Dilemmas With Restrictive Visiting Policies in Dutch Nursing Homes During the COVID-19 Pandemic: A Qualitative Analysis of an Open-Ended Questionnaire With Elderly Care Physicians.

OBJECTIVES: To mitigate the spread of COVID-19, a nationwide restriction for all visitors of residents of long-term care facilities including nursing homes (NHs) was established in the Netherlands. The aim of this study was an exploration of dilemmas experienced by elderly care physicians (ECPs) as a result of the COVID-19 driven restrictive visiting policy. SETTING AND PARTICIPANTS: ECPs working in Dutch NHs.
METHODS: A qualitative exploratory study was performed using an open-ended questionnaire. A thematic analysis was applied. Data were collected between April 17 and May 10, 2020.
RESULTS: Seventy-six ECPs answered the questionnaire describing a total of 114 cases in which they experienced a dilemma. Thematic analysis revealed 4 major themes: (1) The need for balancing safety for all through infection prevention measures versus quality of life of the individual residents and their loved ones; (2) The challenge of assessing the dying phase and how the allowed exception to the strict visitor restriction in the dying phase could be implemented; (3) The profound emotional impact on ECPs; (4) Many alternatives for visits highlight the wish to compensate for the absence of face-to-face contact opportunities. Many alternatives for visits highlight the wish to compensate for the absence of face-to-face opportunities but given the diversity of NH residents, alternatives were often only suitable for some of them. CONCLUSIONS AND IMPLICATIONS: ECPs reported that the restrictive visitor policy deeply impacts NHs residents, their loved ones, and care professionals. The dilemmas encountered as a result of the policy highlight the wish by ECPs to offer solutions tailored to the individual residents. We identified an overview of aspects to consider when drafting future visiting policies for NHs during the COVID-19 pandemic.

In the Netherlands, the first confirmed case of coronavirus disease 2019 (COVID-19) in a nursing home (NH) was reported on March 12, 2020, and by the first week of April, approximately 40% of Dutch NHs reported COVID-19 infections (Figure 1 ). Approximately 115,000 people reside in one of the estimated 1000 NHs or care homes across the Netherlands, for whom medical care is provided by physicians with an elderly care medicine specialty (ie, elderly care physicians [ECPs]). To mitigate the spread of COVID-19, strict social distancing policies were implemented by the Dutch government as of March 12, 2020. By March 19, a nationwide restriction for all visitors of residents of long-term care facilities including NHs was established (Figure 1). This decision was made in view of a lack of alternatives, as the Netherlands was facing shortages of personal protection equipment (PPE) and a lack of diagnostic capacities. The only exception of this restrictive policy included residents in the dying phase to allow a farewell moment for family members (ie, maximum 2 visitors per 24 hours).

Fig. 1

Timeline of the Dutch responses to COVID-19 in the nursing home setting.

It is inevitable this policy has consequences for the residents, their families and their formal caregivers. Involvement of the resident's family through visits to the NH has previously been described to be beneficial for the quality of life of residents. , Indeed, family has been reported to promote social engagement and to strengthen identity and dignity of residents. Family visits to the NH allow for the monitoring of the provided formal care as well as for additional care tasks for the institutionalized older adults.

While the rationale for the restrictive visiting policy imposed to the NHs in the Netherlands was clear (ie, to limit the further spread of COVID-19 among vulnerable populations in view of the lack of any alternatives), ECPs in the professional network of the authors reported that the policy led to dilemmas. The aim of this study was an exploration of these dilemmas experienced by ECPs in daily practice as a result of the COVID-19 driven restrictive visiting policy. In addition, the study aimed to provide insights in how ECPs dealt with these dilemmas. Reflecting on the experiences of the ECPs should yield valuable insights to guide policy-making in case of a second wave of the COVID-19 pandemic.

Methods

Design

A qualitative exploratory study was performed to identify dilemmas experienced by ECPs in daily practice as a result of the COVID-19 driven restrictive visiting policy in Dutch NHs.

