Post-Acute and Long-Term Care Leaders’ Perspectives on Leading During COVID-19

Abstract

Post-acute and long-term care (PALTC) delivery is complex, and the COVID-19 pandemic created additional complexities. This qualitative study investigates how PALTC administrators responded to the pandemic, factors that impacted their leadership role and decision-making. Participants from North Carolina (N = 15) and Pennsylvania (N = 6) were interviewed using an interview guide containing open-ended questions. The results revealed three themes: (1) critical knowledge and competencies; (2) resources, supports and essential actions taken; and (3) psychosocial impact. The findings suggest communication and relationship building were the most useful competencies. Lack of staff was a primary stress point during and after the pandemic.

What this paper adds

• This study highlights the importance of communication and leadership skills during a crisis, the emotional toll and stress of leading through the pandemic, and critical resources of staff, supplies and finances needed by PALTC leaders.

Applications of study findings

• Problem solving innovations used by PALTC leaders during the pandemic may be useful for similar challenges in the future.

• Our recommendations may contribute to the mitigation of the ongoing staffing crisis.

Introduction

Leaders in post-acute and long-term care (PALTC) play a critical yet challenging role in providing high-quality care and services for their residents, while also fostering an engaging environment for their staff (Siegel & Young, 2021). Since February 2020, the PALTC sector has been at the forefront of the COVID-19 pandemic in the U.S. (Barnett & Grabowski, 2020). During this time, PALTC leaders and staff faced some of the greatest occupational challenges. While many were able to provide quality and safe care for residents and staff, others encountered greater difficulties, such as loss of life and isolation. The coronavirus pandemic posed a higher risk to PALTC residents than their community-based peers, making them more vulnerable to morbidity and mortality (Robinson et al., 2021). PALTC leaders faced a range of challenges, such as navigating ever-changing and conflicting regulations, addressing the vulnerabilities of residents, and tackling persistent workforce shortages. Their perspective on leading through a pandemic is critical for policy makers, regulatory agencies, educators, and the public to understand how they made decisions and operated during this challenging time. As with other emergencies, disasters, and infectious outbreaks, it is important to understand the key skills, knowledge, and competencies they believed were important and used, the critical resources and supports needed and whether they were available, and what they learned. This study reveals leaders' perspectives on their education, training, the PALTC environment, and policy based on their experiences.

To better prepare for future pandemics similar to COVID-19, experts have put forward solutions and recommendations for decision-makers in the field (NASEM, 2022). For example, the National Academies of Sciences, Engineering, and Medicine (NASEM) released the findings of a consensus study that examined the delivery, financing, regulations, and quality measures of nursing home care. The committee’s report includes seven broad goals with interrelated recommendations that provide a comprehensive approach to improving the quality of nursing home care. In addition, the report emphasizes the need for more effective monitoring of infection prevention and control practices, staffing levels, and other critical aspects of nursing home care to ensure that residents receive safe, high-quality care (NASEM, 2022)

Background

Individuals living in PALTC organizations are among the most vulnerable members of our society. They often reside in small, double occupancy rooms, they have multiple comorbidities, diminished physical, cognitive and immune systems, and most need assistance with activities of daily living. Unfortunately, infectious disease outbreaks, such as seasonal influenza and norovirus, occur predominantly in PALTC organizations in the United States (Kambhampati, et al., 2015). It is crucial that we take every possible precaution to protect these individuals from such outbreaks.

Nursing assistants, nurses, and other caregivers provide care for multiple residents during their shift, increasing the probability of spreading infection. PALTC staffs’ historical challenges and limited compliance with infection control and prevention practices (U.S. Government Accountability Office, 2020) and the asymptomatic spread of the highly contagious respiratory virus made preventing, mitigating, and controlling the coronavirus even more problematic for PALTC leaders. As of June 12, 2022, over 209,000 long-term care residents and staff have died from COVID-19 infections, equating to over one-fifth of all COVID-19 deaths in the United States were among long-term care residents and staff (Chidambaram & Burns, 2022).

Additionally, recruitment and retention of the PALTC workforce has been problematic for decades, and by 2026, U.S. nursing homes will need to fill almost 680,000 direct care worker positions (Scales et al., 2020). High turnover has been linked to poor resident outcomes and instability in the workforce (Miller et al., 2018). The pandemic has exacerbated these challenges, with persistent understaffing making it difficult to provide care and services. The situation was further compounded by staff shortages resulting from COVID-19 positive cases.

