Taking Action to Support Nursing Home Resident Well-Being: Perspectives of U.S. Nursing Home Staff During COVID-19

Abstract

Background and Objectives

Coronavirus disease 2019 (COVID-19) negatively influenced resident well-being in nursing homes (NHs). We examine perceptions and experiences of U.S. NH staff during the COVID-19 pandemic regarding resident well-being.

Research Design and Methods

We sampled 68 NHs (out of 13,423) in strata defined by quality ratings, urban/rural location, and whether they served a resident population of <70% White. We enrolled 10 NHs and interviewed 11 nursing staff (8 certified nursing assistants/aides, 3 registered or licensed practical/vocational nurses), 12 managerial staff (4 administrators, 8 directors of nursing), and 5 infection preventionists. Thematic analysis identified themes related to challenges of quarantine/isolation, attempted solutions, and lessons learned concerning resident well-being.

Results

Nursing home managerial, infection prevention, and nursing staff described how COVID-19 policies contributed to increased resident loneliness and declines in physical and cognitive well-being. Solutions/strategies employed across the United States and in low- and high-quality NHs included proactive mental health support, resident-centered family visitation, increased communication and care planning with families and efforts to maintain resident normalcy.

Discussion and Implications

Strategies to mitigate and alleviate concerns with resident well-being were both structural and made via staff choices. NH leadership needs to proactively plan how to adapt processes and structures that prioritize resident well-being along with resident care in times of crisis. Research is needed to outline the planning, implementation, and recommendations required to operationalize these strategies into practice. Determining the most effective ways to implement these structural changes within NH practices and workflows is critical to ensure that staff have sufficient time to spend with residents.

In 2020, the airborne infectious nature of coronavirus disease 2019 (COVID-19) prompted strict guidelines for nursing homes (NHs) to follow that included policies of resident quarantine and isolation with the aim of preventing the transmission of the infection (Centers for Medicare & Medicaid Services, 2020). The Centers for Medicare and Medicaid Services indicates that a person quarantines when they might have been exposed to a virus and may or may not have been infected, and a person isolates when they are sick or when they have been infected with a virus, even if they don’t have symptoms. Although quarantine and isolation were necessary protective measures to safeguard NH residents, especially those with chronic conditions such as diabetes, coronary artery disease, or cardiovascular disease (Abbasi, 2020; Aggarwal et al., 2022), these actions resulted in unintended negative consequences on the well-being of NH residents, manifesting in forms of loneliness, cognitive decline, and emotional breakdown (Aho, 2022). Figure 1 depicts an illustration of loneliness during coronavirus disease 2019 (COVID-19). In NHs, residents often rely on daily communication with family caregivers and NH staff. With strict visitation policies, resident’s daily routines changed, and the in-person interaction with their loved ones and medical staff was greatly reduced and modified to accommodate the need for isolation and personnel to wear full personal protective equipment (PPE). The loss of physical connection with families and care workers led to a decline in residents’ emotional and cognitive abilities. In NHs with staffing issues, where burnout was prevalent, the lack of NH staff assigned to each resident further exacerbated resident loneliness, not to mention the staff’s ability to address residents’ needs (Lapane et al., 2023).

Figure 1.

An illustration of loneliness in COVID-19. COVID-19 = coronavirus disease 2019. Source: Rose Wong, Commonwealth Fund.

The decline in NH resident well-being began before the onset of the COVID-19 pandemic. Research indicates that loneliness was already prevalent among NH residents in the United States (Lapane et al., 2023). The negative consequences on the health of NH residents resulting from loneliness are well-documented (Aho, 2022; Hado & Friss Feinberg, 2020; Lapane et al., 2023) and include both cognitive decline (e.g., experiences of confusion, homesickness, dislocation, anger, or even a sense of imprisonment; Aho, 2022) and physical decline (e.g., weight loss due to reduced food and water intake resulting from depression; Shrader et al., 2021).

Evidence on how COVID-19 negatively influenced resident loneliness and well-being in NHs has been described previously (Bethell et al., 2021; Kemp, 2021) in both quantitative and qualitative studies. For example, using the Long-Term Care Minimum Data Set, Levere et al. (2021) examined changes in resident well-being in Connecticut NHs and found that COVID-19 adversely affected the physical (weight loss and incontinence) and emotional well-being (depressive symptoms and cognitive functioning) of residents. Staff and resident experiences of loneliness during COVID-19 were also richly described in qualitative studies that focused on the emotional discussions, feelings, and lived experiences that were an integral part of contending with the COVID-19 pandemic (Abbott et al., 2022; Aggarwal et al., 2022; Aho, 2022; Hado & Friss Feinberg, 2020; Hendricksen et al., 2022; Long, 2023; Shrader et al., 2021; Van Orden et al., 2022).

Current evidence identifies several strategies implemented during COVID-19 to mitigate loneliness and improve resident well-being resulting from quarantine/isolation. NHs attempted to address resident loneliness by facilitating different avenues of resident interaction and family communication (Hado & Friss Feinberg, 2020; Lapane et al., 2023; Williams & Dedeo, 2023). Lapane et al. (2023) administered a nationally representative survey to NH staff about their experiences implementing strategies to alleviate resident loneliness during the COVID-19 pandemic. The authors identified that the efforts tried, and perceived as most useful, included using technology (tablets, phones, and emails), assigning staff as a family contact, and increasing staff time with residents with adequate staffing cited as the most frequent barrier to implementation. Other strategies described were NHs that tried weekly email exchanges between residents and individuals outside the facility, which led to perceived significant improvement in resident emotional well-being (Long, 2023; Yeo et al., 2020). This solution provided an alternative for residents with low technology fluency to connect with people and establish a sense of connectedness with society. Other solutions identified include facilitating physically distanced games among residents (Lapane et al., 2023), encouraging more frequent phone calls and emailing between residents and their families (Monin et al., 2020), or implementing early and repeated COVID-19 testing to dictate and ensure safe social environments for residents within facilities while allowing as much visitation as possible (Shrader et al., 2021). However, these studies were primarily conducted in single institutions or select regions of the United States, with the exception of Lapane et al. (2023) who conducted national survey of NHs regarding solutions tried.