Data Collection

Discussions on the impact of the COVID-19 driven restrictive visiting policy in NHs emerged spontaneously during the weekly training days of ECPs-in-training with their academic teachers of the Department of Medicine for Older People of the Amsterdam University Medical Center (UMC) (ES, MS). Based on these discussions, an open-ended questionnaire was designed to explore cases in which ECPs experienced dilemmas and difficult situations (ES, MS, AM, CH). Questions aimed to explore whether the dilemma related to the resident, the resident's family, the nursing staff, care unit, and/or organization. The questionnaire also explored the decision-making process that followed-up on the dilemmas. An overview of the open-ended questions is shown in Supplementary Table 1. A maximum of 3 cases could be described per questionnaire participant. The Web-based questionnaire (Survalyzer, Survalyzer Nederland BV) was sent to ECPs-in-training at the Amsterdam UMC and their supervisors (ie, ECPs) by e-mail on April 17, 2020. Recipients could forward the questionnaire to colleagues working in their institution. The questionnaire was closed on May 10, 2020 (Figure 1). All solicited ECPs were working in NHs in the central or Northern regions of the Netherlands.

Supplementary Table 1

Open-ended Questionnaire

1. Please describe a situation related to the restrictive visitor's policy that led to dilemmas. 2. What affected you most in this situation? Could you describe what impact it had on you? 3. Did considerations relating to the resident play a role? If yes, which ones? 4. Did considerations relating to the resident's family play a role? If yes, which ones? 5. Did considerations relating to the nursing staff play a role? If yes, which ones? 6. Did considerations relating to the care unit play a role? If yes, which ones? 7. Did considerations relating to the organization play a role? If yes, which ones? 8. Did any other considerations play a role? 9. What was decided upon regarding the dilemma and who was involved in the decision? 10. Are there any other (not previously) mentioned considerations that should be taken into account regarding the visitor's policy?

Analysis

An inductive thematic analysis was applied to identify concepts and patterns of meaning in the data. The analysis included the following steps: (1) familiarizing with the data, (2) inductive thematic coding, (3) searching for themes, (4) reviewing of themes, and (5) finalization of themes. An iterative approach (ie, the process of going back and forth between the data, the codes, and themes) was followed across the different steps to ensure a systematic analysis.

The coding of the first 14 cases was performed independently by 2 researchers trained in qualitative research methods (ES and AM). The results of the 2 independent codings were then merged into a single codebook. The codebook was used to code the remaining questionnaire data. The cases collected within the first 2 weeks were coded by 1 of the 2 researchers (ES and AM). Changes to the codebook (eg, renaming of codes and addition of codes) were made in consensus between the 2 researchers during research meetings (ES and AM). A third researcher (MB) validated the coding by checking for inconsistencies to make sure no relevant information was missed and coded the last 20 cases. Doubts were discussed with 2 other researchers (ES and AM). Regular meetings between the researchers involved with the coding allowed for frequent reflections on the data analysis including the collation of codes into themes and the evolution of the identified themes. The questionnaire data were analyzed using Microsoft Word and Microsoft Excel.

Ethical Approval

All participants were informed about the aim of the study and the purpose of data collection. Formal ethical approval from a medical ethical committee was not required for this research in the Netherlands since it did not subject participants to any medical treatment or impose any specific rules of conduct on participants.

Results

The questionnaire was sent to 103 ECPs-in-training and 92 ECPs and anonymously returned by 76 physicians (ECPs or ECPs-in-training). These 76 physicians, further referred to as “ECPs,” described a total of 114 cases in which they experienced a dilemma.

Thematic analysis of open-ended questions revealed 4 major themes related to the restrictive visiting policy. Quotes illustrating the 4 themes are shown in Table 1 . Furthermore, we identified dilemmas related to other COVID-19 measures in NHs (Supplementary Table 2).

Table 1

Quotations of Elderly Care Physicians Illustrating the Emerging Themes

I. Dilemmas as a result of the general strict visitor restriction

1. “It remains a ‘Devil's bargain’: protecting clients from infection (keeping the outside world out) and having contact with the people you love.” 2. “The dilemma concerns allowing visits for the patient's quality of life versus the risk of loved ones becoming ill and further spread in society.”

Infection prevention3. “In my nursing home, I observe how much suffering Corona causes and how many people fall victim to it. The risk of spreading should really not be taken.” 4. “… for that person, it does not actually matter whether corona is an added condition (although I understand that it is about the protection of the institution and not of the individual patient).” 5. “Obviously, you want to ensure the safety of the residents in the department.” 6. “Measures also protect the professionals in particular: they are very vulnerable to be infected or to spread the coronavirus.” 7. “Society knows what is going on. You do not need to explain to loved ones they are not allowed to come.” 8. “Remarkable how much understanding we receive from family members when we explain the dilemmas we face.” 9. “Relatives who continue to argue about the framework in which visits are possible.”

