Safe Visiting is Essential for Nursing Home Residents During the COVID-19 Pandemic: An International Perspective

Blanket and total bans of nursing home visitors were widespread at the beginning of the COVID-19 pandemic when governments and homes were unprepared to prevent and manage outbreaks. However, these visitor restrictions have been prolonged and often reinstated after having been lifted, despite increased home and health system COVID-19 readiness and mounting evidence of harms to residents. Further, in most nursing homes, visitor bans were introduced without discussion or consent from residents or their advocates, constituting a violation of the resident’s rights to have visitors.¹

Our recently published literature review identified evidence that total visitor bans and visitor restrictions have had negative impacts on residents, family and friends, and emerging evidence of negative impacts on staff.² Specifically, research reported increases in loneliness, mood disorders, behavioral symptoms related to dementia, and resulting increased antidepressant and antipsychotic prescription, as well as loss of function, for residents. Additionally, families described increased negative emotions such as guilt, fear, stress, and worry about their loved one. Staff experienced additional workload and burnout, though it is not possible to attribute these solely to visitor restrictions and lack of family supporting daily care and emotional needs of residents.

A Dutch study³ and editorial from Hong Kong⁴ suggest that if safe visiting procedures are followed when there is low community transmission, visitors do not bring COVID-19 into nursing homes. There are no data on whether visitors increase the risk of nursing home outbreaks when there are higher levels of community transmission. The Centers for Medicare & Medicaid Services (CMS) September 2020 memo specifies that to reopen to visitors, the county’s test positivity rate should be <10% (ie, less than 10% of all SARS-CoV2 tests conducted are positive).⁵ However, our scan of international practices of when homes were permitted to reopen to visitors found wide variability and no consensus on the level of community transmission that is safe for reopening.² Furthermore, community transmission data may not be accurate if testing is restricted (eg, only to symptomatic people or if there is a fee for testing) or not widespread.

We recommend that blanket visitor bans not be reinstated by governments or individual nursing homes. A policy against blanket visitor bans has been introduced in the Netherlands and the World Health Organization’s updated infection prevention and control guidance asks homes to provide criteria and considerations for safe visiting.⁶ In the United Kingdom, the Joint Committee on Human Rights has indicated that new laws are required to ensure meaningful visits are reinstated for all residents.

We recommend that every resident have at least 1 designated caregiver essential to that resident’s daily care and/or well-being. Essential caregivers should be permitted to visit even if general social visits are restricted because of high levels of community transmission or COVID-19 nursing home outbreaks. Examples of jurisdictions that allow essential caregiver visits even during outbreaks are Ontario in Canada, Minnesota and Illinois in the USA, and the Netherlands. The frequency, length, and other visiting conditions should be planned based on resident needs and in collaboration with essential caregivers and staff. Essential caregivers should follow safe visiting practices including screening, use of PPE, testing, and other infection prevention measures.

An emerging issue relating to safe visits is vaccinations. Almost all jurisdictions delivering vaccinations to date have prioritized residents and staff. There is emerging evidence from the USA that nursing home vaccinations may reduce transmission.⁷ Germany and 5 Canadian provinces are also giving high vaccination priority to essential caregivers. It is plausible that once vaccination becomes more widely available, some jurisdictions will make it mandatory for nursing home visitors to have had a vaccination.

We recognize that governments and nursing homes face the difficult balance of protecting residents and staff from COVID-19 while supporting resident, family, and staff well-being and work within ever-changing guidance and regulations. We stress the need to involve residents, their advocates, families, and staff in discussions around safe visiting. If someone lives in the community, they choose the degree of risk that they are prepared to live with. As the nursing home is the residents’ home, they have the right to have a say around visitors and to continue their relationships with people outside the home.

Our international consensus is that we need to urgently reopen nursing homes to visitors safely and effectively with appropriate consideration of community transmission, nursing home outbreak status, and the preferences of residents, families, and staff. With innovation, we can begin to tackle the other pandemic of social isolation and loneliness that has accompanied COVID-19 and been devastating for nursing home residents.