To further fill in this gap in the literature, we examined NH leadership and staff perspectives from a national sample of NHs, including NHs with high/medium/low quality, urban/rural locations, and serving predominantly minority/White residents. Our interviews focused on the leaders and staff experiences, changes related to COVID-19 policies, and the well-being of residents. We describe their perceptions and lived experiences during the COVID-19 pandemic regarding quarantine/isolation measures implemented to protect residents and the associated unintended negative consequences on resident well-being, with the objective of identifying the solutions attempted to support resident well-being during COVID-19 that could be used for navigating similar health emergencies in the future.

Method

Setting and Sample

These interviews were collected as part of a larger national study addressing the impact of COVID-19 on care transitions and health outcomes of older, vulnerable patients and identifying health disparities in postacute care settings (Glance, Benesch, et al., 2023; Glance, Joynt Maddox, et al., 2023).

After merging the June 2021 Provider of Services (POS) file, 2019 Medicare Post-Acute Care and Hospice (PAC PUF) file, and Q3 2021 Nursing Home Compare data, there were 13,423 eligible facilities in our sample. Eligible facilities were identified in POS as: a skilled or nursing facility; an active provider; eligible to participate in Medicare and/or Medicaid; participating in Medicare or Medicare and Medicaid; and located in the 50 U.S. states, the District of Columbia, and Puerto Rico. Facilities were also ineligible if they did not have any observations in Nursing Home Compare or PAC PUF. We also excluded facilities from the sample if they did not have any race/ethnicity data for residents in the PAC PUF file. From the merged data set, we constructed a random sample of 68 NHs in strata defined by overall Quality Measure (QM) rating from Nursing Home Compare (low ≤ 3; medium = 4; high = 5), urbanicity based on the Core Based Statistical Area (CBSA) Urban Rural Indicator from POS, and race/ethnicity of the resident population (i.e., whether or not they served a population <70% White) from PAC PUF. By design, participating NHs were evenly recruited across low/medium/high overall QM rating and from the four U.S. census regions. Here, we describe the perspectives and lived experiences of 28 staff at 10 NHs, including 8 certified nursing assistant (CNA)/aides, 3 registered or licensed practical/vocational nurses (RN/LPN/LVN), 5 infection preventionists (IP), 8 directors of nursing (DON; two of which were also IPs), and 4 administrators.

Study Design

We randomly selected and contacted NHs via telephone to verify their mailing address, the name of an administrator or director of nursing, and their preferred contact method (telephone or email). We mailed personalized informational participation packets to each NH (in batches of 5–10) including an overview of the study, aims of the research (to learn from participant experiences during the COVID-19 pandemic and improve infection prevention and control and emergency preparedness in NHs), description of the study team, volunteer nature of the interviews, and our recruitment incentives. We followed up in 2 weeks via telephone and emailed (up to four times) until the facility agreed or declined to participate. We continued this process (repeated in multiple waves) until a total of 10 NHs were enrolled in the study. Forty NHs were active but never enrolled, 5 were not mailed packets because we closed enrollment, 4 were interested but were delayed in responding, 8 NHs declined, and 1 NH was closed. After at least half of the NHs completed interviews, we employed a more targeted recruitment approach to ensure participation was met across certain strata (e.g., rural, <70% White population served).

We enlisted the administrator or DON at each participating NH to assist with recruiting three staff members of different roles who had been employed within the organization for at least 1 year (i.e., CNA, RN/LPN/LVN, Administrator, DON, and IP).

Data Collection

We developed interview guides (see Supplementary Table S1 for NH interview topic guide; interview guides available upon request) tailored to the participant’s role using theoretical frameworks (i.e., existing, evidence-based theories; Donabedian, 1966), infection prevention and control guidelines in NHs (Rhinehart & McGoldrick, 2006), COVID-19 policies and regulations aimed at NHs, published literature (Kenneley, 2012; Markkanen et al., 2007), and research in other settings (Cohen et al., 2015; Raveis et al., 2014; Stone et al., 2015; Travers et al., 2015). Prior to data collection, the interview team (composed of two nurse scientists, three public health researchers, and a social scientist, all with over 7 years’ experience in studying infection prevention, nursing home care quality, and resident well-being, and a master’s in public health student) participated in training sessions on the interview protocols, conducted pilot interviews (n = 3), and mock interviews between team members (n = 4).