Quality of life Importance of visitors10. “In this phase of life, quality is most important. Living secluded, away from loved ones in quarantine is not appropriate for quality of life.” 11. “For patients on the psychogeriatric care units, maximizing quality of life is the main aim. To this respect, visiting and contact with loved ones is the most important thing.” 12. “She literally said: now that I can no longer see my family, I have nothing left to live for.” 13. “The need to allow her to be supported her in her suffering.” 14. “The partner visits a patient with dementia daily. Partner helps the patient with feeding, among other things.” Impact of visitor restriction15. “Her fear, sadness and loneliness, very tangible and strongly present, mimicking depression.” 16. “Partner explained he visited his wife with dementia daily, helped her feeding for hours. Since he has not been allowed back, she did not eat and drink enough.” 17. “Several other residents who suffer more psychologically and even experience more physical pain as a result of the social suffering. As a doctor, you try to treat this but the solution is elsewhere.” 18. “Still, there are several poignant cases with severe cognitive decline, partly as a result of the absence of daily contact with family, which is an essential factor.” 19. “The resident is in danger of not recognizing the partner after a long time, in particular when video calls are not understood.” 20. “Increase of behavior problems, in particular agitation and physical contact towards nursing staff after the wife was not allowed to be with her husband in the afternoon. Causes an increase in psychotropic drug use and major pressure on nursing staff.” 21. “No visits also results in peace on the care units. For some of the people it is very hard, but another part is more calm and thrives.”

II. Dilemmas as a result of the exception in the dying phase

22. “The dilemma is allowing visitors from the angle of quality of life for the patient, versus the risk of infection from loved ones and further contamination into society.” 23. “The right to being surrounded by family as you pass away.” 24. “A goodbye in person is something I see as very valuable.”

Assessing the dying phase25. “Wife was asked to husband short before he passed away, sometimes it is hard to estimate being terminal. Then we are too late. This occurs sometimes, also during normal times, but then the family would already have had the opportunity to say goodbye when the patient became ill.” 26. “Is the daughter allowed to visit her mother despite the mother not being terminal yet, but while she is still communicative.” 27. “His last days/weeks/months are lonely.” 28. “I would not be surprised if this resident passes away during the corona crisis from something other than corona. It is tough for the family that they are not able to follow this process, not until he is on his deathbed. The processes of saying goodbye and acceptance are much harder to start.” 29. “If we allow visitors now, we might have to allow it with others as well.”

Implementation the exception30. “That I have to decide how many family members can say goodbye or not. Conflict between adhering to policy and rules and the human dimension.” 31. “Mrs with 4 daughters (…) You can't let children decide amongst themselves who is allowed to visit, right?” 32. “Allowing low-threshold visitation (if life expectancy is uncertain) we will have even fewer PPE at our disposal, since family also needs to wear PPE.” 33. “Patient was terminal and visitors were allowed, a maximum of 2 people per day. Except, these 2 would walk in and out throughout the day (…) This made me realize that the policy of ‘2 people a day in the terminal phase’ is not specific enough. Are they allowed to walk in and out? How long are they allowed to stay?” 34. “Nursing was given the job and responsibility to lead the process of visiting which went well, but it was scary for them.” 35. “The care unit was still covid-free at that point. The risk of infection coming in with this family was deemed high, due to contact with the covid-positive wife who had passed away.” 36. “Family was invited to come visit sir (a maximum of 2 people at a time, without symptoms and without a fever). The eldest daughter has coughing complaints, chronically according to her. How do you make a decision in a case like that.”

III. Impact on Elderly Care Physicians

37. “The fact that I had to decide whether a son could see his mother was something I found agonizing, while it wasn't even necessarily my decision in the first place, it was the government's decision.” 38. “Suboptimal care. Normally in these situations, family that could help with care are now shut out. Is this a good decision?” 39. “Seeing agitation increase, and knowing that family could have a positive influence but not being allowed to allow them in and having to explain that to the family. Feels terrible. Painful. Poor quality of care.” 40. “But sometimes it is so unexpected when it comes to COVID, it makes me feel scared that I am withholding a goodbye from family and patient.” 41. “Impotence to find a good solution. It occupies my mind, day and night.” 42. “This is unacceptable, I feel I am falling short, powerless and also angry at this entire situation. Inhumanly sad, it deeply affects me.” 43. “Very poignant, this should not have happened this way.” 44. “So tangible (…) it is such an inhumane happening and I am personally having a really difficult time with this decision.” 45. “It gives you a real feeling of injustice and doubt about whether something weighs up against the risk that comes with allowing visitation.”

