Authors: Dr Tamara Sussman, McGill University, Ms. Susan Mintzberg, McGill University Canada and Dr Sharon Kaasalainen, McMaster University Canada
Date of publication: April 2021
Keywords: moral distress; family visitation; compassion
Over the past year, many nursing home residents have died without their loved ones by their side due to COVID 19 family restricted access measures. Nursing home staff who often rely on the presence of families for individualised support to residents, have had to adapt to restricted family visitations. Residents have suffered, families have suffered, and nursing home staff, who have been left to support ill and dying residents without family support, have also suffered. Deployment of extra employees from other sectors has done little to alleviate the heart ache of residents left without the physical contact and emotional support family visiting provides. Staff working at the front-lines in nursing homes have been placed in the impossible position of witnessing resident loneliness and suffering. This experience has had a profound and lasting psychological effect on staff 
At the onset of the COVID-19 pandemic, families across the globe were forbidden to visit their relatives in nursing homes. Twelve months in and, in Canada, restricted visitation remains in place in the hopes of controlling the spread of COVID-19 in nursing homes. Myriad of reports and opinions have emphasised the collateral damage such restrictions have caused to residents and families [2, 3]. Yet, little has been said about the impact on staff working within nursing homes.
Family carers are often described as the invisible front-line workers in our health care systems. They offer personalised support and care that over worked staff do not have the opportunity to provide. Without their presence for meals, information, companionship, and connection, demands on staff become overwhelming. At the height of the pandemic, in the absence of families, gaps in care exploded, as did the workload. In some cases residents unable to feed themselves became dehydrated; those with incontinence remained for hours in soiled clothing, and when dying many were alone [2,4]. Families who had been an active part of daily care were left on the outside, in some cases with limited communication. Staff, the only source of human contact for residents, were overworked responding, with insufficient resources, to added public health protocols such as monitoring resident adherence to safety procedures and serving meals in rooms instead of dining halls.
Support staff such as nursing, recreational and dietary assistants who provide over 80% of the hands-on care in nursing homes and often know the residents best because of daily and intimate interactions, were especially impacted . They regularly witnessed the suffering that resulted from the restricted visiting measures in place. In findings from our research support staff described the torment of knowing residents were dying alone, as workloads often impeded them from being by their side at the end of life .
Study after study has documented the mental health impacts of COVID-19 on nursing, physicians and other allied health professionals, yet the voices of these essential support workers have not been heard [1, 6-7]. Like families, these front line workers are the invisible backbone of our nursing home system. That many workers are now leaving the Canadian nursing home sector at unprecedented rates should serve as a critical indicator of the moral distress we have placed upon them .
Families are not only visitors in nursing homes; they provide much needed support to a healthcare system that undervalues, underestimates, and underfunds the essential work of staff in nursing homes . The COVID-19 restricted family access measures during the pandemic highlighted the daily pressures placed on overworked support workers. It is now of vital importance that we acknowledge and address the damaging impact that these measures have had on staff in nursing homes.
Moving forward, it will be essential to address how the approach to care within nursing home settings, where physical safety is prioritized over compassionate care, is impacting residents, their families and staff. Creating a culture that recognises the value of compassion  and offers an environment that encourages and supports staff to fulfil the compassionate care they have been trained to deliver, will improve the quality of life for residents in nursing homes while mitigating the distress of families and staff [ 9]. Let us emerge from this pandemic wiser, stronger, and committed to improving the shortcomings exposed in nursing homes this past year.
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Meet the authors:
Dr Tamara Sussman, McGill University Canada, mySupport study partner lead
Dr Tamara Sussman is an Associate Professor with the School of Social Work at McGill University. Her research focuses older persons’ and family/friend caregivers’ experiences with and access to in-home community supports and long-term care homes. Her recent projects aim to improve communication about preferred end of life care between older people, families/friends and care providers. [https://www.mcgill.ca/socialwork/about/people/faculty/sussman]
Selected journal publications:
Sussman, T., Pimienta, R., & Hayward, A. (2020). Engaging persons with dementia in advance care planning. Challenges and opportunities. Dementia. The international journal of social research and practice. 0(0), 1-6. https://doi.org/10.1177/1471301220973059
Sussman, T., Kaasalainen, S., Bimman, R.,* Punia, H., Edsell, N., & Sussman, J.(2020). Exploration of the acceptability and usability of advance care planning tools in long term care homes. BMC Palliative Care. 19 (179). https://doi.org/10.1186/s12904-020-00689-9
Susan Mintzberg, McGill University Canada, mySupport early career collaborator
Ms Mintzberg, is a PhD candidate in the School of Social Work at McGill University. Her doctoral research explores the role of family caregivers in psychiatry with a focus on collaboration between family members and mental healthcare professionals. This work evolved from ten years of clinical practice with individuals and families in community mental health.
Selected media publications:
Mintzberg, S. (2020, April 13). It’s essential to let families back into seniors’ residences. Opinion-Montreal Gazette. https://montrealgazette.com/opinion/opinion-its-essential-to-allow-families-back-into-seniors-residences/
Mintzberg, S. (2020, May 4). Seniors dying of a broken heart, alone and afraid without their families’ support. Opinion-Toronto Star. https://www.thestar.com/opinion/contributors/2020/05/04/seniors-dying-of-a-broken-heart-alone-and-afraid-without-their-families-support.html
Mintzberg, S. (2020, June 2). Why did it take armed forces reports to get attention? Opinion Montreal Gazette. https://montrealgazette.com/opinion/opinion-only-some-heroes-are-getting-listened-to
Mintzberg, S. (2020, May 14). Mintzberg: One way to fix the manpower crisis in long-term care – let the families back in. Opinion-Ottawa Citizen. https://ottawacitizen.com/opinion/mintzburg-one-way-to-fix-the-manpower-crisis-in-long-term-care-let-the-families-back-in/
Dr Sharon Kaasalainen, McMaster University Canada, mySupport study partner lead
Dr Kaasalainen, is a Professor and the Gladys Sharpe Chair in Nursing at McMaster University. She is also an Associate member of the Department of Family Medicine at McMaster University. Dr Kaasalainen’s research program is focused on improving the quality of life for people living in long term care homes with a particular focus on implementing a palliative approach in dementia care.[https://nursing.mcmaster.ca/faculty/bio/sharon-kaasalainen, https://www.spaltc.ca]
Selected Journal Publications:
Kaasalainen, S., Sussman, T., Thompson, G., McCleary, L., Hunter, P., Venturato, L., Wickson-Griffiths, A., Ploeg, J., Parker, D., Sinclair, S., Dal Bello-Haas, V., You, J., and the SPA-LTC team (2020). A pilot evaluation of the strengthening a palliative approach in long-term care (SPA-LTC) program. BMC Palliative Care.19(107), 2-12. https://doi.org/10.1186/s12904-020-00599-w
Kaasalainen, S., Sussman, T.., Thompson, G., McCleary, L., Hunter, P.V., Venturato, L., Wickson-Griffiths, A., Sinclair, S., Dal-Bello Haas, V., Earl, M., Ploeg, J., Hill, C.,** Parker, D. & You, J. (2019). A Stakeholder Analysis of the Strengthening a Palliative Approach in Long Term Care (SPA-LTC) Model. Canadian Journal of Nursing Leadership, 32(3), 27-39. DOI: 10.12927/cjnl.2019.25974