Early studies showed that the lack of personal protective equipment (PPE) significantly hindered the implementation of infection control practices in PALTC organizations (Abbasi, 2020; McGarry et al., 2020). The disruption of the supply chain and the prioritization of hospitals for PPE made it difficult for PALTC leaders to obtain PPE for their staff during the early months of the pandemic (McGarry et al., 2020). As a result, working conditions in PALTC organizations worsened during the pandemic, with staff experiencing increased stress, fear of contracting the virus and taking it home to family members, as well as sadness, exhaustion, and helplessness (Resnick, 2020). Staff providing care for the residents were at increased risk of contracting COVID-19 due to daily exposure to infected residents. Additional sources of stress included caring for residents experiencing social isolation, illness and death, being short staffed, and increased workloads. Staff also faced emotional and financial hardship, such as separation from family members, relying on public transportation, and being short on PPE (White et al., 2021).

In the PALTC sector, major decisions are usually carried out by administrative and/or clinical leaders who hold significant responsibility for all administrative, operational, and clinical aspects of the organization. These leaders must possess the requisite education and training to make informed decisions in complex and ever-changing environments. However, the educational requirements, licensure, and certification for PALTC leaders are not standardized across states and organizations. For example, nursing home administrators are required to obtain state-level licensure in accordance with the Social Security Act (2012), which grants each state the authority to establish and regulate licensure requirements. All states mandate that administrators pass an evidence-based exam developed and administered by the National Association of Long-Term Care Administrator Boards (NAB). Conversely, assisted living administrators are currently not subjected to federal guidelines, with only state-level requirements in effect.

During the COVID-19 pandemic particularly, many decisions were made based on the guidance of the CMS and the Center for Disease Control and Prevention (CDC). To maintain the highest level of safety and well-being of PALTC residents and staff, decisions made during COVID-19 included but were not limited to proactive and real-time responses to the suggested and mandated protective measures. Examples included wearing facemasks, hand washing, using PPE, and nonpunitive sick leave policies that allow potentially contagious staff to stay out of work (CMS, 2020). To avoid further clusters of infections, recommendations also included guidelines on how to segregate residents who were infected, as well as to segregate units/wings and work assignments among the direct care workers (CMS, 2020; Van Houtven et al., 2021).

The devaluation and ageism bias of the PALTC work environment was also accentuated by the COVID-19 pandemic. Examples include: the public campaigns recognizing hospital staff as “heroes,” the lack of PPE in nursing homes 2 months into the pandemic, public health response focused on the acute care sector with little or no initial guidance or increased resources for the PALTC providers. Research indicates that events such as the COVID-19 pandemic increased employee stress, decreased job satisfaction, and created other unintended negative outcomes (Zhang et al., 2020). Yet, little is known about PALTC administrator’s fears, stresses, experiences, and perspectives providing leadership during a pandemic.

This study may be the first to focus on PALTC leaders’ reflections of their experiences leading during the COVID-19 pandemic. This study aims to address the following questions: (1) What insights did PALTC leaders gain from their COVID-19 experiences? (2) What competencies and resources proved essential to their decision-making and response efforts? and (3) What steps can we take to improve our response to future pandemics?