IV. Diversity calls for tailored solutions

46. “It is a young man with a one-sided paralysis after a CVA, but he is cognitively well. He can make informed considerations and express himself well.” 47. “Relatively young patient, with MS with severe paraparesis (…) She is able to communicate with loved ones via several forms of media.” 48. “She can't express herself well, verbally, which makes communication through the telephone or video calls not possible, which creates more emotions and frustrations.” 49. “Communication with daughter through video calls led to more agitation, paranoia and delirious phenomena.” 50. “Really account for the humanity. As per usual, also in this case, we weigh the risks, not only to the patient but also to their loved ones and the nursing staff.” 51. “The government policy is not pleasant. There is too little attention for proportional decision-making and tailoring.” 52. “Individual tailoring is strongly preferred, especially when considering the rights of the hospitalized patient.” 53. “It also depends on location. Some places have gardens where visitation ‘at the gates’ works really well.” 54. “On the ground floor we were able to make arrangements that the rest of the family could stand at the window to be a part of the moment [ritual when passing away] with the pastor.” 55. “Audiofiles of sir, that could then be played back.” 56. “On scaffolding in front of a window also won't work, Mrs does not understand that and it will only end in drama.” 57. “When you're sick, a videocall is not enough.” 58. “Allowing the husband onto the care unit would most likely have caused such unrest and aggravation with other patients that we decided against it.” 59. “If you make an exception for one person, then why not for the other. Who is suffering the most under this measure.” 60. “Because then more cases would qualify for this exemption which would make it hard to safeguard the boundaries (in consultation with the local crisis team).” 61. “A decision was made with all involved disciplines (nurse, supervising elderly care physician, teamleader, psychologist).” 62. “Eventually the husband decided to take the patient home for an indefinite amount of time. Not ideal because of the severity of care, but when weighing the risks they still made this decision.” 63. “Client with many children discharged themselves for terminal care at home so that everyone could say goodbye at home. Eventually satisfactory for the family, though still hectic in a terminal phase.”

Supplementary Table 2

Codes and Illustrative quotes Relating to COVID-19 Measures in Dutch Nursing Homes Beyond the Restrictive Visitors' Policy

Isolation	• “Covid-negative client, displays no symptoms, has to stay in his room because the care unit is closed due to a covid-positive client, family member wants to put on PPE and pick up client in PPE, to take them outside so they are no longer in a sad mood and will eat and drink again.” • “Yes, that too, it would be more pleasant to be able to go outside with a few people to keep the situation on the care unit bearable. In many cases, this prevents agitation and behavioral problems among clients with dementia.”
Isolation and psychotropic drugs	• “Sedating patients who are infected and don't remain in their rooms. Isolating and sedating ‘walkers,’ with as a result: an unpleasant end of life.” • “Severe agitation with a PG-resident who can be calmed by family and requires more sedating medication out of necessity.” • “Psychiatric drugs became necessary to improve the quality of life, with drowsiness and decreased mobility as a result.” • “Sir now receives an increase of clozapine-medication, while it is unclear whether a nonmedicated visit of family could be more effective.”
Freedom restriction	• The residents' world was already small, now it is even more limited because they can no longer receive family and friends, and are also locked inside the nursing home. • The fact that residents cannot go outside themselves is very restrictive and increases psychological complaints.
Freedom restriction and tailoring to residents	• “It would be nice if national policy would be that those to whom it relates, and to whom sitting in the courtyard is not enough, could go for a daily walk around the house or (duo)cycling accompanied by a member of staff.” • “I find it difficult that they are not allowed to go outside under the condition that they have no social contact, don't go to the supermarket etc. A stroll around the block of a client with dementia accompanied by a member of staff, without any other form of social contact, should be possible.” • “The client with the spinal cord injury has complete autonomy over his life, despite the dependence on care. He would be capable of adhering to social rules. However, he is in a total lockdown and I am in an intelligent lockdown.” • “It feels unethical to restrict someone in their freedom, if your expectation is that he would act responsibly.” • “In my opinion, riding around on empty parking lots or visiting quiet parks barely increases the risk of infection, but increases the feeling of freedom.” • “Taking away the option of going out for fresh air from a cognitively competent person on an uninfected care unit, even when they adhere well to regulations, is something I consider a strong intervention of their right to lead their own life. The risk of spreading corona verses the restriction of freedom is, in my opinion, disproportional. ”
Communication	• “What is difficult is that most of the contact is through telephone, there is no face-to-face contact. It makes communicating different, and more difficult.” • “Immediate incident with a resident, rectal blood loss. Considering the stage of dementia, we will wait and see, and temporarily stop using anticoagulants. Scared wife on the phone, fears cancer, cries. Reassured with difficulty. A personal conversation would have been better.”
Less help	• “There is little deployment of volunteers, spiritual care or psychologists possible, because they are also required to work from a distance as much as possible. This has caused the deployment of help with her mood to be slowed down.”
Alternatives for therapies and care	• “She currently does receive a psychologist and spiritual caretaker in her room because of the urgency, but visitors are still not allowed. An attempt will be made to improve that through videocalling or standing on the balcony with a baby monitor.”

