When visitors can hug again

LACONIA — COVID’s lockdowns and health precautions sparked a revolution in social life – especially for nursing home residents.

Teleconferencing by laptop and tablet replaced in-person family visits, which have always been critical to emotional health. After COVID closed nursing homes to the outside world, the closest approximation to getting up close-and-personal with spouses, children and grandchildren was waving and smiling through window glass while chatting by cellphone.

“I felt kind of isolated, but at least we could see them,” said Pauline Bolduc, 93, of Laconia, who has lived at St. Francis Rehabilitation and Nursing Center in Laconia for two and a half years. “I missed being able to hug and touch them.” 

Anita Landry, 78, a Laconia resident, sat in a chair in her room at Belknap County Nursing home and exchanged symbolic embraces through the window with her sister Lisa, age 62, on routine visits for almost a year, until the CDC’s guidelines recently lifted prohibitions against physical touch. 

“We’d go through the motions of hugging each other. It’s one thing to see someone through a window like a jailbird,” Landry said. “When my sister finally came, she gave me a big hug, and was crying and crying. She was happy. I was happy – just to see her and touch her again.”

The drought of physical contact and lack of in-person interaction was a pandemic of emotional deprivation, similar to a kind of lasting grief.

“It’s one of those experiences that you can’t put a price on. Just the need for human contact, just a hug or a handshake. There is no way to estimate how important that is,” said Paul DeHart, chaplain at the New Hampshire Veterans Home in Tilton, who ministered to veterans alone in their rooms during the coronavirus shutdowns. “It’s really easy for us to identify physical needs, but we have an emotional and spiritual life. Those things are unseen and often aren’t as easy to address, and they’re just as important. It’s a holistic approach to a person,” DeHart said.

That inner person suffered the slings and arrows of misfortune during COVID, on physical, social and emotional fronts.

Now, as information on vaccine safety and availability shifts, cases spike in younger people, and concerns about variants spread in medical circles and online, it’s still unclear what the new normal will look like at nursing homes.  But one thing is certain: social and emotional bulwarks will be defended.

“It’s really hard to predict what life will look like,” said Brenda Buttrick, administrator at St. Francis. With the unprecedented and evolving nature of the coronavirus, and the highest death rates among people in their 80s and older, and among seniors with serious, chronic health conditions, “life in nursing homes has changed for the foreseeable future,” she said.

“We’re trying to do as much as we safely can to bring back a sense of normalcy,” said Shelley Richardson, administrator at the Belknap County Nursing Home in Laconia. That normalcy includes social and emotional connections.

Getting closer

Directives and new information are still shifting nursing home protocols. But staff and residents are relieved that their facilities are inching closer to what normal once looked like, despite the shields, masks, hand sanitizer, and temperature checks and screening at the front door.

In accordance with CDC guidelines, in-person visits from family members (one or two at a time) are encouraged, and must be scheduled in advance. Hugs and hand holds are welcome, with precautions and limits on length.

Spontaneous, surprise visits are no longer possible, and places to sit, talk and walk inside are limited to protect patient safety and curtail contagion. Flowers can be delivered, and are brought to rooms after the vases are wiped down and the bouquets sit for a couple of minutes. Meetings occur in private patient rooms or supervised common areas where people can remain socially distanced. Families call ahead to book appointments, are pre-screened for COVID symptoms by phone, then again when they arrive. At St. Francis, visitors have the option to get rapid COVID tests and wait 15 minutes for the results.

A gathering in a semi-private room requires the permission of the other resident and their guardian or family members – an awkward situation that might become hurtful if a roommate says no. Nursing homes are coming up with less compromising or contagious alternatives, and residents and staff are anxious to move things outside. Still missing are big community events, including ones that allow family members to attend.  Outings such as going home to celebrate a holiday or have a family meal, which have been treasured day trips in the past, require residents to quarantine upon their return – a period of isolation from nursing home friends and peers that no resident wants to risk. “Maybe (home visits) will come as more people get vaccines and we see how that will work,” Buttrick said.

“Are we always going to be concerned about testing and vaccines? Yes, but hopefully not to the point that it impacts being able to come for a visit, or a simple touch,” said Mary Wakefield, director of nursing at St. Francis. Many residents feel bereft when they are separated from close family members, and lose the ability to express and receive affection toward them. “A basic, simple human hug is a huge, huge thing,” said Wakefield. “If you take a away a basic human need, what are you leaving them with?”

At Belknap County Nursing Home, “Some of the residents said, ‘We’ve lived through so much. We lived through polio and measles.’ They would be OK with just being able to hug a grandchild,” Richardson said.

After a year-long pandemic, and the shuttered society that resulted at nursing homes, one goal will be guarded closely: preserving human interaction and emotional connections in the most meaningful and intimate ways allowed. For many residents and family members, that boils down to meeting face to face, hand holding, hugging, sitting close and occasionally touching, which now happens by mutual agreement, and requires sanitizing hands before and after.

After a year-long hiatus, contact with guidelines is much better than no contact at all. “They say they feel grateful to see their families in person and not through the glass," Buttrick said. "The physical face-to-face interaction is always the very best. I don’t think anything could ever truly substitute for that.”

