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Promising Best Practices Implemented in Long- Term Care Facilities During the COVID-19 Pandemic to Address Social Isolation and Loneliness: A Scoping Review

Authors:

Idrissa Beogo ,

École des sciences infirmières | School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario; Center of Research and Study for Health, National University Autonomous of Nicaragua, Managua (CIES UNANManagua), Nicaragua; Institut du Savoir Montfort, Ottawa, Ontario, CA
About Idrissa

RN, MBA, PhD

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Nebila Jean-Claude Bationo,

Faculté des sciences de l’éducation, Université Laval, Québec, QC, CA
About Nebila Jean-Claude

PhD

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Stephanie Collin,

École des hautes études publiques, Université de Moncton, Nouveau Brunswick, Moncton, CA
About Stephanie

PhD

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Diane Tapp,

Faculté des sciences infirmières, Université Laval, Québec, QC, CA
About Diane

RN, PhD

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Jean Ramdé,

Faculté des sciences de l’éducation, Université Laval, Québec, QC, CA
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Marie-Pierre Gagnon,

Faculté des sciences infirmières, Université Laval, Québec, QC; VITAM, Centre de recherche en santé durable Université Laval, Québec, QC; Centre de recherche du centre hospitalier de l’Université Laval (CHU), Québec, CA
About Marie-Pierre

PhD

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Eric Nguemeleu Tchouaket,

Département des sciences infirmières, Université du Québec en Outaouais, Québec, QC; Université de Montréal, Département de gestion, d’évaluation et de politique de santé, Montréal, Québec, CA
About Eric Nguemeleu

PhD

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Drissa Sia

Département des sciences infirmières, Université du Québec en Outaouais, Québec, QC; Université de Montréal, Département de médecine sociale et préventive, École de santé publique, Montréal, Québec, CA
About Drissa

MD, PhD

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Abstract

Context: Throughout the current COVID-19 pandemic, tremendous effort has been made to implement innovative practices to address social isolation and loneliness (SIL) in long-term care facilities (LTCFs), disproportionally affected by COVID-19. These interventions have not yet been synthesized. This review intended to gather the current promising best practices (PBPs) implemented in LTCFs to alleviate SIL in older persons during the COVID-19 pandemic as well as during the SARS and H1N1 pandemics, using an intersectional lens.

Methods: An extensive search was done in nine electronic databases. Arksey and O’Malley’s framework was used to format the scoping review. Two independent reviewers screened citations for inclusion, blindly. The selection of articles was conducted blindly by two coauthors. Finally, 16 studies were analyzed out of 9,077 records.

Results: Two main themes of findings arose from this review. They comprised proximal PBPs directly addressing SIL in LTCF residents such as pseudo-contact interventions (e.g., chat from balcony or behind transparent barriers/glasses), remote communication tools (e.g., phone or video chat, voice mail/text messaging), and humanoid robots. Distal PBPs included measures implemented to prevent or mitigate the development of COVID-19, including COVID-19 screening approaches, outbreak preparedness, quarantining approaches for both residents and staff.

Conclusion: This scoping review found varied PBP implemented during the multiple waves of the COVID-19 pandemic as well as evidence supporting their effectiveness. The contribution of this study is significant as most of the PBP investigated should be prioritized by public policymakers or institutions to provide more satisfactory services to the elderly and their families.

How to Cite: Beogo, I., Bationo, N.J.-C., Collin, S., Tapp, D., Ramdé, J., Gagnon, M.-P., Tchouaket, E.N. and Sia, D., 2022. Promising Best Practices Implemented in Long- Term Care Facilities During the COVID-19 Pandemic to Address Social Isolation and Loneliness: A Scoping Review. Journal of Long-Term Care, (2022), pp.298–311. DOI: http://doi.org/10.31389/jltc.138
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  Published on 29 Dec 2022
 Accepted on 14 Oct 2022            Submitted on 09 Feb 2022

Background

Prior to the COVID-19 pandemic, social isolation and loneliness (SIL) was present in high numbers among certain groups. SIL was already high in superaged (>80 years old) Canadians, in about 50% of individuals living with comorbidities (e.g., physical or mental illness) or in marginalized groups, and in those experiencing loss (e.g., loss of employment, or a spouse) (National Seniors Council, 2014; National Seniors Council [NSC], 2017). Research indicates that the COVID-19 pandemic has heightened the presence of SIL, particularly for older adults living in long-term care facilities (LTCFs) (Inzitari et al., 2020) by severely impacting their quality of life (de Medeiros et al., 2020). Social isolation is the relative lack of social relationships and loneliness is defined as a subjective feeling of being isolated (Wenger, Daviesj, Shahtahmasebi, & Scott, 1996).

