Nursing Students Visiting People with Dementia Online during COVID-19: A Qualitative Study

Abstract The coronavirus disease 2019 (COVID-19) crisis has impacted the daily routines of students, people living with dementia, and their care partners. Social distancing results in fewer interpersonal interactions and enjoyable activities which makes life more challenging for those living with dementia. The purposes of this multiple case study were to understand how nursing students, people with dementia, and care partners (a) describe online visits between nursing students and people with dementia during stay-at-home directives in response to COVID-19 and (b) the perceived visit benefits. Nursing students participated in online visits to socially engage with their mentor (person living with dementia). During the visits it was anticipated that care partners would enjoy a brief respite. After 12 visits, investigators completed one-to-one online interviews with students (n = 10), care partners (n = 8) and mentors (n = 8). All cases reported a positive experience, perceptions of the conversations, improved social connection and meaning and purpose, mentor’s enhanced cognition and planned future connections. Relationships were formed between students, people with dementia, and care partners during online visits, an activity that might be implemented outside of a crisis to prevent social isolation across generations. Future efforts to engage people with dementia in residential facilities should be formally integrated into the care plan and staff dedicated to help with technology assigned.


Introduction
Social distancing or limiting face-to-face contact is the best way to reduce the spread of COVID-19 (Centers for Disease Control and Prevention [CDC], 2020) and has become the new normal. However, social distancing results in fewer interpersonal interactions and enjoyable activities. A dementia diagnosis results in loss of relationships and social roles (Blais et al., 2017;Galbraith et al., 2015) and stigma (Gove et al., 2016) ultimately leading to social isolation. Stay-at-home directives brought on by COVID-19 potentially compound dementia-related social isolation causing older adults with dementia to experience psychological or behavioral symptoms of dementia such as anxiety, anger, stress, agitation or withdrawal (Jiloha, 2020). New opportunities to provide and exchange social support are called for. Online meeting applications provide an opportunity for people to connect face-to-face and offer young and old the ability to work together and save lives by limiting contact. Intergenerational programs (IGPs) bring different generations together for shared activities (Galbraith et al., 2015) and can positively impact both older and younger generations. The aim of this study was to examine the feasibility and impact of nursing students visiting with people with dementia online during COVID stay-at-home restrictions.

Literature review
CINAHL, PubMed, and Google Scholar were searched for intergenerational intervention studies involving young adults and people with dementia. The following search terms were used: intergenerational, intergenerational programs (IGPs) and dementia, and social isolation and dementia; searches were limited to English. One review (Gerritzen et al., 2019), three quantitative and five qualitative articles which explored the impact of IGPs on young adults and people with dementia were located. Reference lists were reviewed for additional sources with no additional studies identified.