“We’re bringing back physical touch. We all need the warmth that comes from that," said Lisa Henderson, executive director of LeadingAge Maine-New Hampshire, an association of nonprofit nursing homes, including those operated by Catholic Charities. "It’s an essential human need. It’s just so reassuring to see someone face to face.”

Dave Killian, assistant director of nursing at the NH Veteran’s Home, is hoping for a return to unrestricted resident visits. “It’s so important for them to have this connection, and physical touch is a very important.” It would help if masks, now a safety precaution, weren’t routinely required, he said. “While it’s true that you can see a smile in someone’s eyes, it’s a paltry substitute for a full-faced smile. Residents with cognitive difficulties do better with facial expressions to cue them.”

Window visits and Skype, Zoom, Face Time and Google Duo haven’t always been effective or rewarding, especially for elders with cognitive deficits or those close to the end of life. Those without issues say looking through glass and speaking by phone or walkie-talkie is the next best thing to meeting in person, with less of the feeling of physical distance that’s hard to ignore while using technology.

But window visits don’t always feel the same on both sides of the window. “If I have dementia and occasional delusions and anxiety and my loved one jumps out from behind a bush, I’m not sure that’s reassuring, or not more confusing,” said Henderson at LeadingAge.

Residents and family members press their hands together through the glass. “It’s heartwarming at the same time it’s melancholy,” said DeHart at the Veteran’s Home. “It’s not ideal, but it’s something.” When that happens in the dementia unit, residents can find that symbolic gesture hard to fathom, and they may not comprehend or remember why a loved one is standing outside.

'No substitute for human touch'

Greater freedom of movement inside nursing homes is also important, said Brendan Williams, director of the NH Health Care Association, which represents 74 of the state’s for-profit nursing homes, including 11 that are county-run. “We want to give people the freedom to move about the facility, because those facilities are their homes. And we want to have family members come back in an unfettered way. Part of the care environment is being able to observe how residents interact with their families, which provides clues to cognitive and emotional wellbeing, Williams said.

Although virtual meetings will certainly continue – much more often and in more circumstances than before COVID introduced the whole world to Zoom – “There’s no substitute for human touch and intimate interaction,” Williams said. Meeting outside can be challenging, too, for people with any cognitive decline who don’t understand social distancing, the need to keep a mask on, or the reasons why they can’t automatically hug someone they love.

Williams is a champion of health precautions, but not of the fallout COVID caused.

 “We’re seeing failure to thrive as a consequence of the lack of social interaction, worsening cognitive decline and greater depression,” Williams said. “People stop eating.” Sometimes it’s been necessary to prepare family members who are resuming in-person visits after a year away, that their loved one’s mental and physical health have diminished. “The toll of the pandemic has made them a changed person,” Williams said.

Emotional life and feeling intimately connected with someone impacts physical health and longevity, decades of studies have shown. In the wake of COVID some states are trying to make it impossible to bar family members from coming into nursing homes, because positive family visits can be life-savers and purpose-givers.

Will there be a wholesale return to allowing families members to come and go as they wish and join in meals and nursing home activities and events?  “I don’t see that happening for a long time,” Buttrick said. “Little by little, slowly, restrictions will be lifted.”

Vaccines are not a requirement for visitation, but masks and face shields are. Nursing home workers are not legally required to get vaccinated, but they are encouraged to do so in a spirit of working together and caring for residents and each other, Buttrick said.

“I’d never seen anything like COVID,” said Laurie Wajda, who has worked as a nursing assistant at St. Francis for 21 years, and laments the interpersonal changes the virus has wrought: “Even if we get the flu or GI issues, it’s usually a week or two. This is just on and on and on, all the challenges we’ve had making sure residents are as safe as possible. When it hit and people started passing away it broke your heart. It was like losing so many friends all at once. I found myself cherishing the moments of spending time with them.”

Bringing their favorite coffee and donuts, making sure they called their sons or granddaughters and reading letters aloud to them became more moving and meaningful, she said.

Many residents had trouble understanding why family members were no longer there in person – a visit they counted on, and a highlight in otherwise predictable days. “No matter what we did, the bond they had with their family members was the most important,” Wajda said. And without that contact, “you could see people fading.

“It was almost like they felt they were abandoned when they weren’t,” Wajda said. “Some were used to seeing family every day. You could explain why, but they couldn’t remember. It think it was almost like being a shut-in at home without any family. We did what we could to walk and talk with them, but it was never enough. If you’re wearing gloves, it’s not like human touch.”

Now that visits are happening again, and residents are doing small, socially-distanced activities while wearing masks, they’re “coming alive again,” Wajda said. “It’s something to look forward to. It gives them hope when before there was none.” In anticipation they want to look nice, and are getting their hair done, she said.

For people in their 80s and 90s, family links are life preservers. “When you get older you’ve had so many losses. So many people are gone. Some families are huggers. Others are not,” Wajda said. But if families have been close, those bonds survive regardless of age or circumstances, and the pattern of caring continues and is passed to the next generation.

“Families mean a lot. So very much,” Wajda said. Now that the nursing homes are opening up, “The family members are feeling better to see their family members again.”

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The Sunshine Project is underwritten by grants from the Endowment for Health, New Hampshire’s largest health foundation, and the New Hampshire Charitable Foundation. Roberta Baker can be reached by email at Roberta@laconiadailysun.com