The COVID-19 virus poses a heightened risk of death for individuals aged 65 and older (Wu & McGoogan, 2020), resulting in a devastating death toll in nursing homes worldwide since the onset of the pandemic (United Nations, 2020). According to the 2016 Census, 6.8% of Canadians aged 65 years and older were living in a nursing home (NH) or residence for senior citizens (hereafter referred to as a seniors’ residence, SR). This proportion jumps to 30.0% among Canadians aged 85 years and older (Statistics Canada, 2017; Statistics Canada [SC], 2017). SIL has been identified as a determinant of elderly health (Linehan et al., 2014) and a risk factor of premature mortality (Rico-Uribe et al., 2018) as well as poor health (cardiovascular, obesity, etc.) (National Academics of Sciences Engineering and Medicine, 2020; Shankar, McMunn, Banks, & Steptoe, 2011), psychiatric (depression, anxiety, etc.) (Evansa, Martyra, Collinsa, Brayne, & Clare, 2019) pathologies or functional limitations among individuals with diabetes (Corno & Burns, 2022).

Liotta et al. (Liotta, Marazzi, Orlando, & Palombi, 2020) discuss how increased social connectiveness during the pandemic was a powerful tool used to decrease SIL among NH residents. The use of the conventional Information Technology and Communication (ICT) platforms (Skype, FaceTime, etc.) currently offered by LTCFs to connect older adults with their families has also been shown to be very helpful (Y.-R. R. Chen & Schulz, 2016). The negative impacts of social isolation later in life have been widely reported, ranging from declining mental and physical health to reduced quality of life, increased mortality, and higher Medicare costs (Gardiner, Geldenhuys, & Gott, 2018; MacLeod et al., 2021).

Canadian LTCFs experienced the highest mortality toll due to COVID-19 among the Organisation for Economic Co-operation and Development (OECD) countries – double the average mortality rate (Canadian Institute for Health Information [CIHI], 2020). In their pre-COVID-19 systematic review (2019–2020), Gardiner et al (Gardiner, Laud, Heaton, & Gott, 2020) estimated the mean prevalence of ‘severe loneliness’ to be 35% (95% CI: 0.14, 0.60). One pan Australian study revealed that 41% experienced loneliness and 33% experienced anxiety linked to COVID-19 (Brydon et al., 2021).

Thus, recent literature shows a vigorous involvement of families in hygiene care or emotional and social support (Bangerter, Van Haitsma, Heid, & Abbott, 2016). About 82% of LTCF residents require family involvement in care and activities of daily living (Canadian Institute for Health Information, 2016; Organisation mondiale de la santé, 2020), with one out of five Canadian families having spent at least 10 hours a week caring for a loved one in a LTCF before the start of the pandemic (Turcotte & Sawaya, 2015).

Prior to the pandemic, six categories of interventions were defined to prevent SIL, including anxiety, among older people: social facilitators, psychological therapies, health and social care, animal interventions, befriending interventions, and leisure (Gardiner et al., 2018). However, these interventions were all designed to take place in person. Over the different waves of the COVID-19 pandemic, restrictions regarding family visits and the varied lockdown and pseudo lockdown procedures put in place by LTCFs (Armitage & Nellums, 2020) heightened SIL among residents. Asides, Van der Roest (Van der Roest et al., 2020) showed an increase in severity of sadness, agitation, depression, anxiety, and irritability in residents even after their initial quarantine.

Many promising best practices (PBPs) were implemented in LTCFs, contributing to the prevention or diminishment of the virus. Based on the report published by the Canadian Foundation for Healthcare Improvement in July 2020 (Canadian Foundation for Healthcare Improvement, 2020), we defined a promising best practice as an innovative practice developed and successfully implemented to protect the LTCFs by reducing and/or lowering the community transmission of COVID-19 and combatting the different waves of the pandemic. As such, examples such as hand sanitizer availability or coordination with public health officials, are not considered to be PBPs because of their world-wide implementation.

This scoping review aims to present a synthesis of the PBPs and their significant effects on SIL among the residents of LTCFs. The review is extremely relevant within the current pandemic context and is valuable for several reasons: 1) it covers the last three recent and most important pandemics, namely the Severe Acute Respiratory Syndrome (SARS), the H1N1 and the current COVID-19 pandemic; (2) it updates the Chen and Schulz (Chen & Schulz, 2016) systematic review published in 2016; and (3) it identifies strategies they may be quickly implemented, both during COVID-19 as well as post-COVID-19 pandemic, to strengthen the social connection between older adults residing in LTCFs and their families. These objectives are aligned with the urgent needs of managers and stakeholders to support COVID-19 research in Canada and internationally.

