COVID-19 Highlights the Need for Trained Social Workers in Nursing Homes

A nursing home social worker knew it was going to be a challenging day when she arrived at work to find an ambulance at the front door and a hearse at the back. Coronavirus disease 2019 (COVID-19) had struck. This spring's pandemic has forced a new psychosocial playbook in nursing homes across the country as fears run high, emotions run hot, and distress runs rampant. Social workers are trained to run toward the emotional chaos, offering their skills to support people's own coping process. Good psychosocial care, even in the midst of a pandemic, can help people identify and build on their natural resilience.¹ Core features of psychosocial care in a crisis include access to information and emotional support.²

This editorial provides examples of how nursing home social workers are adapting the way they connect with residents and families during the pandemic, and concludes with suggestions. Some of the information comes from experiences shared by nursing home social workers who have participated in weekly online support sessions initiated in April by the National Nursing Home Social Work Network https://clas.uiowa.edu/socialwork/nursing-home/national-nursing-home-social-work-network. These weekly support sessions provide an anonymous space for social services staff around the country to share experiences and ideas about coping with COVID-19 challenges. The editorial also highlights the need for trained social workers in nursing homes.

One of the first topics to surface during the online support sessions was the shortage of personal protective equipment (PPE). Many nursing homes around the country still struggle to get enough PPE for the nursing staff who provide hands-on care. In nursing homes experiencing PPE shortages, the lack of equipment means activities and social services staff cannot safely enter resident rooms. Much of the psychosocial care provided to these residents now occurs over the phone, computer, or through direct care staff. In nursing homes where PPE is available, training on how to use it safely may not be. This leaves untrained activities and social services staff with a false sense of security and vulnerable to catching and spreading the virus.

In some nursing homes, staff members are expected to re-use the PPE. In others, there is not enough PPE for families who want to visit dying loved ones. Some hospice workers are arriving at nursing homes to provide services to residents but lack their own PPE. The PPE shortage endangers the physical health of residents and staff and damages emotional health as well. During our weekly online support sessions, social workers shared they are as deeply concerned about bringing COVID-19 home to their families as they are about bringing it to the nursing home.

In part because of the lack of PPE, social workers are spending more time on the phone and on the internet communicating with residents. Some of these contacts can happen directly between the social worker and the resident. Other contacts must be facilitated by busy nursing staff who have access to PPE. Cooperation, coordination, and collaboration among staff can improve care provided to residents and enhances communication with concerned family members.

Although a core function of the social work role has always been to anticipate, assess, and address resident psychosocial needs, social workers have also been key liaisons between the family and the facility. During a pandemic, that connection is more important than ever and often occurs over the phone. Engaging in this level of conversation with anxious family members requires skill. Not all nursing homes have a staff person skilled in delivering bad news, listening to distraught families, and helping to identify and affirm family resilience. The federal government requires only nursing homes with more than 120 beds to hire 1 full-time equivalent social services staff member, and that person does not have to hold a degree or license in social work.³ The unrealistic staff-to-resident ratio and the disregard for professional standards has been a problem for decades. The inadequacy of this lax regulatory stance toward the credentials of the key on-site professional responsible for psychosocial care is even more apparent during a crisis when residents, families, and staff are simultaneously and chronically in distress.

Nursing homes are being inundated with phone calls from families concerned about their loved ones contracting COVID-19 and about the impact of social isolation. Families have a lot of questions. Some questions have no answers. Families wonder why the nurse has not called them back in 2 days and why no one picks up the phone. Suspicion brews. Families hold themselves responsible for being there for their loved ones.⁴ This sense of responsibility is heightened during a crisis. Families want their mothers/brothers/sisters to know they are not forgotten and have not been abandoned. Families feel helpless. Feeling helpless, responsible, and uninformed can provoke intense feelings of anxiety and sometimes anger. Without clear information from a trusted source, fears can run amok. Amok people can be difficult to deal with.