Social isolation for people with dementia during COVID-19
Social isolation during COVID-19 had a negative impact on people with dementia. Lack of activity engagement and social isolation resulted in reduced self-confidence, feelings of low self-worth, being undervalued, and depressed, (Talbot & Briggs, 2021). Increased behavioral and psychological symptoms of dementia (BPSDs), loneliness, and anxiety were also reported (Parish, 2021). Pandemic restrictions and social isolation caused faster deterioration for people with dementia (Talbot & Briggs, 2021) which in turn caused worsening functional disabilities, BPSDs and increased risk of premature death (Kimura et al., 2020).  Gerritzen et al. (2019) performed a scoping review and identified elements that promoted successful IGPs involving people with dementia. Successful elements relevant to young adult participation included: (a) buddy systems to promote relationship building, (b) dementia education to facilitate knowledge and positive attitudes, (c) careful planning and preparation, (d) student reflection, and (e) reminiscence programs. Diverse dementia inclusion criteria and various age groups of younger participants make it difficult to generalize findings or compare program elements across studies. Tables 1 and 2 present results by type of intervention and sample.
Quantitative studies examined the effect of reminiscence (Chung, 2009) and art (Lokon et al., 2020(Lokon et al., , 2017 programs on young peoples' dementia attitudes (Lokon et al., 2020(Lokon et al., , 2017 and dementia knowledge (Chung, 2009). Chung (2009) also examined the effect of reminiscence on quality of life (QoL) and depression for persons with dementia. Both the reminiscence and art programs involved weekly meetings for an hour and a half over 12 weeks. The reminiscence program significantly improved QoL and reduced depressive symptoms for older participants with dementia and improved dementia knowledge for young adults (Chung, 2009). Youths' responses to 19 out of 20 items on the Dementia Attitude Scale (DAS) significantly improved after participating in the Opening Minds through Art (OMA) program (Lokon et al., 2017). Moreover, a large effect on the overall DAS and the social comfort subscale and a moderate effect for dementia knowledge were reported (Lokon et al., 2017). No difference in attitude as measured by the Allophilia (liking another person) Scale was noted between students who participated in OMA and a no-treatment comparison group; however, the intervention had a large effect for allophilia, affection, comfort/kinship, and a moderate effect for engagement and enthusiasm (Lokon et al., 2020). Qualitative findings suggested that IGPs had diverse effects on young adults, persons with dementia and care partners. Interventions included the performing arts (Dassa & Harel, 2020), conversation and structured activities (Guerrero et al., 2017), an intergenerational choir (Harris & Caporella, 2014, and OMA (Lokon et al., 2012). Young adults connected with people with dementia (Dassa & Harel, 2020;Harris & Caporella, 2019), enjoyed time together (Harris & Caporella, 2014;Lokon et al., 2012), and formed friendships (Lokon et al., 2012). As a result, young adults gained greater understanding of dementia (Guerrero et al., 2017;Harris & Caporella, 2014, a positive attitude (Lokon et al., 2012) and reduced stigma toward people with dementia (Harris & Caporella, 2014Lokon et al., 2012). They learned to see beyond the disease (Dassa & Harel, 2020) and appreciated capabilities of people with dementia (Harris & Caporella, 2014 and how they coped with challenges (Lokon et al., 2012). Engagement stimulated young adults' honor and admiration for people with dementia (Dassa & Harel, 2020). Care partners and people with dementia enjoyed time with young adults and reported decreased isolation (Harris & Caporella, 2014) and a greater sense of community (Harris & Caporella, 2019). Further, care partners felt that the socialization and stimulation kept the mind active for their family member with dementia (Guerrero et al., 2017).

Theoretical framework
The Need-driven, Dementia-compromised Behavior (NDB) Model (Algase et al., 1996) provided a foundation for the intervention and potential outcomes. The NDB model suggests that background and proximal factors, independently or combined, have the potential to result in behavioral and psychological symptoms of dementia. Symptoms are the expression of an unmet need or goal. Background factors include the individual's stable cognitive, neurological, health and psychosocial factors. Proximal factors are more fluid in nature and reflect environmental and social influences as well as an individual's fluctuating needs. People with dementia reported that friends abandon them upon learning about the diagnosis (Devlin et al., 2007) adversely affecting their socialization (Katsuno, 2005). Lack of social connection is a proximal factor compounded by reduced visitation during COVID-19 stay-at-home directives.

Purpose, research question and propositions
Most of the literature examined the impact of IGPs on young adults, few examined outcomes for people with dementia and their care partners. The purposes of this study were to understand how nursing students, people with dementia, herein referred to as mentors, and care partners (a) describe online visits between nursing students and people with dementia during stay-at-home directives in response to COVID-19 and (b) the perceived visit benefits for people with dementia. The research question was: To what extent does the NDB model explain the relationship between social connection made during online visits with nursing students and behavioral and psychological symptoms for people with dementia?
Theoretical propositions in case study research serve to guide a study and provide the foundation for analytic generalizations (Yin, 2018). For the purpose of this study propositions considered during data analyses included: (a) mentors experienced social isolation during stay-at-home directives, (b) online visits with nursing students decreased social isolation for mentors, and (c) online visits with nursing students contributed to reduced behavioral and psychological symptoms of dementia for the mentors.