Methods

Study Design

Consistent with the research inquiries, this study used a qualitative study design. Specifically, we conducted semi-structured audiovisual interviews with PALTC administrators using an open-ended interview guide which was developed from a previous work on emergency preparedness. We adopted the framework from an emergency preparedness interview guide to fit information gathered during the pandemic crisis. To ensure a comprehensive understanding of pandemic preparedness in the PALTC sector, we drew upon literature from previous infectious disease outbreaks, such as Ebola, severe acute respiratory syndrome (SARS), and Middle Eastern Respiratory Syndrome (MERS). The insights gained from these outbreaks were integrated into the development of our interview questions, which focused on six significant topics related to pandemic preparedness in PALTC organizations (Rajakaruna et al., 2017). The six topics used to gain insight into how leaders responded to the pandemic were: (1) What were leaders’ thoughts or concerns during the early months? (2) What was learned as a result of their COVID-19 experiences? (3) Was the training they had received adequate to address the tasks associated with the needs of their constituents? (4) What was the degree of stress experienced during the COVID-19 pandemic? (5) Were organizational resources available and sufficient to address their needs? and (6) What levels of support and planning were required? (Croke, 2020) The interview guide was reviewed by two PALTC leaders to ensure appropriateness. The final version contained two questions about the overall first response, 10 questions on individual leaders’ perspective including their training and resilience, and 10 questions on organizational resources, supports, and resident and family concerns. The interview guide is attached in the supplemental materials (Supplement 1). Institutional Review Board approvals for exempt status were obtained from the two universities, Appalachian State University and Des Moines University, where the PIs are affiliated. All information about the participants were de-identified and presented qualitatively and quantitatively, as each type of data is useful in different ways. Quantitative data offers a concise and objective overview of participant characteristics, while qualitative data provides a more in-depth and nuanced understanding of their experiences and perspectives.

Study Setting, Participants, and Process

To recruit PALTC leaders for the study, the researchers chose North Carolina and Pennsylvania for several reasons. First, one of the co-PIs resides in North Carolina, and a colleague willing to recruit participants lives in Pennsylvania. Second, both states have relatively diverse populations and a mix of urban and rural areas. In terms of their urban-rural divide, North Carolina has a more even distribution of its population across urban and rural areas than Pennsylvania, where about 64% of the population lives in urban areas (U.S. Census Bureau, 2010). Conversely, in Pennsylvania, about 77% of the population lives in urban areas, while the remaining 23% lives in rural areas (U.S. Census Bureau, 2010). Furthermore, because the CDC and CMS established national infection control guidelines, different states interpreted and implemented these guidelines in diverse ways, and resources such as staff and PPE availability also varied. By choosing two different states, the researchers aimed to gain some insight into how leaders in different contexts responded to the pandemic, providing a more comprehensive understanding of the challenges and opportunities faced by PALTC organizations.

Email invitations were sent to the NAB list of Administrators in North Carolina and Pennsylvania. In addition, invitations were sent by the North Carolina Health Care Facilities Association and LeadingAge NC to their members during January and February 2022. Email invitations included the following documents: (a.) informed consent; (b.) the interview guide, and the estimated time length for the interview. Those interested in participating were asked to email the Co-PI to establish a time for an interview. Emails were received from 20 potential participants in North Carolina and 6 in Pennsylvania. Interview dates and times were set at mutually beneficial times with 18 participants in North Carolina and 6 in Pennsylvania, (2 never responded to the co-PI’s email with potential dates and times). Three participants in North Carolina did not log into the established Zoom meeting. In total, 21 interviews were conducted, 15 with North Carolina, and 6 with Pennsylvania PALTC leaders. Interviews were conducted by one of the co-PIs using the university’s Zoom platform. Open-ended questions were asked in a conversational style, allowing participants to discuss their experiences leading during the pandemic and any other relevant topics they wish to raise. The interviews were recorded and securely stored in a university file storage location. Interview times ranged from 20 to 60 minutes. Transcripts were generated using the Zoom transcript feature, which was then reviewed and edited by the research team for accuracy. At the conclusion of each interview, the co-PI asked participants for recommendations of other PALTC leaders who might be willing to participate in the study. Eligibility criteria for participants included being employed in a leadership role in a PALTC organization that served the PALTC population during the pandemic and (e.g., nursing homes, assisted living facilities, continuing care retirement communities, and senior housing) located in North Carolina or Pennsylvania.

Data Analysis

This qualitative study was conducted from January through March 2022 with one additional interview in May 2022, the third year of the pandemic. We used thematic analysis to investigate PALTC leaders' perspectives from their experiences of leading through a pandemic.