From February 2022 to April 2023, we recruited 10 NHs and conducted one-on-one, semistructured interviews with NH staff via phone; the interviews ranged from 30 to 90 min. Each participant was asked about emergency preparedness at the facility, infection prevention and control policies and procedures (i.e., monitoring/compliance, surveillance, and vaccinations), care coordination, facility staffing, as well as their lived experience during the COVID-19 pandemic in the context of infection prevention and control (i.e., staff and resident well-being). Each participant received a $100 Visa gift card or $300 in gift cards to the facility. Interviews were audio-recorded and professionally transcribed; all transcriptions were deidentified and reviewed for accuracy. Interviewer field notes supplemented each audio-recording and were used during transcript review and finalization. Team members held weekly meetings to discuss study progress, debrief on any new interviews, and discuss feedback on the interviewing process including data saturation. We did not gain feedback from participants on the transcripts, themes, or findings.

Data Analysis

We entered transcripts into NVivo R.1 (Dhakal, 2022; Lumivero, 2024), a web application for analyzing qualitative data. Coding began when about one-third of the interviews were completed. From the larger interview team, we had a four-person coding team (composed of a nurse scientist, two public health researchers, and a social scientist) tasked to code and analyze the transcripts.

We developed a code structure using systematic, inductive procedures to generate insights from responses (Bradley et al., 2007; Thomas, 2003). Within each coding team, four researchers independently reviewed and coded transcripts (n = 4) using inductive open coding, analyzing each transcript for parent and subcodes (Bernard & Ryan, 2010). A preliminary codebook was developed from codes that emerged from these initial transcripts. We applied these initial codes to two additional transcripts, identifying topics, adding, and refining codes. A final codebook was created and iteratively refined throughout the coding process. All remaining interviews were coded, with every third transcript being double-coded. We used regular team meetings to reach consensus on topics, identify discrepancies, refine concepts, codebook changes, define codes, and dialogue about concepts and preliminary themes (Miller & Crabtree, 1999). After code training, we compared differences among the coders in applying codes to the same interview text and obtained percent agreement indicating “very good” (>86%) coder agreement (Landis & Koch, 1977).

Thematic analysis identified themes related to the challenges of isolation, attempted solutions, and lessons learned concerning resident well-being. We reviewed theme presence by NH location across the United States and among high- and low-quality NHs.

We followed the consolidated criteria for reporting qualitative research (COREQ) checklist (Tong et al., 2007; see Supplementary Table S2). All research activities were approved under a single protocol by the lead institution’s Institutional Review Board and participants provided verbal informed consent prior to the interview.

Data Availability

The qualitative data (i.e., interview transcripts) are confidential and not available to other researchers for replication purposes. The studies reported were not preregistered.

Results

Characteristics of Nursing Homes and Staff

Among NH staff, we interviewed eight CNA/aides, three RN/LPN/LVNs, five IPs, four administrators, and eight DONs with an average of 3 years and 6 months in their role in the 10 NHs with an average bed size of 139 beds. Enrolled NHs were for-profit and had 30% or less of residents that identified as people of color. Table 1 lists the enrolled NH characteristics and the interview respondent characteristics.

Table 1.

Characteristics of Nursing Homes and Nursing Home Interview Respondents

Characteristics	Overall
Nursing home characteristics	N = 10 Nursing homes
Nursing home bed size (Mean, range)	(134.6 beds, 60–259)
Small (<100 beds)	2
Medium (100–150 beds)	4
Large (≥150 beds)	4
CMS Star quality rating
Low (<2.5 stars)	3
Medium (3–3.5 stars)	4
High (>3.5 stars)	3
Ownership
For profit	7
Nonprofit	3
Percent people of color (POC)
High (over 70% of residents are POC)	3
Low (<70% of residents are POC)	7
Region
Northeast	3
South	2
Midwest	3
West	2
Nursing home staff characteristics	N = 28 Nursing home respondents
Role
Certified nursing assistant/aide	29% (8)
Registered, licensed practical/vocational nurse	10% (3)
Infection preventionist	18% (5)
Administrator	14% (4)
Directors of nursing	29% (8)
Years in current role (mean)	3 years 6 months
Biological sex
Male	11% (3)
Female	89% (24)
Ethnicity
Hispanic	7% (2)
Non-Hispanic	86% (24)
Unknown	7% (2)
Race
Asian, Native Hawaiian or other Pacific Islander	11% (3)
Black or African American	28% (8)
White	54% (15)
Unknown	7% (2)

Note: CMS = Centers for Medicare & Medicaid Services.

Factors Contributing to Resident Loneliness.

Table 2 provides illustrative quotes for themes identified related to resident loneliness and decline of resident well-being during COVID-19. The effects of COVID-19 and its associated policies upon resident well-being were universally mentioned across all interviewees across staff roles and types of NHs, highlighting residents’ need for communication and interaction. Interviewees discussed several different factors that contributed to an increase in resident loneliness. First, with respect to the strict quarantine procedures and isolation precautions that were in place in NHs across the country, nursing, managerial, and infection prevention staff (from urban and rural facilities) compared and contrasted mandatory versus voluntary versus self-imposed quarantine/isolation measures. One NH administrator from an urban low-quality NH described how isolation precautions affected single residents who contracted COVID-19, whereas other administrators (from urban, rural, and low- and medium-quality NHs) talked about resident loneliness that arose when quarantine procedures were implemented on entire wings or floors. Residents were thereby unable to partake in the usual social activities available at the facilities, such as eating meals together, attending religious services as a group, and playing card games with friends. When under those precautions/procedures, nursing staff were dressed in full PPE, reducing their ability to communicate well with those with hearing or sight disabilities. Moreover, those staff were in resident rooms for only brief periods of time to limit exposure, further reducing the social interactions that residents had. Second, loneliness intensified when resident care was reduced to only those related to activities of daily living because of staffing shortages, as described by nursing, managerial, and infection prevention staff from across all types of NHs. Third, several administrators and nursing staff across all types of NHs pointed out how facility visitation restrictions for family and friends added to residents’ feelings of loneliness. Also, when COVID-19 vaccinations were required for nursing home residents and staff, policies related to being vaccinated added to resident loneliness as they required unvaccinated residents to be quarantined even when other residents could interact with others, according to nursing, managerial, and infection prevention staff across all types of NHs.