Design
A multiple case study design was used to explore how nursing students', mentors' and mentors' care partners experienced online visits during COVID-19 stay-at-home directives and perceived visit benefits. For the purpose of this study, three cases included the following groups: students, mentors and care partners. Case study research aims to explain contemporary phenomenon (Yin, 2018), in this case, social connection via online visits during COVID-19. Case study research can reveal potential complex causal links beyond the scope of survey methods and inform why an intervention worked (Yin, 2018). Further, case study has the potential to shed light on theoretical concepts which can provide a framework for generalizing findings (Yin, 2018). No research was located to suggest possible outcomes that might result from students visiting people with dementia online during a pandemic and the NDB model provided propositions to guide the intervention and explain findings.

Ethical considerations
Institutional Review Board approval was obtained from the universities where investigators are employed. The study was explained during videoconference meetings with individual care partner and mentor dyads and a student group. All participants provided signed informed consent without any assistance. Investigators were not faculty of record for any courses in which students were enrolled. No personal identifiers were collected or identified in interview transcripts to preserve anonymity and confidentiality.

Cases
In case study research, a case might be a single person, small groups such as families, communities, organizations, or events (Yin, 2018). In multiple case studies individual cases predict comparable and/or contradictory results (Yin, 2018). Analytic generalizations can be made based on one or several cases (Yin, 2018). Three cases: students, mentors and mentors' care partners, were purposefully recruited to offer diverse perceptions of the phenomenon. Recruitment took place during May and June 2020. Undergraduate nursing students were recruited via e-mail flyer by the primary investigator. Students were eligible if they had completed either the Behavioral Health Nursing course or the elective, Care of People Living with Dementia. Mentors and care partners were recruited via e-mail flyer from local community organizations dedicated to early-stage dementia support. Eligibility for mentors included a self-report of dementia and ability to consent to study; care partner eligibility was the willingness to participate and ability to consent to study.

Intervention
The intended intervention, which took place between May and August 2020, consisted of 12, 10-minute visits between the nursing student and their mentor three times a week. The goal of the online visits was for nursing students to socially engage with their mentors. It was anticipated that care partners would assist mentors with getting online then enjoy brief respite. Before visits commenced, students attended a one-hour online orientation with the coinvestigators. Talking points included dementia basics, visit topics, guidelines, and expectations, which covered the need to discuss termination of visits on first visit with subsequent reminders. Students who were paired with a person living with dementia based on availability, contacted their mentor and the mentor's care partner and scheduled online visits.

Measures
Participants completed a demographic questionnaire. Separate interview guides for each case queried participants about their experiences with online visits, the best part, what could be improved, and what was gained from the experience.

Data collection
After the visits, investigators recorded all one-to-one online Zoom interviews with students, care partners and mentors. Interviews lasted between four and 37 minutes. Data was collected between June and September 2020.

Data analysis
Interviews were transcribed verbatim and verified. Researchers simultaneously listened to audio recordings of the interviews and read transcripts correcting any errors made during transcription. Frequency and percentages were computed to describe the characteristics of the sample. Qualitative analysis was performed, simultaneously with data collection so that earlier findings informed later interviews; no revisions to interview guides were necessary. With the NDB model and propositions as a backdrop, each co-investigator coded the raw data and identified categories. Researchers compared, discussed and resolved discrepancies, and together identified patterns across cases and collapsed themes. Yin (2018) suggests methods to promote construct, internal, and external validity and reliability. Construct validity was achieved via multiple sources of evidence, the three cases, multiple researchers coding and discussing data, and member checking. Internal validity was ensured via pattern matching across cases and explanation building. A theory-based study promotes external validity and a study protocol and interview guides ensured reliability. Researchers avoided and challenged one another regarding inferences or assumptions. Two students, one mentor and one care partner provided feedback on a draft of the findings (Glaser & Strauss, 1967). Participants felt that the experience was accurately represented, and no revisions were required.