To ensure the accuracy of the transcripts and their alignment with the actual words spoken, we cross-checked them with the zoom recordings and reconciled any discrepancies found. They were then loaded into NVIVO [Version 12.1] (Nvivo, 2021) for data analysis. In this case, two researchers independently coded the first three transcripts to determine key emerging themes (Doyle et al., 2020). The researchers then met to reach consensus on a codebook, definitions and emergent themes. The two researchers (co-PI who conducted all of the interviews and research associate), both of whom had experience in qualitative design and PALTC, independently coded the other 18 transcripts. The other co-PI was consulted to discuss emerging themes and coding every couple of weeks. During the meetings among our research team, one topic of discussion was whether the number of participants (only 21 respondents) was sufficient for the study. It was concluded that, despite the limited sample size, the co-PI’s conducting of all the interviews allowed for a thorough capture of the human and emotional elements of the responses. Additionally, the repetitiveness of the responses was closely examined to determine data saturation. This process allowed the co-PIs and the research associate to learn the perspectives of PALTC leaders. Data rich quotes were extracted from the transcripts as examples of the subthemes.

Results

Overall, the 21 participants expressed a lack of knowledge about the coronavirus. They also identified challenges with the constantly changing regulations. Emotional toll, lack of resources such as staff, supplies and financial support were other constraints they faced during the pandemic. Importantly, all participants were the leaders of PALTC organizations including assisted living, nursing homes, and continuing care retirement communities during the pandemic (Table 1). Twelve of the twenty-one participants were women, nine had been PALTC leaders for more than 11 years, and a majority worked in for-profit nursing homes. Three participants were no longer leading PALTC organizations, while two had left and returned to leadership roles. Sixteen participants remained in their PALTC leadership roles.

Table 1.

Participants Demographic Information.

	Pennsylvania frequency %		North Carolina frequency %		Total frequency %
Gender  Female  Male	3	25.0	9	75.0	12	100
	3	33.3	6	66.7	9	100
Tenure as administrator c  <5 years  6–10 years  >11 years	1	20.0	4	80.0	5	100
	1	33.3	2	66.7	3	100
	3	33.3	6	66.7	9	100
Type of home  Nursing homes  Continuing care retirement communities	6	40.0	9	60.0	15	100
	1 a	14.3	6	85.7	7	100
Ownership  For profit  Non-profit	6	42.9	8	57.1	14	100
	1*	12.5	7	87.5	8	100
Number of beds b  <100  101–200  >201	1	25.0	3	75.0	4	100
	3	21.4	11	78.6	14	100
	2	66.7	1	33.3	3	100
Location  Rural/small town  Urban	1	11.1	8	88.9	9	100
	5	41.7	7	58.3	12	100

^aOne respondent worked in both nursing home and CCRC during the pandemic.

^bnumber of beds was not asked during the interview therefore not available for all participants.

^ctenure as an administrator was not an interview question, many offered this information.

Analysis of the responses generated three themes and six subthemes, as shown in Table 2. The themes include: (1) knowledge and competencies, (2) resources, supports, and essential actions taken, and (3) psychosocial impact. These themes are supported by six subthemes: communication, relationship building, resources and supports, essential actions taken, stress, and public image.

Table 2.

Themes, Sub-themes, and Codes.

Themes	Subthemes	Codes
Knowledge and competencies	Communication	Staff and residents
		Families
		Local agencies (health department, state DHHS, hospitals)
		Corporate office
	Relationship building	Staff and corporate staff
		Families and community
		Local agencies (health department, state regulatory agencies, hospitals)
		Corporate office
Resources, supports and essential actions taken	Resources and supports	Staff
		Corporate Office
		Health department
		Churches/Family members
		Other administrators
	Essential actions taken	Planning—financial and emergency preparedness
		Implementing guidance as soon as received
		Educating and reeducating staff as new guidance is released
		Communication and transparency, repeatedly through multiple channels
		Taking care of staff
Psychosocial impact	Stress	Lack of COVID knowledge
		Lack of staff
		COVID getting into building
		Lack of PPE
		Ever-changing regulations
		Isolation versus resident rights
		Caring/supporting staff
	Public image	Media barrage villainizing staff
		Funeral home, EMS, food delivery personnel refusing to enter the building
		Long-term underfunding LTC services
		Resulting in staff felt underappreciated, abandoned, depressed, demeaned, disheartened, and devalued
		Society’s unrealistic expectations of PALTC organizations

The themes and sub themes that emerged from our analysis, along with examples of participant statements are discussed below.

Theme 1: Knowledge and competencies

Knowledge and competencies that contributed to success were communication and relationship building. Many participants noted the importance of communication, internally with staff, residents, and families, and externally with community organizations (i.e., health departments, hospitals, and state regulatory agencies).