Table 2.

Illustrative Quotes for Themes on Decline of Resident Well-Being From COVID-19

Identified themes	Illustrative quotes	Interviewee role, nursing home
Resident loneliness
Driven by COVID-19 policies	No one liked the isolation [laughs] because residents are used to interacting with someone all the time. But I knew it was necessary. I just didn’t like it. [Laughs] They had to be confined to their own space when they had COVID. Most of them are used to be around someone, someone talkin’, laughin’, jokin’, always doin’ somethin’ with ‘em. I think that was the hardest part for them once they had COVID.	Certified Nurse Aide, Urban, Low Quality, Ohio
From someone on floor having COVID-19	Everybody had to stay in their room on this hall because a resident on your hallway had tested positive so now, we’re all in isolation. I feel like that really was what affected our residents. I would say it was detrimental for our residents because they like to be out of their rooms, and it was very hard to have to stay in their rooms all the time and eat in their rooms and never see each other. It was just really sad to see them. Everybody was almost in prisons in their rooms. They’d come out in the hallway and you’re like, “Oh no, you gotta stay in your room.” It was just horrible.	Nurse, Rural, Low Quality, Indiana
From low staffing reducing interaction to activities of daily living (ADL) care	Because of low ratio staffing, when we’re in crisis that really impacts the patient. Because you skip their daily dressing-up routine and it’s basically their ADL care. As it’s just one staff or one Certified Nurse Aide most of the time.	Infection Preventionist, Urban, Medium Quality, Maine
Driven by visitation policies	I’ve never felt so terrible about doing something in my life as locking out the families. I know that really took a toll on everybody, not just the residents but families and staff. I think the number one impact of COVID-19 was the isolation that came from the restrictions that were in place.	Administrator, Urban, Medium Quality, Alabama
Driven by vaccination policies	Residents weren’t allowed to even eat in the dining rooms during the initial outbreak. They were all isolated to their rooms, and not allowed to come out, but our unvaccinated residents, they still eat in their rooms. They’re pretty much confined to their rooms.	Administrator, Rural, Low Quality, Indiana
Decline in Well-being
Psychological and physical decline	The impact of COVID was evident in resident’s behaviors. I think when COVID first started, and the residents were being contained, and they couldn’t go out, and they couldn’t leave their room, and they couldn’t see their loved one, depression set in and played a role; we saw a lot of physical symptoms and several residents who lost weight; several residents had major depression. I think that type of decline played a large role in resident well-being in the beginning, … they all had to wear masks when they left the room. They didn’t like that, so I think that played on their mental psyche. We saw a lot of behaviors, a lot of people actin’ out.	Nurse Director, Urban, Low Quality, Ohio
Stress and loss for residents	I have noticed as far as psychologically, a lot of our residents have suffered through COVID, just not being able to see their family members and everything. Care got a lot harder because it was trying to get them up every day, and they didn’t want to, or trying to get them around and dressed, and what for because they had nothing to look forward to. They just wanted to sit in bed all day or sit in their chair. It wasn’t the care, per se. It was the resident’s refusals most of the time that we had issues with.	Nurse, Urban, High Quality, Michigan
Stress and loss for staff	The loss of the residents impacted us and the residents—some of the residents have been there forever and we’re all attached to them. They would get COVID, and we would all gasp. We thought that way about all of’em, but it’s just really certain ones in long-term care, they’re like your grandma. It’s hard ’cause we see them every day. They’re there, they live there, that’s their home. You’re going into their home and you’re taking care of them. It’s like family, losing family. It was that way for residents, too.	Nurse, Rural, Low Quality, Indiana
Due to added tasks for staff to address resident need	I think mentally, we were a little unprepared on how hard it hit our geriatric population and what it did to them. That’s not on the facility. That’s more like, “Wow, this is real, and it’s right here in front of me. COVID’s hit this patient really hard mentally, emotionally. Now, it’s my job to try to protect myself and take care of them socially, emotionally.”	Nurse, Urban, Medium Quality, Maine
Heightened need for interaction and communication	Through COVID-19, we learned about the importance of touch and communication and interaction and involvement with residents; that’s something that’s really been highlighted.	Administrator, Urban, Medium Quality, Alabama
Heightened need for emotional support	COVID really affected the residents. We saw a lot of people being isolated and feeling lonely. Now, during the pandemic when residents can’t see nobody, it’s much worse, ‘cause even though you as a staff wanted to spend more time with them, you couldn’t. You had many other things to take care of added to your plate. They [residents] felt lonely.	Certified Nurse Aide, Rural, Low Quality, Texas

Notes: COVID = coronavirus disease; COVID-19 = coronavirus disease 2019. States included Alabama, Hawaii, Indiana, Maine, Massachusetts, Michigan, New Jersey, New Mexico, Ohio, and Texas.