Findings
Ten students, mentors and care partners were recruited; all students who initially volunteered completed visits. Nine students and mentors completed 10 or more visits. Data were collected from 10 students, nine mentors and nine care partners. One mentor lived in a residential setting and did not have the support necessary to complete all visits. Details are provided later in this section. Demographics represent all student participants, mentors, and care partners from whom data was collected. Students were all females with mean age of 24.4 years (range 21-36 years); five students mentioned having a family member with dementia. Mentors included five females and five males with a mean age of 71.6 years (range 58-84 years). All lived at home with spouses except for two females who lived with daughters and one lived in a long-term care facility. Care partners included seven females and three males with a mean age of 63.3 years (range 45-77 years). Excluding the mentor in assisted living, the average number of visits/students was 11 and the total number ranged from 9-12; visit length ranged from 10 minutes to 62 minutes, with a mean of 30 minutes. The number of visits varied because of student and mentor schedule and travel conflicts.
Students, mentors, and care partners, reported a positive experience, perceptions of the conversations, improved social connection and meaning and purpose, mentor's enhanced cognition and planned future connections. Some care partners and mentors reported unclear expectations; care partners and students commented on technology and students shared perceived benefits. One student shared her experience engaging with an assisted living resident. Mentors' and care partners' perceptions are represented. Themes are presented according to cases from which data emerged.

A positive experience
Across the three cases, visits were described positively. The visit experience was described as "beautiful" (care partner), "I enjoyed and looked forward to it" (mentors and students), "fun" (mentors and students), "I loved it; it was the best thing" (student) and "uplifting and joyful" (mentor). A care partner found visits "relaxing" and a mentor said that they "keep me going." Mentors and students reported that visits helped "decrease boredom." One student eloquently shared: (visits) brought a lot of joy to my days . . . I knew it was going to be a great day because she was just so fine . . . she made me feel important, especially right now when I can't really talk to anybody.

Conversations
Respondents across cases shared perspectives about the conversations. Care partners and students recognized the need for conversation starters. A student reported, You had to plan (topics) in the beginning, but once you've figured out what he enjoyed talking about and what he lit up and could talk a lot about, it was very easy to kind of pinpoint those things . . . By the last couple weeks, there was really no need for (planned topics) because I'd be like, 'How's the family? How's everything?' And we'd catch up.
Two care partners helped mentors plan topics of conversation and shared with the student before the visit: "We (care partner and mentor) would talk and we'd send her (the student) a few things that might get (mentor) talking." One care partner assisted the mentor by asking prior to the visits, "what would you like to talk about with (student's name)?," which "gave me and (mentor) something to talk about and he had fun sharing it with (the student)." Another care partner engaged her mother in keeping a journal in which she would "jot down daily activities and important things . . . to tell (the student)." A student shared, "(my mentor's daughter) would show her (mentor) a picture of me and say what we we're going to do" and would text the student "about thirty minutes before to kind of let me know if there's anything I needed to know . . . if she was anxious or nervous or if she was having a good day." Four student and mentor dyads shared an interest in medicine which facilitated conversation; "I had fun because I used to work as a nursing assistant, and so I got to have fun talking with her about my experience in the emergency room" (mentor). Other mentors said, "(the best part) was just having the conversation" and "(visits) made me think about things and say words and conversation."

Benefits derived: social connections
Students, mentors and care partners expressed making social connections. Several students mentioned the social connection during the pandemic was positive: "It was nice for me to have a set person that I could talk to, especially when it was harder . . . to get to talk to as many people especially during isolation," "(the visits) gave us something that we knew we had that day because there's not a lot going on right now," and "I've been around the same 10 people since this started. It was good to just meet someone new and get a completely new perspective . . . it was like catching up with an old friend." A care partner described benefitting from the social connections stating, "they gave us something meaningful to talk about during the pandemic." One mentor enjoyed "having the someone to laugh at my jokes." A care partner valued the connection with the student declaring, "she is more like one of the grandkids than just a student."