“…Communication was huge, you couldn't communicate enough, you know every opportunity to talk to people and let them know what's going on and why we're doing this and all of that. (#4)”

“…We had constant meetings to keep us abreast of interpreting the daily new guidelines, sometimes we'd have, you know, three, four or five meetings a day. (#15)”

“… For the staff it is transparency, being transparent, saying hey guys this is what's going on, this is what's going on in our community, (#5)”

Career experiences and leadership skills also contributed to communicating decisions and process changes, and in the support of staff. PALTC leaders made decisions on how to implement the ever-changing infection control, testing, and vaccination regulations and guidance using a priori knowledge, information shared from other leaders, and assistance from corporate offices and local health departments.

“… the daily changes in Regulation was no joke. That was something difficult even for the most organized professional to keep up with. I'm not sure that the institutions that were creating the regulations were keeping up with them either, so that was difficult to change on a dime. (#15)”

“… So, you know, having a team you've been with for five years versus being a new administrator in a building. You're going to have completely different outcomes and, obviously, that was evident in that we had no cases until I left, (#16)”

Infectious disease experts’ lack of knowledge of the spread, prevention and treatment of the coronavirus muddled accurate communication and appeared to create fear and disbelief. However, many participants stated that there was nothing that could prepare them for a pandemic like this even through academic education, continuing education, or previous experience. This is extremely understandable since no one has ever dealt with an issue of this momentum—one that was sustained for over 3 years.

“…The first year was obviously fear, when we realized it was something different than what we've experienced before. (#13)”

“…So, whenever my building had become positive one thing that I was not prepared for was the fact that we really did not understand the disease and how rapidly it was going through the building, nor how it would affect our residents' lives. (#5)”

“…I’ve worked in nursing homes my entire career. It’s all I’ve done for 38 years. So, I was just completely at a loss, because. You know, we have outbreaks of the flu or, norovirus or something like that, but this was just totally different, you know we had no experience and nothing to be able to relate it to. (#4)”

Building relationships was expressed as an important competency that contributed to success as leaders needed to constantly connect with and build relationships with staff, families, hospitals, health departments, and community members during the pandemic.

“… relationship building was very key because one of the big things you have to make sure is that you're connecting with your team. And then we also had to build better relationships with county government, because we rely heavily on that interdisciplinary connection with the health department, and with the hospitals (#9)”

“…And I felt like relationship building was the biggest for sure and then authentic leadership… here's what we're doing so, I think that probably the biggest focus was on open communication and building a strong relationship (#14)”

Theme 2: Resources, Supports, and Essential Actions Taken

Several participants noted staff as a critical source of support. Staff from all levels pulled together, floor staff, department heads, administrators, and corporate staff did what needed to be done to care for residents. Many worked extra shifts and completed tasks outside of their normal scope of work.

“…You’re out there and you’re hopping in and you’re helping to change residents, if needed, you’re working in the COVID section overnight as administrator trying to keep the building afloat. (#8).”

“… department heads who normally would have spirited arguments, to see them come together when we’re doing room moves and trying to comply. Everyone was all gowned up, all masked up, face shield and everything-sharing the battlefield like that really promoted more cohesion out of the tragedy, but it was still very scary. (#18)”

Other sources of support included the increase in reimbursement that were passed down to staff via salary increases and bonuses. Many reported that corporate entities supported them by interpreting the constantly changing guidelines, ensuring that PPE was available, financial support to purchase supplies such as individual room HVAC units, tents and heaters for outdoor seating, and room renovations to improve infection control, as well as hands-on care. Other sources of support came from health departments providing infection control guidance and supplying PPE, local communities and churches provided handmade masks, gifts and food. Additionally, support included other administrators serving as sounding boards and providers of emotional support.

“…There is somebody that goes through all of the ever-changing guidance and tells us, you know, this is how you interpret this, this is the way to do this. (#4)”

“…You know, universally all over the place, but the biggest, the biggest help, I would say, the top three would be the Department of Health, CMS, and our contract services (#10)”

“We ended up developing a wonderful working relationship. (#1)”

However, a few participants indicated that corporate staff was nowhere to be found and did not provide assistance or support. Community support also varied from churches and family members bringing food and gifts to the PALTC staff, to ambulance, funeral and restaurant delivery staff refusing to enter the building. Instead, they asked staff to push the residents outside and they left food at the door.