The conceptual framework considered: Intersectionality

As the presence of SIL in LTCFs results in multiple proximal and distal intersecting factors (Figure 1), intersectionality will therefore be the overarching theory that guides the research process. It provides a lens through which to view, understand and interpret the complexities that contribute to healthcare inequities and considers how health issues are influenced by intersecting social factors, as opposed to considering social factors as acting in isolation, that overlap in a manner that can enhance negative health outcomes.

Intersectionality in addressing SIL in LTCFs over the Covid-19 pandemic
Figure 1 

Intersectionality in addressing SIL in LTCFs over the Covid-19 pandemic.

Figure 1 demonstrates how proximal and distal factors may intersect and overlap to result in SIL in older adults. In the context of COVID-19, LTCF residents’ experiences of SIL were complex and comprised of multiple factors. Some are viewed as proximal factors, being associated to SIL in a more direct way, such as family support in continuing pre-per pandemic social connections. Others are viewed as distal factors, slightly more removed but still strongly contributing to SIL, including both upstream and downstream strategies: long lasting individual factors (e.g., comorbidities), managerial factors (e.g., performance factors), and infection prevention and clinical case management strategies. The performance factors of the proposed framework stem from a healthcare performance framework published by the Québec government: accessibility of services, quality of services, optimization of resources, quality of care (Ministère de la Santé et des Services Sociaux, 2012, 2017).

The use of an intersectional lens corresponds well to the aim of our study, as it is used to portray and examine diverse patterns (social, geography, disability/ability, power relations and experiences…) intersecting and leading to SIL during the pandemic context (Hankivsky, 2014). We adapted the Intersectionality theory in considering (i) infection prevention strategies, (ii) performance management, (iii) cases management and (iv) capitalized social connection (Figure 1).

Methods and analysis

Due to the novelty of the COVID-19 virus and its subsequent impact on the SIL of LTCF residents, we deemed the scoping review to be a more appropriate review methodology allowing for a preliminary portrayal of the extent of available evidence on PBPs in LCTFs during the COVID-19 pandemic. The methodological framework employed in this review was first introduced by Arksey and O’Malley (2005) and later enhanced by Levac (2010) and is comprised of six proposed steps: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) charting the data; (5) collating, summarizing, and reporting the results; and (6) developing a knowledge translation plan involving all stakeholders of the fields in order to present evidence-informed policy recommendations. The review’s protocol was registered in Research Registry (reviewregistry1157, https://www.researchregistry.com/browse-the-registry#registryofsystematicreviewsmeta-analyses/).

1 – Research question

Our research questions were:

  1. What are the current promising best practices implemented in LTCFs to alleviate SIL in older individuals during the COVID-19 pandemic and what were the promising best practices implemented in the previous SARS and H1N1 pandemics?
  2. How did the use of these best practices reduce SIL among residents of LTCFs during the COVID-19, SARS and H1N1 pandemics?
  3. What lessons, knowledge and recommendations might be learned and translated into interventions, including the use of digital interventions, to alleviate SIL in residents of LTCFs both during and after the COVID-19 pandemic?

2 – Relevant literature identification

Following the PICOTS framework created for this review (Appendix 1), searches were conducted in scientific databases (BDSP, Medline-Ovid, EMBASE, CINAHL, Web of Science, PsycInfo, Cochrane, ScienceDirect and Scopus) and grey literature databases (OpenGrey, Age UK, Google Scholar). Finally, the reference lists of selected key papers were searched by hand for relevant literature.

Studies were included if (a) participants were older adults (≥ 65 years) residing in LTCFs and not living with major neurocognitive impairments, (b) interventions reported effectively addressed SIL during the major recent pandemics (COVID-19, H1N1 and SRAS), and (3) the publication languages were English or French. Search strategies were well-calibrated and adjusted to each database, after refined iterative processes to improve the likelihood of retrieving relevant articles (Appendix 2).

3- Studies selection

The search yielded 9,077 papers published between 2003 and December 2021, which were then transferred into the Rayyan Intelligent Systematic Review (Ouzzani, Hammady, Fedorowicz, & Elmagarmid, 2016) platform for screening. After screening 200 references in a pilot test, the PI (IB) and one of the co-authors (NJ-C) independently screened the citations of all articles, adhering to the review’s screening algorithm (Figure 2). This was followed by the full reading of potentially relevant articles to confirm their relevance and determine final inclusion. Studies were eligible for inclusion if 1) they were related to older adults living in LTCFs, 2) their interventions were effective, original and aimed to prevent and/or address COVID-19 cases, and 3) they directly combatted SIL. For our review, we considered any type of study design (e.g., observational studies, randomized controlled trials and qualitative studies) as well as commentaries.