Benefits derived: meaning and purpose
An additional theme across cases was gaining meaning and purpose in life. Mentors stated they often feel discouraged due to their inability to work, "sometimes I think that my brain, because of my dementia, makes me not very valuable." One care partner stated, "it really encouraged him (mentor), I think, to feel part of something" while a mentor stated, "I felt like it was good to give back a bit." Another care partner said, "It gives both of us (care partner and mentor) still purpose in a way to give back and feel like we're still engaged." A student concurred stating: I thought this was a really great opportunity to-especially with all the free time we all have right now, to get to learn more because I do feel like I'm like losing so much of my knowledge in these last four months or however long we've been here (away from campus/school). I just feel very-I feel like I have enough knowledge to be helpful, but not enough to do something in this-I just felt very like, "What is my purpose? What am I-?" because I can't finish school, but I can't go help. So, this was a perfect opportunity to . . . feel like I was doing something.

Benefits derived: improved cognition
All cases believed online visits had the potential to improve mentors' cognition. A mentor stated, "I sometimes felt like I was able to remember things." Care partners reported "anything that's social interaction and is stimulating his brain is helpful," "COVID isolation tends to bring out his dementia a little bit. I think it's because it's physically and mentally straining. And this, I think, was very good for him" and I think she really enjoyed the visits because it helped her cognitive ability . . . (The visits) gave my mom an opportunity to have contact, because I feel like she has declined a little bit without the social interaction that she normally is able to have when it's not COVID circumstances.
Students voiced similar perspectives: "He actually started remembering who I was and remembered things from our previous conversations, which was really awesome because I wasn't expecting that at all . . . so we were able to build that relationship" and "retracing his memories, talking about his guitars and his profession and her profession, how they met, just various things like that" (helped mentor with his cognitive abilities). According to a care partner, scheduled visits "kept him on a schedule . . . he has things that he has to do."

Future connections/interactions
Relationships developed over a short period of time and many intended to continue connecting online. One mentor and care partner stated they "hope to keep in touch and send her graduation gifts and just keep this an ongoing relationship." One student stated, " . . . it's not something that has to end. I can keep talking and meeting with them." A care partner mentioned we would "not hesitate to contact her if we had any questions."

Similar codes across care partner and mentor cases: unclear objectives
The aim of the visits caused confusion for some mentors and care partners. Some were unclear if the visits were intended to be educational or social. One mentor stated, "I was not really sure the purpose" while another voiced concern for the student, "is there something we need to talk about to meet your (student) objective?" Additionally, a care partner mentioned, "there wasn't any really set agenda or list of objectives." For future clarity, a mentor recommended that the researchers provide a list of objectives at the onset of the visits.

Similar codes across care partner and student cases: technology
Technology worked well: "we had a couple of times where it was tough to get the links to come in right . . . I think the first time was the hardest. And then after that, it worked pretty good" (care partner). Many care partners and students denied having technology difficulties. Student observations included "honestly, it was nice being on Zoom because it was doable anywhere"; "meeting online actually went really well" and "if anything, I think it (computer) was beneficial for us because we could move it around and show each other what we were talking about." Care partners confirmed limited issues with technology: "it wasn't a hardship," "(it) probably would have been (a challenge) except that when everything shut down our church services are online . . . he (mentor) has been using Zoom since April or March."