Aspects of Decline in Well-being

Along with loneliness, our interviews identified several main areas of decline and concern related to resident well-being during COVID-19 including mental and physical deterioration (see Table 2 for illustrative quotes). One nurse director (from urban low-quality facility) described how the restricted environment and mask wearing led to weight loss, depression, and aggression for several facility residents. Resident death rates during the pandemic were devastatingly high; one nurse from an urban high-quality NH described that, on top of loneliness, residents were dealing with grieving the loss of fellow residents, and that staff also felt substantial grief similar to losing family members. Grief coupled with loneliness on a facility-wide scale were issues that nursing home staff were unprepared for, in addition to ensuring staff/patient safety and providing clinical care. One nurse (from an urban medium-quality NH) and an aide (from a rural low-quality NH) described their experiences of realizing the heightened mental, emotional, and social needs frontline staff were needing to address.

Solutions

Our interviews identified several themes pointing to the types of solutions and supports that addressed resident well-being. Themes were found consistently in NHs across the United States and among high-, medium-, and low-quality nursing homes.

Proactive mental health support

Almost all NH managerial, infection prevention, and nursing staff across the array of NHs described how facility staff from social workers to therapists to nurses to CNAs stepped up to provide additional mental health support, caring interactions, reassurances, commiserating, humor, being present, and taking “that extra five minutes” to actively sit down and talk with residents to help with loneliness; they described this best as “being family for the residents.” See Table 3 for illustrative quotes.

Table 3.

Illustrative Quotes on Solutions Related to Resident Well-Being During COVID-19

Identified themes	Illustrative quotes	Interviewee role, nursing home
Proactive mental health support
Nurses using humor and being present for residents	With the isolation, really, our hands were tied. We did have activities in-house, but the residents had to limit that exposure to certain people ’cause some people, obviously, didn’t get vaccinated, and some people did. How to help them was pretty much left up to the individual nurse. I know my approach every day with my patients—and still is—is using humor and just trying to be there for them as well. I think everybody was scared. Nurses were scared. The patients were scared. We experienced that together, so it brought us closer together as people.	Nurse, Urban, Medium Quality, Maine
Social workers and providers to talk to and lean on	As COVID progressed, isolation was huge, and people were feeling it. Obviously, we did have people that it hit hard mentally, we had this added issue not only for ourselves to handle as nurses, but we had social workers too that we could lean on and providers that could come in and talk with the residents and try to put their mind at ease. I think the residents felt too that we were all going through this together. There was some comfort in that. I firmly believe that.	Nurse, Urban, Medium Quality, Maine
Be family for residents	The thing that I’m most proud of is the fact that we stepped in to be that family for residents, especially for residents when their families couldn’t really be here. We provided them with that sense of you’re okay. You’re safe. You’re here with us. We’re gonna do our best to take care of you. We kept them informed the whole time on what was going on. It’s funny “cause we would talk about it all the time. Take that extra five minutes and sit down and just talk. I know you’re busy, and I know everybody’s got a lot goin” on, and you’re taking care of very sick people, but take that five minutes and talk about something unrelated to what’s at hand. Just start a conversation, make a friend, and spend time. Probably out of everything that we did that would be the one thing I’m most proud of is the fact that you can just walk through the organization, the campus, and know that residents and staff support had taken place because our folks are happy, and they’re feeling hope.	Administrator, Urban, Medium Quality, Alabama
One-on-one visits with residents and nurses/staff	Within the past year of being here, we tried to do one-on-ones with the residents. We tried anything we could possibly do just to keep the residents happy, safe, and, like I said, just day by day of what we could do to help them out in any way.	Nurse, Urban, Low Quality, Ohio
Extra time for emotional support	At the beginning when no families were able to come, we had to try and step in and take that place of families visiting. It was extra, extra time consuming “cause you would spend 20–30 minutes with the resident gettin” ‘em up outta bed, showered, dressed and then spending an extra maybe 30–40 minutes with each resident only because you wanted to give ‘em that time, emotional support, that they aren’t receiving and that they’re not having with their families.	Certified Nurse Aide, Urban, Low Quality, Ohio
Personal preferences and needs documented in the care plan	We would “care-plan it.” We would care-plan isolation by adding things that were the specific resident needs and preferences; like this resident likes Gunsmoke, so we made sure that every day when Gunsmoke was on, that they could watch that. Or if another resident liked certain types of magazines, we would try to do that. We would find specific things to do in that personal way for each of the residents. We did a lot of that just to try to mitigate some of the isolation. ’Cause obviously, people that are already depressed or had a mental health issue, COVID only compounded the issue. Things that we could do personally to make their life a little bit better, we did. I personally took on that task anytime. I would certainly update the care plan and include, “Hey, they really like playing checkers,” or, “They like playing cards.” Or some people had iPads, and we’d set that up so that they not only could Zoom with family, but some of them didn’t know you could play cards on the iPad.	Nurse, Urban, Medium Quality, Maine
Psychologist visits for residents	They brought in psychologists in to talk to individuals because of the isolation.	Nurse Director, Rural, Low Quality, Texas
Tracking risk of depression	If they’re on isolation, we had in their care plans that they may be higher risk for depression due to isolation and not bein’ able to visit family and friends; so, we’d all be on high alert.	Nurse Director, Rural, Medium Quality, New Mexico
Being on the COVID-19 unit	[COVID-19 policies] was very isolating, but when a resident was on the COVID-19 unit, they were not as isolated as in their rooms.	Administrator, Rural, Low Quality, Texas
Cohorting within COVID-19 units	Let me describe the set-up of our building. When I came, each resident was in their own room. It’s a 172-bed facility, but functionally it’s 115 beds, but they had—if I remember right, they had about 38 residents when I got there, and everybody in their own room, but when you were on the COVID-19 unit, they cohorted them on that unit so they would have somebody consistently with them in there, the COVID-19 unit, so the residents were less isolated in my opinion than they were in the regular resident population or living in the cold zone.	Administrator, Rural, Low Quality, Texas

Notes: COVID = coronavirus disease; COVID-19 = coronavirus disease 2019. States included Alabama, Hawaii, Indiana, Maine, Massachusetts, Michigan, New Jersey, New Mexico, Ohio, and Texas.