References screening algorithm
Figure 2 

References screening algorithm.

Legend: 

1 The reference has a TITLE or does not have a publication date or does not have an ABSTRACT.

2 Long-term care facilities: Nursing home, Assisted-living facilities, Long-term care facility, Home for the Aged, Retirement home.

Excluded: Acute care, Hospital (medicine, surgery, intensive care, etc.) or clinics.

3 Population: all the residents of long-term care facilities.

Excluded: elderly persons staying in community.

4 Studies: published in 2003-onward.

Excluded: published before 2003 and in countries without LTCH system.

5 Context: COVID-19, H1N1, SARS epidemics.

6 Outcome: Promising Best Practices (PBP) including digital health aiming to reduce social isolation. LTCH: long-term care home.

4- Data extraction

Data from the included papers were extracted based on a template created in Excel®, which had been discussed beforehand among coauthors.

As shown in Supplementary Table 1, the following data were extracted: 1. study details (authorship, year of publication, and the setting); 2. the study design, outcomes measured and the participants’ demographic; 3. the intervention characteristics (duration, type of intervention); 4. the results (evaluation of the effects of the intervention, as well as barriers and facilitators); and 5. the conclusion.

5- Results

Study participants

In total, 59 references were considered for plain text canvassing, and 16 studies were included (Figure 3). They had been published in journals across a wide range of health science disciplines. The studies included different types of LTCF populations: older people who reside in nursing homes (Dichter, Sander, Seismann-Petersen, & Köpke, 2020; Dolveck et al., 2021; Gilbert, 2020; Mo & Shi, 2020; Wammes et al., 2020), nursing facilities (Maggie Collison et al., 2020; Song et al., 2020), as well as geriatric acute care units, long-term care, and nursing homes (E. E. Office, M. S. Rodenstein, T. S. Merchant, T. R. Pendergrast, & L. A. Lindquist, 2020; Sacco, Lléonart, Simon, Noublanche, & Annweiler, 2020). Several study designs were included in the review, as demonstrated in Supplementary Table 1. We organized the findings of the included studies into themes and further grouped them into natural clusters around certain topics. That is, we identified the following three key PBPs themes i) strategic approach (example) ii) COVID-19 prevention-related interventions (Primary and secondary), iii), COVID-19 free interactive communication (pseudo-contact, ICT support to reduce SIL). None of the included studies were related to SARS or H1N1.

Prisma flow diagram illustrating the search strategy
Figure 3 

Prisma flow diagram illustrating the search strategy.

Bibliometric categories

All included articles were published in 2020 or 2021. In terms of geographical distribution, there are five studies from the USA (Abbasi, 2020; Maggie Collison et al., 2020; Lipsitz et al., 2020; Mo & Shi, 2020; E. E. Office et al., 2020), two from France (Dolveck et al., 2021; Sacco et al., 2020), two from Germany (Dichter et al., 2020; Follmann et al., 2021), one from Canada (Siu, Kristof, Elston, Hafid, & Mather, 2020), one from South Korea (Song et al., 2020), one from Australia (Gilbert, 2020), one from the Netherlands (Wammes et al., 2020), one from Brazil (Moraes et al., 2020), and two scoping reviews that include articles from varied countries around the world (Bethell et al., 2021; Mobasseri, Azami-Aghdash, Khanijahani, & Khodayari-Zarnaq, 2020).

Two main classes of findings arose from this review. First, there are PBPs related to preventive measures. Using an intersectional lens (see the framework), as contended by Dichter et al. (2020) and (Flatharta & Mulkerrin, 2020), they are interventions implemented to prevent or mitigate the development of COVID-19 (in the event of an outbreak). The second class includes interventions directly addressing the SIL of LTCF residents, considered proximal interventions. Three subareas are also presented (pseudo-contact, physical contact, and remote communication).