Importance of visitors

Impact of visitor restriction

Dilemmas as a Result of the General Strict Visitor Restriction

The core dilemma experienced was that on the one hand, ECPs wanted to protect residents against COVID-19 infections, implying adherence to the strict visitor restrictions, but on the other hand, as a consequence quality of life of most residents seriously decreased (quote 1 and 2).

Infection Prevention

ECPs encountered serious suffering as a result of COVID-19. Hence, they wanted to minimalize the risk of contamination (quote 3). According to ECPs, for some residents, the risk of contamination was acceptable but it was not just about the individual resident (quote 4). ECPs emphasized infection prevention concerned safety of all residents (quote 5) and health care professionals (quote 6).

The visitor restriction policy contributed to limiting the further spread of COVID-19. Most ECPs encountered understanding of the dilemmas they were facing among family members (quote 7 and 8), although not in all cases (quote 9).

Effect on Residents' (Quality of) Life

ECPs used the words “loved ones,” “partner,” “family members,” and “next-of-kin” instead of “visitors.” ECPs considered the presence of these “visitors” as essential to quality of life. As most residents of NHs have limited life expectancy, ECPs estimated quality of life was often considered more important than life duration (quote 10–12). Furthermore, according to ECPs, next-of-kin could have provided company and support in uncertain times (quote 13). Moreover, ECPs described cases where they missed additional care otherwise provided by next-of-kin (quote 14).

ECPs described cases in which the visitor restriction had profound impact on residents. ECPs observed loneliness, depressive symptoms (quote 15), decreased intake (quote 16), increase in somatic symptoms (ie, pain) (quote 17), physical deterioration and in psychogeriatric residents' rapid cognitive decline (quote 18, 19), and changes in neuropsychiatric symptoms including agitation and aggression (quote 20). The latter was even reported to result in increased psychotropic drug prescriptions for some of the residents. On the other hand, ECPs observed visitor restrictions brought peace for some of the psychogeriatric residents (quote 21). In addition, the restrictions impacted next-of-kin and nursing staff (Supplementary Table 3).

Supplementary Table 3

Additional Consequences of the Restrictive Visitors' Policy

Impact on next-of-kin	• “Family also found it very hard to hear her speech was declining as a result of ALS and they could not come to see her, to talk to her about it.” • “Family is losing autonomy: I can see this is painful for them.” • “The powerlessness and frustration of partner and the major worries this caused.”
Impact on nursing staff	• “Informing families more often and better, many extra reports by nursing staff, use of video calls etcetera. Nursing staff experience this impotence too and are not always able to provide extra care.” • “The team is more at ease as there is no traffic of various people and professionals across the care units. Therefore, they have more time for residents.”
Practical implications for ECPs	• “This took a lot of effort by phone from my side to maintain a good doctor-patient relationship.” • “Guidance of care-teams and explaining decisions take a lot of time.”