Commonly, despite staffing shortages and contact precautions, we heard about nurses and CNAs making one-on-one visits with residents and spending extra time with residents for emotional support. Some NHs (primarily rural and low-quality) brought in psychologists to talk with residents about the stress and isolation from COVID-19. Other nurses of all types also described recording the needs and preferences of residents in their care plans or charts to support resident’s individualized social needs, such as playing cards or checkers on an iPad, or watching a specific TV show, or providing certain reading material. Several NH directors across all types of NHs mentioned that when residents were in isolation, they tracked their mental health more closely by including in their care plans whether a resident was at higher risk for depression due to isolation.

Additionally, several NH administrators from both urban and rural and medium-and low-quality NHs described the common use of cohorting (Centers for Disease Control and Prevention, 2020; Lee et al., 2005; Sanchez et al., 2020) of staff and residents in their COVID-19 units (i.e., limiting contact between defined groups to reduce disease transmission); this was done to reduce social contact and disease transmission but also to build consistency of staff relationships for residents when residents were in isolation. Another administrator from a rural low-quality NH pointed out that if a NH resident needed to be on the COVID-19 unit, the resident was not as isolated as they were in their rooms.

Focus on resident-centered family visitation

Almost all NH managerial, infection prevention, and nursing staff across all types of NHs described the constant changes in policies surrounding family visitation during the pandemic, starting with no in-person visitation moving to the use of video visits, phone visits, and window visits. See Table 4 for illustrative quotes.

Table 4.

Illustrative Quotes on Solutions Related to Resident Well-Being During COVID-19

Identified themes	Illustrative quotes	Interviewee role, nursing home
Focus on resident-centered family visitation
Constant changes in policies for visitation	When it first happened, of course, everybody was shut down. There was no visitation. Then there was visitation if you had a resident who was on hospice and maybe imminent. Then when they opened up visitation, we had visitors having to make appointments. We had to have visitors at a general location. They couldn’t visit in rooms, and there was a time limit. That’s how it first started out. Then that changed to where they didn’t have to make appointments. We opened up visitation even more—opened up the hours of visitation because before, we were only doin’ two hours in the morning and two hours in the evening. Then we opened it up that you could have more hours in total per visit, and that if they were in a private room, they could visit in their room. However, if they had a roommate, you still had to visit in a common area. We went through that for a while. Now, again it’s changed. We still monitor how many people are in a room “cause the rooms are small. We still want them to maintain that six-feet protocol. It just depends on how many visitors that you’re havin,” or if somebody wants to have a party, we have rooms dedicated for a bigger crowd than what was previously done.	Nurse Director, Urban, Low Quality, Ohio
Compassion visits	During the height of the pandemic, we had no visitors unless they were on hospice. We always allowed compassion visits. If somebody was on hospice or actively dying, we would allow the family members to come in for that.	Nurse Director, Urban, High Quality, New Jersey
No visitation during an outbreak	In the beginning, we had strict limitations. We decided to stop all visitations when we had the outbreak obviously. We did still do window visits, so family could come to the windows of patients’ rooms. We did not open the windows, though. We had a phone on both sides so the family member would have their own phone, and the resident would have their phone, and they would talk. That lasted for a while. I think that almost lasted for two years.	Nurse, Urban, High Quality, Michigan
Window visits	Within the past year of being here, with the families we could do window visits and things like that. Most families still stood outside, and we just communicated with them over the phone, through the windows, and things like that. They wanted their loved ones to heal, but when it got to a point, we’d reach out to them to connect and things, and they were fine with that. It was more trying to embrace anything we could to maintain a connection for the families and the residents.	Nurse, Urban, Low Quality, Ohio
Facetime	We used a lot of Facetiming and a lot of Facetime visits with residents and families.	Nurse Director, Urban, Medium Quality, Massachusetts
In-person with masks and maintaining distance, as allowed	We did televisits and did the Zoom calls—used the iPads. The nursing home even gave window visits, where the family could come and could talk through the window to residents—then once it loosened up a little bit more, the family visitors were doing outside visits once it warmed up a little bit, but they had to maintain the six feet apart from each other and have their masks on.	Certified Nurse Aide, Urban, Low Quality, Ohio
Outdoor tented visitation	We did outdoor visits. Residents gained outdoor visits during summertime; they enjoyed that. We set up tents outside and tables so that way residents and family could enjoy time with no masking or if they preferred with masking and no social distancing. We still recommended the current policies, but we provided them all with products for hand hygiene and all the things they needed, masks, etc., because they’re also exposed to other staff or other residents.	Certified Nurse Aide, Rural, Medium Quality, New Mexico
Nurses/staff holding phones for residents to have conversations	When we had, no visitation, the residents could make phone calls for those that had phones. Those that didn’t, the families could call the nurse’s desk, and they would get an update, or the nurses would have a cell phone that they could video call so they could see each other, but the residents couldn’t hold the phone. So, the staff would have to hold the phone while the residents had conversations with family and loved ones.	Certified Nurse Aide, Urban, Medium Quality, Alabama
Activities staff to facilitate family communication	We had Zoom meetings with the families and had outdoor visits. If the residents were well, they could visit their family member outside. During the height of the pandemic, we had our room numbers on the windows outside, so they would have window room visits. The family would stand outside and talk to the resident while—the residents could see their families that way. Some just stood out there and waved at the windows. Some residents were incapable of doing that, so they just used video visits. I’m telling you, most of the families enjoyed it; they really did. They would have folding chairs, and they’d sit out by the room. If they had problems communicating, like if the resident couldn’t hear well, we had an activities staff there that could help’em translate: “Your daughter said this,” or whatever. It seemed to go okay and was for a lot of our residents, truthfully. I don’t remember one person complaining about visitation, nothing by the residents. From families, yes some, but the residents, no.	Nurse Director, Urban, High Quality, New Jersey
Communication and care planning
Intentional, frequent care planning, and communication	We were havin’ regular conversations with families regarding when and whether outbreaks happened, as well as what is the kind of treatment you want for your loved one. We were making plans with family members even before we had an outbreak to know, do you want them sent out to the hospital for treatment? Do you want us to keep ‘em here, and keep ‘em as comfortable as we can? Do you want them ultimately put on a ventilator? What are the plans? Again, building those relationships with families to support the residents. If someone got COVID, we started calling. As soon as we got our first case we called. I would say, we called a couple times a week to update families during our heaviest outbreak period. We had our management team make these calls; we have about 20 managers on our team that we split those calls between. Everybody would just take—they basically, for probably the first year, they all had the same assignment, the same family members.	Administrator, Rural, Low Quality, Indiana
Education of families	As far as education for the resident’s family members, that’s all been done through Robocalls, just educating them on the importance of not visiting or, if you’ve been sick or if you’ve been out into the public or if you’ve traveled lately, and then also educating them on the importance of getting vaccinated as well as the residents. We’ve educated them all on that.	Nurse, Urban, High Quality, Michigan
Efforts to maintain resident normalcy
Exercise and games for residents in hallways	We had nurses, we have great nurses that were exercisin’, they would all do exercises with each other in the hallway as much as they could. They would come to the door, and she’d be in the hallway showin’ the residents raise your arms, kick your feet. Play bingo in the hallway sometimes, they would at the doorway. They all had to have masks on, but they would come to their doorway and play bingo. Our nurses were like, “They’re miserable. They’re stuck in their rooms and they’re lonely.” It was just hard.	Nurse, Rural, Low Quality, Indiana
Promoting games	Or if they liked cards, we would use that for distraction and have them focus on those things to keep their mind off the COVID-19 issues that were going on. Things that we could do personally to make their life a little bit better, we did.	Nurse, Urban, Medium Quality, Maine