COVID-19 prevention-related interventions

The COVID-19 pandemic resulted in the reorganization of care services, particularly in LTCFs, based on public health recommendations. Despite public health restrictions, families and LTCFs workforce prompted PBPs to addressed SIL experienced by residents. Of the best practices, Song et al. (2020) noted the implementation of systematic screening, temperature taking, and the suspension of external visits to detect possible cases of contamination as quickly as possible. Success was noted in systematic screening, as regular (twice daily) assignment of staff to specific residences or floors to help maintain prompt case detection and clinical management initiation (Song et al., 2020). These were supplemented through the prohibition of family visits and the isolation of staff and residents (Maggie Collison et al., 2020; Gilbert, 2020), as well as through the permanent presence of nursing staff (Dichter et al., 2020; Dolveck et al., 2021). Siu et al. (2020), in the province of Ontario, laid out the following strategies: 1) the active and passive screening of visitors and staff, 2) the establishment of respiratory isolation procedures, and 3) the encouragement of sick staff to take time off work. Finally, Ditcher et al. (Dichter et al., 2020) advocated for the availability of protective equipment for all involved parties.

At a strategic level, Maggie et al. (Maggie Collison et al., 2020) highlighted the development of a procedure guide, and the establishment of a team that is properly trained and prompt to intervene in case of need according to a well-defined framework (Dolveck et al., 2021; Gilbert, 2020). Framing guidelines were reported to be important PBPs to proactively prevent an outbreak and/or to address it. Additionally, all types of resource allocation and their timing were highlighted (Collison et al., 2020).

In addition to these primordial preventive measures (at the clinical microsystem level), facilities used certain practices when an outbreak occurred. These include quarantining positive or suspected cases (Song et al., 2020), breaking the chain of horizontal transmission through the ‘3-tier system’, and isolating infected individuals (Collison et al., 2020). The ‘3-tier system’ consists of forming three separate cohort groups according to one’s COVID-19 test result (or COVID-19 situation) using different colors: positive (red), negative-cleared (green), and negative-exposed (yellow). This allows actions to be taken to prevent contamination among residents. The study by Moraes examined similar elements, although emphasis was given to PCR testing (Moraes et al., 2020). In addition to these interventions directly addressing the spread of the virus, seen as distal tools to combat SIL, this review found proximal approaches to address SIL.

Proximal approaches to address SIL

Three main categories of solutions were implemented (1) pseudo-contact between people, (2) physical companionship and (3) total remote contact using ICT applications (Supplementary Table 2).

Pseudo-contact

The term pseudo-contact is coined to mean a physical contact from a distance. That is, included studies reported a wide range connection format that was implemented for the benefit of families who wanted to go on offering human warmth to their loved older adults while respecting social distancing measures. Pseudo-contact through glass or so-called ‘window visiting’ from the LTCF balcony was laid out by Mo and Shi (2020) and Abbasi (2020) in the USA, Follmann et al. (2021) in Germany and Gilbert (2020) in Australia. Behind a transparent barrier strategy was also used. In that case, family members were asked to stand behind and chat as reported by Wammes et al. (2020) in Netherlands and Gilbert (2020).

Physical companionship

In certain cases, when permitted, some residents spent time with care takers while following rules and guidelines, in aim of addressing SIL. For instance, in Dichter et al. (2020) study, residents took a walk outside with their loved ones to get some fresh air and clear their minds. In similar vein, some LTFs offered the possibilities to families to gather and chat outside in maintaining physical distance. That experience was very satisfactory in terms of communication (Wammes et al., 2020).

Remote contact using ICT applications

Besides these physical contacts, virtual communication was overwhelmingly reported by the studies and varied tools employed. Several formats of communication between older adults in LTCFs and their families were observed, namely (i) phone chat, (ii) voice mail or text messaging, (iii) video chat, (iv) robot use. In Sacco et al. (2020) study, the participants tended to favor telephone calls —ordinary or cellular telephone— to interact with families, but in comparing it with video calls did not find a difference in terms of satisfaction (p = 0.10). Other many included studies demonstrated the effectiveness of phone chatting with LTCFs residents and subsequently preventing their SIL (Abbasi, 2020; Dichter et al., 2020; Follmann et al., 2021; Mo & Shi, 2020; Mobasseri et al., 2020; Office, Rodenstein, Merchant, Pendergrast, & Lindquist, 2020; Wammes et al., 2020).

The second mode of social communication was remote communication through ICT applications that fostered both the relationships between residents and their families, and between residents and their health personnel. Three studies contended the impact of video chat in keeping the older adults connected with their families to subsequently addressing SIL (Gilbert, 2020; Mo & Shi, 2020; Sacco et al., 2020). Third, voice mail and text messaging were also shown to be effective in addressing SIL (Follmann et al., 2021; Gilbert, 2020; Mo & Shi, 2020). These technologies ensured a telepresence to minimize contact between people (caretakers, friends, and families), while maintaining social connections. The scoping review by Mobasseri et al. (Mobasseri et al., 2020) highlights three key usages:

  1. to order services: residents used a web-based ICT platform to order services including ordering meals remotely;
  2. as a COVID-19 preventive tool: Beam Robot 9 was employed to reduce the unavoidable human-to-human contacts, especially care support workers, and to address challenges (ex. insufficient equipment and staff, absence of standards for infection diagnosis, complex needs of residents, staff members who work at more than one facility, untrained workers, and enforcement of quarantine) and;
  3. for social capitalisation: ICT was used to maintain the social ties between residents and their loved ones in the community.