Perceived benefits for students
Students discussed growth in the areas of confidence, insight, openness, and patience. Improved confidence was evident, "I've learned a lot about myself . . . I'm more confident in my ability to talk to my patient outside just their nursing care." Insights were gained, "She was giving me insight on personal things in my life when we talked . . . like (a) mentor relationship," "to fully understand their diagnosis and what they're going through has really given me just a lot of insight." A mentor concurred stating, "(visits) gave them (students) insight into the life of a person who is living with dementia." The importance of having an open mind was reinforced "never make assumptions and not see people . . . he's such a great person and there's so much more to him than his diagnosis. And there's just so much we can learn from people with this diagnosis" (student). Finally, students recognized that patience was enhanced, "it really does open your eyes because patients that I've worked with . . . can get very frustrating, and it's easy for nurses and techs to lose their patience," and "patience is something that I feel like anyone who does this in the future has to come in with." Students gained dementia knowledge particularly related to early-stage dementia. Students shared: "I learned a lot about early-stage dementia," "seeing someone who's recently diagnosed really gave me a fresh perspective on kind of the earlier stages . . . what the coping process is like for her," and "I also learned a lot about support in the earlier stages of dementia." Further support of dementia knowledge included a mentor who described "dementia episodes" caused by migraines and sleep apnea, "In regard to dementia, his type was so unique to learn about, I learned that, and that it can manifest in so many different ways and ways that we don't even think would exist."

An aberrant experience
One student reported an unsatisfactory experience which involved a mentor in an assisted living facility. Contributing factors included scheduling, "I would get on Zoom and she (assisted living staff) wouldn't show up," the severity of the mentor's dementia symptoms "we kept covering the same information and it was going in circles," distractions "and then you had her care provider on a different (phone) conversation in the room, kind of distracting her," and technical issues "I think technology was a hindrance." In summary, the student said, It was very difficult and frustrating . . . I didn't want to give up and I didn't want to let anyone else down. I tried and tried but it just didn't work out how we planned. And it eats me a lot.

Mentors' perceptions
Mentors provided positive evaluations of the visits. When asked what they gained, a mentor stated, "I think I gained a friend." When asked "what could have been better?" mentors responded with "I just had a wonderful time," "I'm satisfied with the way it was," and "I really don't have any criticism particularly." Suggestions for future visits included, "She might have asked me a few more questions like what my childhood was like or the past and what the dementia is all about," and "I think if you can continue to get people of the quality of (student's name) and willing to open up on their end, because them being open with us has a lot to do with how much we can open up to them."

Care partners' perceptions
Care partners provided unique perspectives about the visits. One care partner acknowledged, "I do think it made her (mentor) feel like someone cared about what she had to say, sometimes more than family does." Another care partner said, "There was a significant impact on me, because it gave me the opportunity to observe how my mom relates and what she remembers in conversation with another individual" and As a result of seeing her interactions and getting a better gauge on what she could remember and not remember, I decided personally to take advantage of one of the programs that the Alzheimer's Alliance puts into effect, and that's the Project Lifesaver bracelet band.