Notes: COVID = coronavirus disease; COVID-19 = coronavirus disease 2019. States included Alabama, Hawaii, Indiana, Maine, Massachusetts, Michigan, New Jersey, New Mexico, Ohio, and Texas.

When some visitation was allowed, the visitation policies determined how many people in a room with specified time windows as well as masking, social distancing, and outdoor visitation. Nursing directors also raised that compassion visits were always allowed for those residents on hospice or near death. CNAs reported how they held cell phones for residents during video calls when the resident was not able to as a way of supporting resident communication and interaction with family. Another nurse director discussed the myriad of communication strategies from Zoom meetings to outdoor meetings for family visitation and how she utilized the NH activities staff to support resident and family communication during window visits when residents or families could not hear well. Amid these constant changes, administrators commonly reported the need to be flexible and remain focused on the social and visitation needs of the residents and families.

Communication and care planning with the families

We heard consistently from NH managers, infection preventionists, administrators, and nurses across all NH types that during the pandemic, they conducted intentional, frequent care planning and communication with families about resident care. We heard about layers of added communication with families that included updates on COVID-19 cases, and education and communication about current policies.

Efforts to maintain resident normalcy

Nurses and CNAs from urban, rural, and high-, medium- and low-quality NHs described efforts to support resident interaction. Several nurses in mostly rural, low- and medium-quality NHs described how they conducted exercises and games in the hallways for residents to maintain resident normalcy as best they could. Another nurse from an urban medium-quality NH indicated that they would play cards to keep resident’s minds off of COVID-19.

Discussion

Our study offered an opportunity to examine and describe nursing home administrators and staff perspectives and experiences related to resident well-being during COVID-19 from a diverse set of NHs across the United States (i.e., geographical region, low/medium/high quality, ownership, and varied race/ethnic population). Our findings can “facilitate sharing of strategies and information to help nursing homes overcome challenges and improve care,” as stated in the 2024 HHS Office of Inspector General Report (The MITRE Corporation, 2020). Our findings across a wide array of NHs confirmed evidence concerning the rise in cognitive and physical deterioration, loneliness, and emotional decline for NH residents during COVID-19 pandemic (The MITRE Corporation, 2020). Our study supports this evidence on how resident well-being suffered as a result of stringent isolation protocols from a diverse of NHs across the United States.