Dilemmas as a Result of the Allowed Exception in the Dying Phase

ECPs noted that although protection against contamination was irrelevant for a resident in the dying phase, protection of other residents in the institution, health care providers, next-of-kin and society remained notwithstanding important (quote 22). ECPs described the presence of visitors in the dying phase implies being surrounded with loved ones and being able to say farewell (quote 23 and 24). We distinguished 2 types of issues raised by ECPs: assessing the dying phase and implementing of the exception.

Assessing the Dying Phase

ECPs struggle with the timing to diagnose “dying.” The beginning of the dying phase is not always clear (quote 25). ECPs describe a gray area classified as “preterminal phase”: life expectancy is short, but the resident is not yet in the dying phase (quote 26). In these scenarios, ECPs observed residents whose last days, weeks, or months were lonely (quote 27) and residents with a rapid course of the dying phase, thereby not being able to say farewell to their loved ones (quote 25). ECPs described that next-of-kin were missing the process of decline and feared this might impact their mourning process (quote 28). ECPs remarked that concluding too early that the resident was in a dying phase implies more visitors (ie, higher risk of infection) and may set a precedent for others (quote 29).

Implementing the Exception

A major aspect causing dilemmas is the number of visitors per resident. Numerous ECPs described cases where the restriction of 2 visitors implied not all close loved ones (family members) could say farewell. For example, it could cause siblings to have to choose who of them could visit their dying parent (quote 30 and 31).

Furthermore, in practice, several requirements for visits were pointed out by ECPs. First, ECPs were aware that PPE was scarce, increasing the urgency to limit the exceptions (quote 32). Second, ECPs emphasized specific directives for and streamlining of the family members could limit the traffic in the institution (quote 33, 34). Last, ECPs pointed out the importance of the health of the visitor. Some direct next-of-kin (intended visitors) had or had a high risk of having COVID-19 (quote 35) or had symptoms more or less suspect for COVID-19 (quote 36).

Impact on ECPs

ECPs perceived the national restrictive visiting policy was not their decision, but felt responsible for its implementation. These feelings were in particular apparent in cases of residents with limited life expectancy as their assessment of the clinical situation would steer the decision to make an exception (quote 37). Encountered dilemmas had profound emotional impact on ECPs. They described feelings of guilt, insecurity, frustration and felt they provided suboptimal care to the residents (quotes 38–40). Some respondents described waking up in the middle of the night, worrying (quote 41). ECPs used phrases as “Devil's bargain,” “unacceptable,” “poignant,” “inhuman,” and “unjustified” to describe some of the dilemmas they encountered (quotes 1, 41–45).

Furthermore, the visitor restrictions had some practical consequences. For example, ECPs perceived the required thorough communication and arrangements they had to make with next-of-kin and colleagues around the policy as extra, time-consuming tasks (Supplementary Table 3).

Diversity Calls for Tailored Solutions

ECPs underscored the diversity of residents in, for example, age, cognition, and decision-making abilities (quotes 46–49). As a result, the impact of the restriction widely differed between individual residents. For example, the impact on a young resident who was able to maintain social contact through video calls (quote 47) substantially differed from the impact on a resident with dysarthria (quote 48) or a resident with dementia unable to understand and use video calls (quote 49). Various ECPs indicated they missed the possibility to tailor the national policy to the individual resident (quotes 50–52).

ECPs described various alternative solutions to enable social contact between residents and their loved ones and/or social presence in the dying phase. NH organizations facilitated technical solutions (for example video calls and 2-way audio connections) and alternatives to realize real-life contact at distance (for example, setting up special visitor areas, crisis apartments, and arranging a cherry picker enabling contact at the window). These solutions applied in some situations (quotes 53–55) but were regularly not deemed appropriate (quote 56, 57).

The latter led ECPs to consider making an exception to the strict policy, where they faced another dilemma: it sets a precedence for others (quote 58 and 59), making it hard to maintain boundaries (quote 60). Most ECPs decided whether or not an exception should be made in a multidisciplinary setting (quote 61). ECPs reported that in some cases, next-of-kin decided to take residents back home (quote 62 and 63).