Social workers are trained to work with people in crisis. Some crises can be minimized or averted by frequent, open, and supportive communication. Social workers phoning families is 1 way to exchange information with families and provide emotional support. Social workers can assist in these situations by listening to family concerns, providing responses when possible, and tracking down answers when necessary. These conversations can reduce family anxiety, increase trust, and free up the nursing staff to provide resident care. One social worker disclosed that although some families use these phone calls to vent their anger, others ask how they can help; she followed up with “…and then a large box of home-made masks appears later in the week.”

What else are social workers doing during these phone calls? A social worker engages constructively and compassionately with families by using skills acquired as part of a social work education, including active listening, crisis management, anger de-escalation, situation stabilization, emotion processing, problem solving, decision-making support, boundary setting assistance, advance care planning, transitions of care discussions, validation of family connectiveness, role playing, role affirmation, clarifying, reflecting, interpreting, reassuring, and meaning-making.^{5 , 6} Social workers also advocate on behalf of residents and families, and provide information on a wide range of topics including health insurance, resident rights, and how to connect with the local foodbank. Social workers with a reasonably sized case load can be expected to provide more frequent and comprehensive support to families compared with social workers with large caseloads. Even before the pandemic, the most qualified and motivated social worker could not possibly provide this level of psychosocial support with all family members of 120+ residents. Nursing homes that do not employ social workers may not have anyone else on staff trained in psychosocial assessment and care and with the skills to successfully engage families in these sometimes difficult conversations. If your nursing home does not employ a social worker, your administrator, director of nursing, and medical director are probably spending more time on the phone with families and may not have the time, skill, or interest to engage in active listening and creative problem-solving with upset family members, leaving both the staff and the family member frustrated.

In facilities in which the virus has yet to strike, social workers are phoning families to collect emails, review goals of care, and revisit advance care planning. Medical directors, directors of nursing, and social workers should be on the same page about how advance care planning discussions are to be conducted and documented. These conversations can be difficult when the resident and family member disagree on appropriate goals of care for residents. They can also be difficult when residents are not cognitively capable of participating and family members disagree among themselves. Sometimes these conversations are difficult because they reflect the mistrust that is present in the larger social context of racism, ageism, and ableism. For example, during a phone conversation with an African American daughter 1 social worker was asked, “Are you saying the same thing to whites?” These delicate conversations call for expertise and compassion.

During our online support sessions, social workers discuss the fine line they walk daily between reassuring family members and not over promising. By keeping family expectations realistic today, disappointment can be diminished tomorrow. For example, many families would like the staff to help them connect daily by phone or computer with their loved one. Most nursing homes do not have the staff capacity for that, even if they have a spare laptop or tablet. From the family's perspective it does not seem to be asking much for a 10-minute daily face-time session, yet from the staff perspective it requires much more than 10 minutes to organize, prepare, and safely deliver a phone or internet session.

COVID-19 is bringing new tension to nursing homes all over the country. Many nursing homes have had to move residents to develop COVID units. These relocations can be stressful to residents. Practices intended to keep residents physically safe are socially isolating them. Knowing how important social interactions are for quality of life, social workers are concerned about this social isolation and looking for new ways beyond the phone and internet to connect. One social worker arranged for a musician friend to play the flute in the central courtyard, with resident windows open for those who wished to listen. When weather and staffing permit, residents are going outside so that families can see them from a safe distance in “drive by sightings.” Weekly car parades, arranged by staff or volunteers, remind residents they are part of the community. Activities and social services staff members are encouraging community groups to send cards.

Many nursing home policies and procedures developed pre-COVID are inadequate during COVID, including some end-of-life policies. In most nursing homes, the only family members now allowed to visit are those whose relatives are actively dying. Even then, the number of family members is limited. Some family members tell social workers they are afraid to enter the nursing home for fear they will catch COVID and are equally afraid they will never forgive themselves if they do not visit in-person to say goodbye. Social workers can help people sort out their feelings, understand PPE options, gain the information they need to weigh the risks, and reach a decision they can live with.