Importantly, our findings also extend the current literature by offering real-world experiences of implemented changes made to mitigate and alleviate the negative effects of isolation on resident well-being. Our findings point to a set of homogenous actions taken by staff and by NHs administrators across a diverse set of NHs to proactively provide mental health support for residents, resident-centered family visitation, continued communication and care planning with the families, and maintain resident normalcy balanced within the guidelines. Specifically, NH administrators and frontline care providers described various avenues of providing proactive mental health support including efforts accomplished through individual choices made by staff in their interactions with resident (e.g., “taking that extra five minutes,” “being present,” and “being like family”) and by administrator decisions that systematically made time for nurses and CNAs to include one-on-one visits with residents and to spend extra time with those who needed more emotional support. A few rural NHs with less flexibility in staffing and structures also figured out how to bring in psychologists to help support the emotional needs of residents. These actions underscore the importance of NHs building into the regular workflow of care staff ability to be the extended family for residents, which takes time, but is a part of high-quality NH care (Munn et al., 2008; Powers & Watson, 2008).

Our findings highlighted that NHs of varying types across the United States also focused on tracking mental health status more closely by charting and adding mental health and resident needs (i.e., emotional, social, and personal preferences) as part of resident care plans. Such systematic documenting and tracking allowed for NHs to follow up and address resident needs in a more thorough, regular fashion. This suggests that NHs may need to establish structured mechanisms for documenting and charting mental health status, mental health needs, and resident preferences and social characteristics in support of resident well-being. Evidence shows that structured documentation increases note quality and improves care quality (Ebbers et al., 2022).

The common practice of cohorting to reduce risk of infection was used also by a diverse set of NHs in our study, but we heard that NHs implemented it for a dual purpose. NHs explained that they used cohorting to reduce social contact but also to pair staff with residents in COVID-19 units to build consistency of staff–resident relationships as part of maintaining social support for residents. Our finding supports the 2020 Coronavirus Commission for Safety and Quality in Nursing Homes practice recommendation to (p. 42) “Update cohorting guidance to balance resident and staff psychological safety and wellbeing with infection prevention and control” (MITRE Partnership Network, 2020), as stated in their final report by The MITRE Corporation (MITRE Partnership Network, 2020). This suggests that cohorting with a dual purpose be investigated as NHs, staff, researchers, and policymakers work out the details of how to operationalize cohorting in NHs.

Our study highlighted several other actions identified in the literature as being important for resident well-being, such as focusing on resident-centered family visitation, efforts that balance strict social guidelines and maintaining normalcy for residents (Powers & Watson, 2008) by ensuring activities with social engagement (Woods et al., 2022), and intentional, regular communication and care planning with families about resident needs. These actions could also be delineated and planned out to be employed when needed and for specific residents.

The actions identified in our study highlight the ways in which during the pandemic NHs, their administrators and staff were resident-centered, which is a core value in providing high-quality NH care. As stated in the 2020 Coronavirus Commission for Safety and Quality in Nursing Homes final report by The MITRE Corporation (p. 13) (MITRE Partnership Network, 2020), “Resident goals, values, and needs often are treated as important—but not central—considerations. Elevating person-centered care requires that care providers first ask what is best for the resident and ensure they are active participants in decision-making about their care.” Taken together, our findings imply that preparing for how to systematically restructure staff–resident interactions in times of crisis is needed to ensure higher levels of staff–resident interaction, increased communication and care planning, and detailed tracking of mental health support and needs while balancing the healthcare and safety needs of residents. These types of needed changes cannot be accommodated within the current time constraints and daily routines and choices of frontline staff; the implementation of such changes need to be planned out so that they are systematic and made through intentional decision-making that adapts the current processes and structures of how resident NH care is provided. Research to understand the needed supports for the implementation of these changes is an important next step in supporting resident well-being.

Our study has limitations. The interviews were not solely focused on implemented solutions, and therefore we did not capture specific information about barriers or facilitators of implementation or any metrics of effectiveness of the strategies discussed. Our study also did not include interviews or survey data from NH residents to understand their perspectives on these strategies and changes. Additional research on implementation and recommended plans is needed.

Conclusions and Implications

Nursing home administrators and frontline staff caring for NH residents across the United States and in low- and high-quality NHs employed a variety of different supports and techniques implemented to mitigate and alleviate concerns with resident well-being during the COVID-19 pandemic. NH administrators and leaders need to have prepared plans at the ready for how to adapt NH processes and structures that prioritize resident well-being and staff–resident interactions along with resident care. Research and expert review are needed to delineate the necessary planning, implementation, and recommendations to operationalize such strategies for practice. Research is also needed that identifies and tests these resident well-being support strategies for NH staff and administrators to employ when caring for residents, as well as how best to implement such structural changes within NH processes and workflow to preserve time for staff to spend with resident.

Funding

This work was supported by a grant from National Institutes of Health’s National Institute on Aging, National Institute of Allergy and Infectious Diseases, and National Institute on Minority Health and Health Disparities [grant number R01AG074492].

Conflict of Interest

None.

Data Availability

Due to the confidential nature of the data collected, we are not able to share the raw transcripts and coded data set. However, our interview guides are available upon request. The conducted research was not preregistered with an analysis plan in a registry.

Author Contributions

Study concept and design: D. D. Quigley and P.W. Stone. Acquisition of data: D. D. Quigley, A. M. Chastain, M. Pogorzelska-Maziarz, and P. W. Stone. Analysis and interpretation of data: D. D. Quigley, A. M. Chastain, M. Pogorzelska-Maziarz, and P. W. Stone. Drafting of the manuscript: D. D. Quigley, H. S. Ma, and A. M. Chastain. Critical revision of the manuscript for important intellectual content: D. D. Quigley, A. M. Chastain, and P. W. Stone.

Sponsor’s Role

The sponsor was not involved in the design or conduct of the study.