Discussion

The analysis of dilemma experienced by ECPs as a result of the COVID-19 driven restrictive visiting policy revealed 4 major themes: (1) the need for balancing safety for all through infection prevention measures versus quality of life of the individual residents and their loved ones; (2) the challenge of assessing the dying phase and how the exception to the strict visitor restriction could be implemented; (3) the profound emotional impact on ECPs; and (4) many alternatives for visits highlight the wish to compensate for the absence of face-to-face contact opportunities. However, given the diversity of NH residents, alternatives for communication were often only suitable for some of them. ECPs missed the opportunity to tailor the policy to the specific needs of the residents. Nevertheless, ECPs often assessed together with colleagues, whether or not exceptions could be made for individual residents.

The core dilemma of safety versus quality of life is encountered in various situations in NHs. However, the dilemmas encountered during the visitors restriction in the COVID-19 pandemic have an extra dimension: it is not just about protection of the resident, infection prevention during the COVID-19 pandemic concerns others, including other residents and staff of the NHs. Interestingly, the respondents rarely used the term visitor to refer to the persons visiting the NH resident. Thus, visitor seems to be an euphemistic term, as it usually concerns loved ones who are part of the inner circle of the resident and often a partner or a close family member. Moreover, these loved ones regularly play an essential role in the resident's care process. , Several authors warned about the possible consequences of the absence of these loved ones, including emotional impact (eg, loneliness, depression, disruptive behavior) and both physical and cognitive decline.18, 19, 20, 21 Our findings are aligned with other research conducted in parallel in the Dutch NH setting. ,

The exception allowing for visitors in the dying phase caused struggles with the assessment of dying phase. Dutch guidelines for palliative care define dying phase as last days of life. It is well-known that diagnosing dying is a highly complex process. , In particular, the course of the new disease COVID-19 in older adults is challenging to predict for professionals, causing additional uncertainty in the physicians' diagnosis of dying. ECPs in our study recognized uncertainty of dying diagnosis regularly applies in NH practice. They usually deal with this uncertainty by closely informing families about the residents' condition and by low-threshold invitations to come over. The required explicit diagnosis of dying under the strict visitor policy limited their possibilities to deal with this uncertainty. In addition to the diagnostic problems, the allowed exception in the dying phase raised both ethical issues and practical conditions. An ethical issue described in several cases was that 2 visitors implied not all close loved ones' presence in the dying phase was possible. Indeed, strictly adhering to the conditions for exceptions cause some family members to be deprived from the opportunity to a proper farewell. Practical requirements to minimize risk of infection were streamlining visits, availability of sufficient PPE (for both health care professionals and visitors) and health of the visitor with respect to the risk of COVID-19. These requirements are recognized by others. ,

The descriptions of the profound emotional impact of the dilemmas (ie, feelings of providing suboptimal care, guilt, injustice) illustrate the moral distress of the ECPs. ECPs missed the opportunity to make tailored decisions, affecting both their own professional as well as the residents' personal autonomy. Furthermore, this moral distress may originate from the conflict between the visitor restriction and principles of good care, including patient-centered care, shared decision-making, and palliative care, that have been guiding NH care over the past decades. , Last, making exceptions meddled with protection of and justice for other residents in the institution.

The examples of alternatives for visits (technical and at distance) underscore the urgency to compensate for the absence of visits and in the Dutch media was parallel reported on various creative solutions to allow contact at distance (eg, using a cherry picker, “coronatainers”). , However, alternative solutions are only suitable for some residents, as many have cognitive impairments, visual or hearing disabilities, and/or speech disorders. In addition, the effect of technical solutions in decreasing social isolation in NHs is limited. , In the dying phase, these alternatives could not replace the presence of close loved ones who wanted to say goodbye. Consequently, ECPs deliberately weighed, whether or not a tailored exception could be made in individual cases. ECPs find it reassuring to take these decisions with a group of colleagues.

