 (22.7)
Sex
Male	31 (27.0)	16 (32.0)	7 (31.8)	0.75
Female	84 (73.0)	34 (68.0)	15 (68.2)
Barthel Index	45.2 ± 24.1	40.8 ± 26.5	28.9 ± 30.9
0–20: Total dependence	25 (21.7)	14 (28.0)	11 (50.0)	0.14
25–60: Severe dependence	63 (54.8)	26 (52.0)	8 (36.4)
65–100: Moderate dependence	27 (23.5)	10 (20.0)	3 (13.6)
Dementia	74 (64.4)	29 (58.0)	13 (59.1)	0.68

Discussion

This study examined the modality of family visits to 4 nursing homes in Japan during the COVID-19 pandemic, when visitation was restricted and family connections were weakened. We showed that the majority of residents and visitors used video calls, irrespective of the visitors’ age, suggesting that video calls provided a useful alternative to in-person visits for communication between residents and visitors. Residents in long-term care facilities and nursing homes are more satisfied with the use of video calls to communicate with their relatives compared to telephone calls [16]. In addition, residents who interact with their families through videoconferencing programs have been reported to experience reduced loneliness [15, 17].

Our findings reported a relationship between the length of stay and the frequency of family visits. One explanation for the less frequent visits to residents who stayed for less than one year could be that family members were hesitant to visit initially after admission to help the resident adjust to the facility. As residents become accustomed to the facility’s environment, their families increase the frequency of visits. However, after two years, the frequency of visits tended to decline significantly. This trend may be influenced by several factors: (1) family members could experience emotional fatigue or “visitor burnout” over time; (2) changes in family dynamics might shift caregiving responsibilities; (3) increased trust in the facility’s care may lead to fewer perceived needs for frequent visits; and (4) as residents’ BI scores decrease, visits may become less meaningful to family members or more challenging. This pattern aligns with findings from previous studies, which have reported different visitation trends. Some studies suggest that visiting habits established within the first year tend to persist, while others indicate a gradual decline in visit frequency over time, even among families who continue to maintain contact throughout the resident’s stay [18, 19]. In addition, we did not identify other factors associated with family visits, but research has reported that older and female residents were more likely to be visited frequently [20].

As our study was conducted in a limited number of nursing homes belonging to the same healthcare provider during the COVID-19 pandemic, further studies are needed to examine the factors associated with visits to identify resident groups vulnerable to loneliness and social isolation. In our study, only 33.2% of residents received any family visits, including in-person visits or video calls. This finding suggests that a substantial proportion of residents may have been at increased risk of loneliness. Therefore, for residents with no or infrequent family visits, such as those with shorter or longer lengths of stay, it may be necessary to encourage family engagement and actively incorporate alternative approaches, such as promoting relationships among fellow residents and staff, to promote social engagement [9].

Our study found that video calls were widely used by visitors. Even after the COVID-19 pandemic has ended, maintaining a variety of visitation methods will enable families to stay connected with the residents of long-term care facilities. Furthermore, we expect that using video calls is promising for families who live farther away from nursing homes and those with difficulty visiting, for example, because of the health status of the visitors. Some studies have highlighted the lack of technological literacy among older adults and their families [21]. In some facilities in this study, staff supported family members (such as spouses) who were unfamiliar with video calls by inviting them to the facility and allowing them to use the facility’s smartphone to make video calls with residents. It is important to encourage and support residents’ families in using various visiting methods, such as video calls, to ensure that differences in technological literacy do not lead to differences in the frequency of communication.

Limitations

This study has some limitations. First, we lacked information on the characteristics of family members (e.g. marital status, number of children, or level of education), and had only limited information on visitors (e.g., age), owing to the retrospective nature of this study. Further, residents without family members should have been excluded from analysis. Second, the short assessment period for visits may have prevented us from capturing visits more accurately. Third, we cannot exclude the possibility that some visitors may not have been recorded in the paper visitation books. Fourth, although there were no differences in COVID-19 restriction policies among the facilities, as all of them were located in Tokyo, visitor restrictions may have varied depending on the infection status within each facility. Finally, this study was based on 4 facilities belonging to the same Japanese healthcare provider; therefore, generalizability to other facilities in Japan and other countries may be limited. The frequency of visits in our study was much lower than that of other facility types and facilities in other countries [10, 22].

Conclusion

During the COVID-19 pandemic, video calls have become more frequently used as a communication tool between residents and visitors of nursing homes, minimizing the risk of the spread of infectious diseases. For residents with no or infrequent family visits, such as those with shorter or longer lengths of stay, we may need to encourage family engagement and actively incorporate alternative approaches to promote social engagement.

Abbreviations

aOR

Adjusted odds ratios

CI

Confidence intervals

BI

Barthel Index

Authors’ contributions

SK contributed to study conceptualization. All the authors contributed to the study design. Material preparation, data collection, and analysis were performed by SK. The first draft of the manuscript was written by SK, and all other authors intellectually contributed to improving the manuscript. All authors have read and approved the final version of the manuscript.

Funding

This study did not receive any specific grants from funding agencies in the public, commercial, or non-profit sectors.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Heisei Medical & Welfare Group Research Institute Ethics Committee, affiliated with the Heisei Medical & Welfare Group (Approval No. 20230402). This study was conducted in accordance with the Declaration of Helsinki. The requirement for informed consent was waived by the ethics committee owing to the retrospective nature of the study and the use of anonymized data.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.