Discussion
Two of the three study propositions derived from the NDB model were supported by the data. Mentors' social isolation was compounded during COVID-19 stay-at-home directives. Online visits with nursing students provided mentors with positive social connections, a proximal factor. All cases agreed that online visits with nursing students contributed to mentors' improved cognition. However, no data supported reduced behavioral or psychological symptoms of dementia.
Our original and primary aim when designing the study was to reduce mentors' social isolation during COVID-19 stay-at-home directives. However, as with earlier research, benefits were recognized across cases. Previous adults with dementia and younger participants enjoyed IGPs (Harris & Caporella, 2014;Lokon et al., 2012) and improved social connection (Dassa & Harel, 2020;Harris & Caporella, 2014Lokon et al., 2012), findings which are supported by current data. Improved cognition for the person with dementia (Guerrero et al., 2017) was reported earlier and is consistent with study findings. As a result of online visits, students gained improved confidence as reported by Lokon et al. (2012) and identified mentors as friends as suggested by Harris and Caporella (2019) and Lokon et al. (2012), the latter a sentiment shared by mentors. One student's comments suggested that visits challenged prior assumptions or stigmatization, specifically, to not make assumptions about people with dementia and recognize what they have to offer, which is similar to findings by Caporella (2014, 2019), and Lokon et al. (2012). Current care partners came to feel students were like family, a finding reported by Harris and Caporella (2019). As with previous research (Chung, 2009;Dassa & Harel, 2020;Guerrero et al., 2017;Harris & Caporella, 2014, students reported increased dementia knowledge. Like past findings, students' appreciation for the capabilities of people with dementia (Harris & Caporella, 2014, how they coped (Lokon et al., 2012) and the need for patience (Lokon et al., 2012) were recognized by current participants. Selected previous findings were not supported by the current study. Earlier research involving people with dementia demonstrated an increase in young adults' attitudes toward people with dementia following IG interventions (Harris & Caporella, 2019;Lokon et al., 2012Lokon et al., , 2020Lokon et al., , 2017, but was not found in the current study. The students in the current study volunteered to participate suggesting an interest in and likely positive attitude toward people with dementia. Previously, people with dementia reported reduced depression and improved QoL (Chung, 2009), results not upheld by current data. Care partners and people with dementia reported experiencing less stigma (Harris & Caporella, 2014), findings not represented in the current data. Conversely, meaning and purpose as cited by students, mentors, and care partners, was prevalent in the current study, but was not previously reported.
One student was paired with a mentor who lived in a residential setting. During COVID-19, the facility was closed to family visits. The mentor relied on staff to help her connect online, which proved challenging because the staff member was not always available at the scheduled time or created distractions during the visit. As a result, the student who was excited to visit had a negative experience.
Unexpectedly, some care partners took an active role in helping mentors to plan topics of conversation, communicating with students before and, in some cases, participating in the visits. Care partners, like mentors and students, were socially isolated and enjoyed the opportunity to meet and talk with someone new. An added benefit was that planning things to share with the student gave care partners and mentors a reason for meaningful exchange. In addition, visits provided care partners feedback regarding their loved one's abilities prompting one care partner to institute safety measures.

Strengths and limitations
Findings should be considered in light of limitations. This was a qualitative design and a small nonprobability sample restricting generalizability. There is a possibility of social desirability bias although the faculty member who interviewed the students was not on faculty at their school. Cause and effect cannot be established. However, the study was conceived in response to a current phenomenon, COVID-19 stay-at-home directives, and grounded in the NBD model which guided the intervention and data analysis. Detailed in-depth data were collected, and three cases provided triangulation of data.

Recommendations
Qualitative and quantitative outcomes for all three cases: students, mentors and care partners should be included during future research efforts. People with dementia should not be excluded from participating in research studies but should take an active part in research design, methodology, reporting and participation. Gaining insight from this population will inform care, policy and resource development and delivery. Studies involving larger samples and visits over a longer period should be considered.
Successful elements of IGPs as outlined by Gerritzen et al. (2019) were incorporated into the current study. Students were provided handouts during orientation to facilitate visits; however, some mentors and care partners were unclear about objectives. Clear written objectives should be provided to all participants. Quantitative measures of students' and mentors' social connection, students' competency for dementia care, empathy, and general self-efficacy, and mentors' cognition, specific behavioral and psychological symptoms, and QoL should be examined. Care partners' engagement might be formalized and their QoL measured. Future efforts to engage people with dementia in residential facilities should be formally integrated into the care plan and staff dedicated to help with technology assigned.

Conclusions
This multiple case study involving student online visits with people with dementia originally aimed to examine outcomes for people with dementia; however, positive effects were realized across cases. Two of the three theoretical propositions were supported: people living with dementia experienced social isolation during the mandate and online visits decreased isolation. Additionally, the aims of the study were met, feasibility was affirmed, and positive impacts were experienced by both generations. Data generated by this case study provides a foundation for adaptation of the intervention and hypothesis testing. The third proposition, decreased behavioral and psychological symptoms for people with dementia, may be more adequately captured by the inclusion of quantitative measures such as depression and QOL scales. Findings suggest that lasting connections were formed between students and people with dementia during online visits, an activity that might be implemented outside of a crisis to prevent social isolation across generations.

Disclosure statement
No potential conflict of interest was reported by the author(s).