After a significant peak in the number of deaths in early April, the number of COVID-19 cases and deaths in NHs has been declining in the Netherlands. On May 11, a pilot in 26 NHs allowed for 1 fixed visitor, which as of May 26 applied to all COVID-free NHs; restrictions were further relaxed June 15 to allow for more than one fixed visitor and more frequent visits under certain conditions (Figure 1). In our study, ECPs struggled with on the one hand the pressure to adhere to the national visiting policy and on the other hand their wish for tailoring for the individual. At first, they experienced largely understanding for the situation. However, since May, families have increasingly been expressing resistance against the visitor policies. , Although there is no “one-size-fits-all” solution for the complex dilemmas faced here, our analysis provides several insights worth considering in assessing and reviewing current and future visiting policies. We observed that the nationwide “top-down” restrictive visitor policy resulted in resistance and a need for more regional and local tailored visiting policies. Important aspects emerging from our study to be considered by policy makers when issuing visiting policies are the regional and local COVID-19 prevalence, the availability of sufficient PPE, the possibility to streamline visits (eg, separate visiting areas, schedules for visitors), and the possibility to isolate residents. Nevertheless, even with visiting policies tailored to the regional and to the local NH organization context, dilemmas may still occur on an individual level. Health care professionals may still have to weigh whether or not the local visiting policy is proportional to the specific circumstances of the resident and his or her visitors. Relevant aspects emerging from our analysis to take into account when decisions have to made for those dilemmas are summarized in Table 2 . We believe explicitly considering these aspects by health care professionals should contribute to cautious decision-making. Our considerations are aligned with the reflections proposed by others on the effectiveness, proportionality, and burden of COVID-19 measures in health care. Furthermore, it is crucial to acknowledge that strong surveillance and diagnostic capacities are important prerequisites to facilitate individual adjustments of the policy.

Table 2

Aspects to be Considered Around Dilemmas Caused by Visiting Policies

Level	Considered Aspects
Resident	Residents' view on risk of COVID-19
	Connotation of receiving visitors for resident:• Saying goodbye to loved ones • Presence in the dying phase • Receiving additional care • Mutual support in crisis • Impact on quality of life
	COVID-19 confirmed?
	COVID-19 related symptoms?
	Life expectancy:• Months to years • Weeks to months • Dying phase
	Symptoms as a result of the visitor's restriction∗, for example:• Loneliness • Depressive symptoms, depression • Decreased intake • Neuropsychiatric symptoms (increased or decreased) • Physical complaints (for example pain) • Physical or mental deterioration
	Are alternative solutions for social contact applicable and satisfactory?• Technical solutions • Creative real-life solutions
	Are alternative solutions to decrease symptoms proportional?
Visitor	COVID-19 confirmed?
	COVID-19 related symptoms?
	Connotation of visiting the resident for specific visitor:• Being able to say goodbye to loved one • Being involved in resident's disease process/process of decline • Being involved in resident's care process • Being involved in resident's daily life • Mutual support in crisis • Impact on quality of life visitor
	Has specific visitor a structural role in the care process:• Assisting with intake • Assisting in communication, ie, in case of dysarthria or language barrier • Involved in daily routine
	Are alternative solutions for social contact applicable and satisfactory for the specific visitor?• Technical solutions • Creative real-life solutions
	Sufficient availability of personal protection equipment for visitors?

Note: Several aspects are illustrative, this is a noncomprehensive list.

As estimated by the physician.

The strength of this work is that it provides a snapshot of the dilemmas that ECPs were facing during the epidemic's peak in the Netherlands. The described dilemmas provide valuable insights in the challenges in older adult medical practice in times of the COVID-19 crisis in the Dutch NHs (Figure 1). Our work highlights the importance of balancing infection control and prevention measures together with quality of life aspects of NH residents in future visitor policies. It also underlines the search for resident-tailored solutions by ECPs. Furthermore, the timeliness of our study together with the fact that our findings were echoed by several other studies in the Netherlands as well as several colleagues should ensure for high content validity of our results. , , ,

Our study also has some limitations. First, the data were collected through open-ended questionnaires and sent to ECPs and ECPs-in-training. Although qualitative interviews would have potentially allowed for more depth in the answers and provided the opportunity for clarification questions, it would also have cost more time from the already oversolicited ECPs. We considered an open-ended questionnaire as a pragmatic study design to gather qualitative data that allowed respondents to reply at their own convenience. In addition, respondents might also be prone to more honest answers in an anonymous survey. Second, we only solicited ECPs but no other health care workers, families, or residents. However, the questionnaire was designed to drive reflections from different perspectives, beyond the ECP, including of the resident, the resident's family, as well as from nursing staff and other health care workers.

Conclusions and Implications

We have shown that according to the ECPs, the restrictive visitor policy in NHs deeply impacts individual residents, their loved ones, and professionals. The dilemmas encountered as a result of the policy highlight the wish by ECPs to offer solutions tailored to the individual residents. We identified considerations relating to both infection prevention and quality of life to take into account when drafting future proportional visiting policies for NHs in times of a pandemic.