“… Um honestly at the time I didn’t feel like I had a lot of support to be quite honest. It was literally our building went positive and it was kind of like well here you go here’s our policy, good luck. (#5)”

“…And it was kind of the perfect storm, the state resources had already been used up in other places, so when you called where we’re supposed to get help, there was no help to send us. (#11)”

“…People were afraid to come into the building, for example, the funeral homes refused to come into the building to pick up bodies. (#3)”

Essential actions taken were the activities that the leaders committed most of their time and focus to during the pandemic. Many actions were taken including implementing guidance from CMS and CDC immediately upon receipt and making changes as new guidance was received, continuously educating staff with new guidance, utilizing past successful processes in the delivery of quality care, implementing the practiced emergency preparedness plan, focusing on taking care of and supporting staff, continuously communicating, and being transparent across all stakeholder groups.

“…We were getting the policies and procedures updated, getting them out to our team, having calls with them explaining here’s what changed today.... (#20)”

“…Being able to support your staff and having them know that you were there, you had their back, no matter what. (#21)”

“…But also, resident education and communication with the residents, making sure that we had a standardized process for all residents and their families, and to be abreast of the situation daily, was very important. (#15)”

Theme 3: Psychosocial Impact

Many imputed emotional tolls of increased stress to the lack of staff and PPE, staff frustration and angry outbursts, challenges of the constantly changing regulations, ethics of isolating residents and the subsequent harm, balancing of family needs and desires with regulations, demoralized staff, mental and emotional health as the pandemic wore on, and the lack of a physical structure to support infection control regulations. Stress also came from the responsibility of making decisions as the administrator and having no one to share challenges, concerns, or experiences with.

“… We had multiple different agencies and so, every day, you were hearing from your local, your state, and your national, and they were all telling you something different. (#11)”

“…Staffing, staffing was my number one thing that kept me up, as well where did all the nurses go? Where did all the CNAs go? (#8)”

“…The other thing was the visitation restriction. Depression among the residents significantly increased. (#18)”

“...those hard decisions with you know, not a lot of support, show up and still be that leader, the fact that people are looking to you to have all the answers and having to tell them, I don’t know but I’ll try and figure it out. (#4)”

Participants described the barrage of media reports as villainizing PALTC and negative, calling hospital doctors and nurses’ heroes and nursing homes death traps. Participants stated that staff felt underappreciated, abandoned, depressed, demeaned, disheartened, and devalued and that society had unrealistic expectations of PALTC organizations.

“…They didn’t necessarily need the accolades, but we could all use some, but they didn't need to be vilified. So, we already had this stigma of people who refer to “those places”, … (#18)”

“…Devaluing was so hurtful, you know when you’re in here working your butt off risking your own life, I mean you know, two thirds of my staff, myself included, two thirds of my staff got COVID. You know, and some of them were very sick. (#11)”

“…So, you know I wasn’t surprised, because we always kind of get that rap. But, I think it, I think it really worked on some of the staff, because you know, all you heard was accolades for doctors, nurses in the hospital, firemen, policemen (#3).”

Discussion

Three themes and six sub-themes emerged that are suggestive of actions that can be taken to advance the capabilities of PALTC leaders in improving outcomes during future pandemics. Among those, communication and relationship between staff and residents, staff and families, staff and PALTC-related social agencies, corporate offices, and public health and regulatory agencies were key competencies they relied on during the pandemic. PALTC leaders reported using their communication and relationship building skills to educate staff on the ever-changing regulations and to mitigate staff and family stress and emotions. Numerous studies highlight importance of a supportive environment with effective communication and recognition (Blanco-Donoso et al., 2021; Miller et al., 2018).

To cultivate these critical skills, administrators in the PALTC sector must prioritize the establishment of relationships and collaborate with other healthcare organizations, as well as local, state, and federal government agencies. By actively sharing information and resources, these stakeholders can effectively address challenges, such as those presented by the COVID-19 pandemic (Laxton et al., 2020). Moreover, the utilization of information technologies, specifically the development of a dashboard, holds significant potential for enhancing communication and coordination between different parties. (Caspi et al., 2020). Furthermore, it is crucial to recognize the significance of incorporating content on communication and relationship building within the existing PALTC curricula. Some have been listed as core domains of practice by NAB (National Association of Long-term Care Administrator Boards, 2022).