Discussion

This scoping review is part of a large interventional project funded by the Canadian Institute of Health Research (CIHR) aimed at addressing SIL that older adults experience in the context of LTCFs, with a specific goal of summarizing the PBPs implemented in LTCFs during both the COVID-19 pandemic and other recent pandemics.

First, the COVID-19 pandemic has challenged the health of populations in general, with a specific impact on the older adults in LTCFs in particular (Leontjevas et al., 2021). Indeed, the measures put in place have resulted in a disconnect between residents and their families, as well as between residents and their peers within the same LTCFs. It has also contributed to reduce contacts with the staff. This has heightened SIL in our study’s population, a group which is already experiencing or at high risk for SIL.

At the same time, the literature is varied, both in terms of initiatives, as well as in the quantity and quality of studies. Based on the multidimensionality and complexity of SIL among older adults throughout the COVID-19 pandemic, we examined the PBPs implemented through an intersectional lens. Thus, findings showed that the PBPs that were developed embraced multiple layers, from the community level to the LTCFs, in terms of planning and intervention in the context of COVID-19. They have made it possible to both prevent potential outbreaks in seniors’ residences and to slow down or limit the spread when an outbreak occurs. Given the vulnerability of the elderly, asides measures taken in LTCFs, the best approach combined community contamination prevention. In this review, despite the paucity of published literature – certainly due to the time lag for publication – a wide variety of ‘bedside’ PBPs to address SIL have been implemented to rule out COVID-19 and allow residents to maintain connections. For instance, the classification algorithm to prevent the spread of COVID-19 in nursing homes (González de Villaumbrosia et al., 2020).

Second, the heavy preventive measures put in place, play against addressing the ‘Geriatric Giant Symptoms’ described in 1965 by Prof. Bernard Isaacs, namely immobility, instability, incontinence and impaired intellect [cited by (Flatharta & Mulkerrin, 2020)]. Some authors highlight the impact of COVID-19 prevention or control measures on the elderly and their loved ones. Dichter et al. (2020) stated that ‘the current infection control measures clearly have negative consequences, especially for a resident’s mental health status as a result of social isolation’. Solutions were then proposed to allow these residents to maintain contact with loved ones. Chen’s study that underscored the link between staff mobility LTCFs and the spread of COVID-19 (Chen, Chevalier, & Long, 2021) led managers to immediately reorganize staffing, through recruitment, improving staffing ratios, and ultimately assigning staff to one working site.

However, once cases were detected, measures such as restricting access to residences, systematic testing, and regular temperature taking helped to limit the spread of the disease within the residence.

The pinpointed PBPs helped lead to prompt decision making thanks to Task force formation (Dolveck et al., 2021; Gilbert, 2020), the development of a guideline (Maggie Collison et al., 2020) and the 3-tiered cohorting approach. The latter separates exposed individuals from unexposed negative-test individuals among residents, combined with standard measures such as contact and droplet precautions for staff in contact (within 1.5 m) with residents (Maggie Collison et al., 2020), staff self-quarantining and furloughing staff COVID-19-positive contact (Gilbert, 2020); single agency was solicited to replace permanent staff (Gilbert, 2020). Besides, tight guidelines including systematic screening of the entire facility’s residents (and workers, including daytimes users), and several rounds of screening of the entire facility (Moraes et al., 2020; Song et al., 2020) has been shown to be effective. Other strategies were highlighted by Collison et al., such as relocation residents based on testing results, broad infection-control strategies according to the 3-tiered cohorting approach that allows the separation of exposed from unexposed negative-test individuals, and increasing the staffing ratios on the memory unit (Maggie Collison et al., 2020).

Third, based on the findings, managers, frontline healthcare workers, and families all played an important role in implementing PBPs to address SIL in LTCF residents and their interactions have remained active with residents. One of the most prevalent concerns experienced by these individuals, SIL was significantly heightened by the current pandemic. Thanks to the collaborative culture observed worldwide in recent years, LTCFs have increased the role of residents’ families and strengthened their relationship with health workers (L. R. Bangerter, K. Van Haitsma, A. R. Heid, & K. Abbott, 2016).