In nursing homes with multiple COVID deaths, social workers leave work with a pit in their stomach from the phone conversations with family members to discuss what to do with the decedent's body and their belongings. Most nursing homes do not have an on-site morgue and many lack sufficient storage space for decedents' possessions. In cities hit hard by COVID, funeral homes are backed up for weeks. One social worker told us that she phoned a funeral home the second week of April to help set up funeral arrangements on behalf of a family. The funeral home said they had an opening for the funeral in mid-May. These are practical problems with enormous psychosocial implications. How families are informed about these issues is important.

Social workers are often the staff member who initiates the development of rituals to recognize the death of residents and of staff and to support survivors. In the age of multiple resident and staff deaths because of COVID-19, when, how, and even whether the facility should communicate these deaths to other residents and other families becomes an issue. Well-intentioned people can disagree. The process of decision-making can be as important as the final decision itself. Social workers can facilitate this process.

During online support sessions, social workers mentioned their fear of communities relaxing COVID precautions too soon. One asked, “How are we going to keep residents safe if we don't have widespread testing and our doors are opened to all visitors?” Social workers also told us that more staff are seeking them out for emotional and logistical support. Concerns range from fear about taking public transportation to and from work, to how to help their children keep up with schoolwork, to feeling neither the community nor administration appreciate their sacrifices. Staff who have a family member with COVID-19 or who has died with COVID-19 are emotionally numb. Working in a facility that is consistently understaffed adds more stress. Despite their strong commitment to the residents, some staff are wondering if it is worth the risk to continue working in a nursing home.

A social work approach to interacting with residents, families, and staff emphasizes the process of communication as central to the quality of the work. It is not enough to conduct a task well; in social work, how the task is undertaken is as important because strong and trusting relationships with residents, families and fellow staff members are the vehicles through which excellent social work is accomplished. Nursing homes in which social workers have had the time and skill to build solid, open, trusting relationships with residents and families and staff are in a much better position to weather this COVID-19 storm. These strong relationships are assets at any time and indispensable during a pandemic. As any seasoned nursing home social worker can attest, good interpersonal relationships are prophylactic.

A strong social work presence has always been necessary in nursing homes; the pandemic underscores the need. After the pandemic, the need will continue. Because we are working with people in physically, emotionally, and socially vulnerable circumstances, many of whom are approaching the last chapter of their life, we know that psychosocial concerns will be ever-present. If we are serious about improving the quality of care and the quality of life in nursing homes, we must be serious about psychosocial care. We need to be concerned with fractures of bones yes of course, but we also need to address a resident's fractured broken heart. We need to do all we can to prevent wounds on the skin, yes of course, and we also need to prevent wounds on the soul.⁷ This pandemic has exposed many ways the country can better support nursing homes and nursing homes can better care for residents and families. Including degreed and licensed social workers as part of the core team is a basic way to provide psychosocial care in nursing homes and enhance resident quality of life.

Recommendations

• •Securing PPE for staff is necessary but not sufficient. Training must be provided to all staff. A good source is https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html
• •Develop and communicate a protocol for securing PPE and training for family members who come to visit residents who are approaching the end of life.
• •Let residents and families know what format (social media, newsletters, phone calls) and frequency of communication they can expect from the facility. Clear, consistent, truthful information from a trusted source is an important factor to help individuals and organizations adapt.
• •Squash rumors and build a sense of inclusion by keeping all staff updated and informed. Encourage questions.
• •Have a mechanism for staff who are in touch with families to relay concerns and compliments back to the whole staff.
• •Consider hosting “drop-in” online support sessions for family members. If staff are not available to coordinate, hire a local mental health provider or enlist a trained volunteer.
• •Regularly recognize the hard work of staff in concrete ways.
• •Maintain a “nurturing environment,” which provides the necessary resources, security, and support to facilitate individual and organizational adaptation. Adaptation is key to resilience.¹
• •Employ a Bachelor's of Social Work or Master's of Social Work trained social worker.