The findings of this study revealed the critical role of the second theme regarding staff support in the PALTC sector during challenging periods. It was evident that corporate entities, health departments, local communities, and churches also offered various forms of support. However, it is important to note that some participants reported limited support from corporate staff. These results emphasize the importance of establishing a robust support system within PALTC facilities and fostering collaboration with external stakeholders to ensure the well-being of both residents and staff. The availability of the support systems identified in the second theme aligns closely with the third theme concerning psychological impact. Research shows that the psychological well-being of staff members during the COVID-19 pandemic is directly influenced by the presence and effectiveness of these support mechanisms (Blanco-Donoso et al., 2021; Laxton, et al., 2020; Reinhart, et al., 2022).

Participants expressed various factors contributing to their stress, including fear of the virus, uncertainty surrounding its transmission and treatment, constantly evolving regulations, staffing and PPE shortages, and decision-making with limited information. To alleviate stress, administrators employed several key strategies such as transparent and frequent communication, and keeping staff informed and updated as guidelines evolved. Education and re-education efforts were implemented to ensure that all staff members were equipped with the latest knowledge and protocols. Supportive conversations were facilitated to provide a space for individuals to share their concerns and emotions. Additionally, administrators drew on their emergency preparedness and operational knowledge to effectively manage the situation. Teamwork across staff and management, opportunities to process emotions, reeducation, and recognition for their work are noted as methods to address the stress levels of residents, staff, and PALTC leaders (Blanco-Donoso et al., 2021; Reinhart et al., 2022).

Participants suggested possible solutions to address the challenges faced during the pandemic. These solutions encompassed immigration reform and the diversification of recruitment pools, targeting groups such as high school students and retirees to increase the direct care workforce. Emphasis was placed on the need for culture and policy changes that foster an inclusive environment for older adults and individuals with disabilities, accompanied by higher reimbursement rates that support higher wages. Similar efforts have been recommended elsewhere (Richard et al., 2022).

In terms of communication, administrators shared various innovative practices that emerged during the pandemic. These included utilizing technology for virtual visits, leveraging social media for communicating messages, creating daily voice mail messages with updates for family members, and hallway/doorway bingo. Innovations for visitation included repurposing a room and installing a plexiglass wall, putting heaters in tents so families could visit, and installing individual room heating, ventilation, and air conditioning (HVAC) units to prevent virus transmission through centralized HVAC. Sharing these innovations contribute to shared learning and improved processes and work environments for future pandemics.

Finally, many participants expressed the belief that enhancing the public’s perception of the PALTC industry is crucial for driving positive change. By transforming the public image, the experiences of the staff and the staffing crisis, can be positively influenced. This perspective resonates with existing research (Manchha et al., 2021).

Limitations

While this study provides valuable insights, there are some limitations to consider. First, the sample was limited to participants from two states who volunteered to participate, and this may not be representative of all PALTC leaders. Moreover, the small sample size of 21 participants may not reflect the experiences of those who did not respond to the invitation or who have left the industry. Second, there is the potential for recall bias. Third, due to the qualitative nature of the study, the results cannot be statistically validated. Last, the recommended solutions have not yet been tested. Despite these limitations, the study collected and analyzed a wealth of information and provides a deeper understanding of PALTC leaders' experiences, their key competencies and knowledge, the resources and supports they require, and the factor contributing to stress.

Conclusion

Given the complicated nature of the PALTC environment, many decisions especially during the COVID-19 pandemic involved policy-makers, regulatory agencies, PALTC owners and administrators, and academic and research collaborations. To enhance PALTC leader’s decision-making and leadership during a pandemic, PALTC education curricula should include evidence-based best practices on infection control and preparedness, and essential competencies including communication, and relationship building. In addition, participants’ innovations and recommendations should be shared and evaluated to determine their appropriateness for use in future pandemics. Future efforts should focus on the key competencies, knowledge areas and critical resources needed by PALTC leaders. These include communication, collaboration, staff and resource management, stress reduction, dissemination of best practices, and improving the public image of the PALTC industry, which are included in NAB’s Core Domains of Practice.

ORCID iD

Sandi J. Lane https://orcid.org/0000-0001-6729-3555