As widely reported, vulnerable populations, namely residents in LTCFs, experienced disproportionately higher death rates during the COVID-19 pandemic (Akhtar-Danesh, Baumann, Crea-Arsenio, & Antonipillai, 2022). Survivors of the two first deadly COVID-19 pandemic waves, as well as those who live through future waves, will face SIL as a result of restrictive policies placed on LTCFs (e.g., residents being placed in solitary confinement for months, not allowing for residents to have personal contact with their loved ones who live outside the LTCF. As seen in this review, in a very recent knowledge synthesis, Choi and Lee (Choi & Lee, 2021) noted that robots (humanoid, animal and mobile) started to be implemented pre-COVID-19.

The public health restrictions have led to the restrictions related to numerous activities in LTCFs as well as outing activities for residents. Similarly, in a large survey comprised of 128 LTCFs, 79% of residents lacking social contact reported experiencing a deterioration in their health (Alzheimer’s Society, 2020). Clearly as shown in the present review (e.g., Mobasseri et al., 2020; Sacco et al., 2020; Wammes et al., 2020), the study of Fearn et al., 2021 contended that remote befriending project positively impacted residents and help to mitigate SIL and subsequent outcomes such as depression, stress, and the like. Befriending is a regular one-to-one conversation about topics concerning both parties (Balaam, 2015).

During the COVID-19 pandemic, LTCFs’ residents had less contact with family/friends (Betini, Milicic, & Lawand, 2021) while group or one-to-one leisure activities (activity, support, internet training, home visiting, service provision) shown to reduce SIL (Dickens, Richards, Greaves, & Campbell, 2011; Windle, Francis, & Coomber, 2011) were interrupted. Only some of these activities were able to be adapted to a virtual format. That is, apart from pseudo-contact PBPs, such as discussing with a loved one by using a balcony (Abbasi, 2020; Gilbert, 2020; Mo & Shi, 2020) or behind glass (Follmann et al., 2021; Gilbert, 2020; Mo & Shi, 2020; Wammes et al., 2020), and interactive virtual forms of socialisation (Abbasi, 2020; Follmann et al., 2021; Mo & Shi, 2020; Mobasseri et al., 2020; Sacco et al., 2020; Wammes et al., 2020), many interventions were devoted to preventing or stopping the transmission of the virus.

The restrictions imposed upon older adults raised issues of human rights restriction (Litins’ka & Karpenko, 2020) particularly in nursing homes (Hartigan, Kelleher, McCarthy, & Cornally, 2021; Ladiesse, Léonard, & Birmelé, 2020). Abbasi’s paper (Abbasi, 2020) pinpointed the effectiveness of pseudo-contact, notably balcony chatting, but further laid out a questionable therapeutic approach in the use of psychotics.

In addition to these proximal PBPs addressing the link between SIL and social interactions among LTCF residents, innovative interventions were also undertaken to either prevent or minimise the transmission of the virus in terms of COVID-19 prevention and case management. Prevention-related interventions that directly prevent outbreaks, subsequently ensure residents in breaking their fear; also contribute to reducing SIL among residents in the context of quarantine or congregation (Dichter et al., 2020).

Strengths and limitations

To the best of our knowledge, this is one of the first scoping reviews to examine the PBPs implemented in LTCFs during the COVID-19 pandemic. During the pandemic, it has become evident that technologies can be the lifeline between residents and their loved ones outside the LTCF, in addition to supporting overworked LTCF staff (Eghtesadi, 2020; Flint, Bingham, & Iaboni, 2020). In addition to the proximal PBPs offering interaction opportunities for residents and their families, the use of an intersectional lens of analysis laid out distal PBPs health interventions (e.g., screening and testing). It is worth noting that our review did not capture any literature describing PBPs implemented during the two last major pandemics, namely SARS (which took place in 2003) (Skowronski et al., 2005) and H1N1 (which took place in 2009) (Alenzi, 2010). Despite the plausibility of the hypothesis that minority groups (sexual, linguistic, etc.) might be at an increased risk and therefore benefited from specific approaches, none of the studies provided evidence for this. None of the studies has neither informed on the interactions that residents without families have benefited. The low yield (16 studies) of this review is certainly due to the recency and on-going status of projects, as we came across several relevant protocols for ongoing studies.

Finally, as it could be seen, we did not find any studies on that subject dealing with SARS or H1N1; nor any studies devoted to COVID-19 immunisation, even though this action has critically decreased mortality among LTCF residents (Macchia et al., 2021).

Conclusion

Greater efforts are required to further develop research on the barriers that older adults in LTCFs encounter, and to tailor initiatives that address SIL and strengthen infection control in LTCFs. This scoping review found two classes of approaches implemented to address SIL experienced by residents that included (i) proximal strategies such as remote connection, physical pseudo-contact or direct contact, and (ii) COVID-19 prevention-related interventions as distal PBPs. Given the substantial evolution of evidence over the pandemic, this study provided the opportunity to contextualize the interpretation of the results, and more importantly, to understand the possible evolution of PBPs based on the evidence. Internet access becomes essential to support social connectedness and enhance residents’ quality of life and well-being, but LTCFs remain the least computerized of the health systems (Inforoute Santé Canada, 2020; Ontario Association of Residents’ Councils, 2020; Saskatchewan Health Authority, 2019). Widespread adoption of various technologies in LTCFs has been largely impeded by limited wireless access (Eghtesadi, 2020). From lessons learnt from the COVID-19 epidemic, other efforts are needed to improve LTCFs’ residents overall wellbeing including redesigning the architectural structure of buildings (e.g., single rooming policy) (Office of the Premier, 2020; Sinha, 2020; Stall, Jones, Brown, Rochon, & Costa, 2020) and increasing staffing levels in LTCF (Britten, 2020). Of all the lessons that the COVID-19 pandemic has taught us, as promoted by health policy makers elsewhere in the world, aging in place policies should be increasingly prioritized.

Data Accessibility Statement

The datasets generated and/or analysed during the current study, that would be necessary to interpret, replicate and build upon the findings reported in the article, will be made publicly available as requested by the funding institution.

Additional Files

The additional files for this article can be found as follows:

Appendix 1

Inclusion and exclusion criteria: Participants, Interventions, Outcome, Time and Setting (PIOTS). DOI: https://doi.org/10.31389/jltc.138.s1

Appendix 2

Concept Plan. DOI: https://doi.org/10.31389/jltc.138.s2

Supplementary Table 1

Full characteristics of the studies included in the review. DOI: https://doi.org/10.31389/jltc.138.s3

Supplementary Table 2

Included studies characteristics. DOI: https://doi.org/10.31389/jltc.138.s4

Abbreviations

LTCF: Long-term Care Facility

CFHI: Canadian Foundation for Healthcare Improvement

CIHR: Canadian Institutes for Health Research

SIL: Social Isolation and Loneliness

Ethics and Consent

As this scoping review is part of a ‘Social isolation and loneliness project’, we received ethical approval from the Ethics Committees for Research of the University of Ottawa (H-08-21-7314) the University of Moncton (dossier 2021-073) and the Research Ethics Board of the Primary Care and Population Health Research Sector of the CIUSSS of the Capitale-Nationale (2021-2303, _SPPL).

Patient Involvement

No patient will be involved. Patients will not be invited to comment on the study protocol design and were not consulted as to how this work may inform patient-relevant outcomes or how a patient might interpret results. However, findings will be disseminated to the public and the healthcare professional networks via conferences, publications, and presentations.

Acknowledgements

This paper stems from the research grant protocol of the PI’s research program on aging and health technology, granted by the Canadian Institutes for Health Research (CIHR) for the program ‘Implementation Science Teams – Strengthening Pandemic Preparedness in Long-Term Care’. We are grateful to the project partners namely: Réseau Compassion Network; Résidence Despins-Villa Aulneau; Jeffery Hale and Saint Brigid’s Home (Quebec); and Manoir Edith B. Pinet Inc. and Résidences Lucien Saindon (New Brunswick). Thanks go to Émilie Bélanger for her contribution to the language edition.

Funding Information

This is project is funded by the Canadian Institutes of Health Research (CIHR) for the program ‘Implementation Science Teams – Strengthening Pandemic Preparedness in Long-Term Care’ (Operating Grant funds: FRN 174865) [https://webapps.cihr-irsc.gc.ca/decisions/p/main.html?lang=en#fq=%7B!tag=pinames%7Dpinames%3A%22Beogo%20%20Idrissa%20%20Lussier%20%20Daniel%22&sort=namesort%20asc&start=0&rows=20]. The CIHR had no role in the process (study design, execution, data analyses, or publication of findings).

Competing Interests

The authors have no competing interests to declare.

Author Contributions

IB conceived the initial idea for the study, designed the search strategy, and is the guarantor of the review. IB, SD, NJ-CB, MPG and ETN were involved in drafting ideas and in a preliminary literature review and provided their expert input on LTCFs. They were also involved in revising drafts of the manuscript. NJ-CB lead data extraction and closely worked with IB to verify all details before submission. All authors read and approved the final version of the manuscript.

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