Abstract
Objective
The Coronavirus disease 2019 (COVID-19) pandemic is an unprecedented challenge for nursing homes, where staff have faced rapidly evolving circumstances to care for a vulnerable resident population. Our objective was to document the experiences of these front-line health care professionals during the pandemic.
Design
Electronic survey of long-term care staff. This report summarizes qualitative data from open-ended questions for the subset of respondents working in nursing homes.
Setting and Participants
A total of 152 nursing home staff from 32 states, including direct-care staff and administrators.
Methods
From May 11 through June 4, 2020, we used social media and professional networks to disseminate an electronic survey with closed- and open-ended questions to a convenience sample of long-term care staff. Four investigators identified themes from qualitative responses for staff working in nursing homes.
Results
Respondents described ongoing constraints on testing and continued reliance on crisis standards for extended use and reuse of personal protective equipment. Administrators discussed the burden of tracking and implementing sometimes confusing or contradictory guidance from numerous agencies. Direct-care staff expressed fears of infecting themselves and their families, and expressed sincere empathy and concern for their residents. They described experiencing burnout due to increased workloads, staffing shortages, and the emotional burden of caring for residents facing significant isolation, illness, and death. Respondents cited the presence or lack of organizational communication and teamwork as important factors influencing their ability to work under challenging circumstances. They also described the demoralizing impact of negative media coverage of nursing homes, contrasting this with the heroic public recognition given to hospital staff.
Conclusions and Implications
Nursing home staff described working under complex and stressful circumstances during the COVID-19 pandemic. These challenges have added significant burden to an already strained and vulnerable workforce and are likely to contribute to increased burnout, turnover, and staff shortages in the long term.
Keywords: Nursing home, staff, COVID-19, pandemic, qualitative
The Coronavirus disease 2019 (COVID-19) pandemic has had devastating effects on nursing homes and other long-term care settings. Long-term care residents are bearing a disproportionate share of morbidity and mortality from the virus, representing roughly 6% of cases but 40% of deaths.1 As of mid December 2020, almost 729,000 residents had been infected and over 100,000 had died.1
Although there has been considerable public scrutiny of the impact of COVID-19 on residents, much less attention has focused on how the pandemic has disrupted the lives of long-term care professionals and their roles caring for this vulnerable population. The only systematic data collection of staff infections and deaths is by the Centers for Disease Control and Prevention; these data are limited to nursing homes and are incomplete before May 2020. Still, these estimates show that as of late November 2020, at least 322,000 nursing home staff had been infected and more than 1100 had died.2
The pandemic has added significant strain to an already vulnerable nursing home workforce, which has historically experienced high levels of turnover, chronic staffing shortages, and high burnout.3, 4, 5, 6 To protect this workforce against the long-term impact of the pandemic, we must first understand how COVID-19 has affected the day-to-day work of staff. We conducted an online survey to document the experiences of front-line staff working in nursing homes and other long-term care settings during the pandemic to reveal key challenges and areas for intervention. In this report, we present qualitative findings from the survey's open-ended questions for the subset of respondents working in nursing homes.
Methods
From May 11 through June 4, 2020, we used social media (Facebook and Twitter) and professional networks to disseminate an electronic survey to a convenience sample of health care professionals working in nursing homes and other long-term care settings. The survey included both closed- and open-ended questions. Because nursing homes and other long-term care facilities face unique and distinct challenges with regard to their COVID-19 responses, we limited our analysis for the current report to qualitative data provided by respondents who identified their employer as a nursing home. Quantitative findings have been previously reported.7 , 8
The survey ended with 4 open-ended questions: (1) What are your biggest challenges or concerns affecting your ability to do your job during the COVID-19 pandemic? (2) Thinking about your facility's experience during the COVID-19 pandemic, what is going well so far? (3) Thinking about your facility's experience during the COVID-19 pandemic, what could be going better? and (4) Is there anything else that hasn't been asked that you would like to share? The 4 investigators independently reviewed the transcripts of responses to these 4 questions. Using thematic analysis and an inductive coding approach, we each independently coded the data and generated initial themes. We then met to review and reach consensus on themes, as well as illustrative quotes for each theme.
Because staff participated in the interviews in a professional capacity and did not provide any personal information, this analysis was not considered human subjects research or subject to Institutional Review Board approval.
Results
We received 251 responses to the survey. Thirteen were excluded because of missing data on all questions. Of the remaining 238 respondents, 152 (63.9%) reported working in nursing homes and were included for analysis. A total of 132 (86.8%) reported providing direct patient care and 60 (39.5%) had supervisory or management responsibilities. The sample included 76 (50.0%) certified nursing assistants, certified medical assistants, or certified medical technicians; 19 (12.5%) physicians; 15 (9.9%) advanced practice clinicians; 14 (9.2%) registered nurses; 10 (6.6%) administrators; and 9 (5.9%) licensed practical nurses. Other disciplines represented less than 5% of the sample. Three-quarters of respondents (n = 113, 74.3%) worked in nursing homes that had at least 1 resident or staff COVID-19 case at the time of the survey, and 72 (47.4%) reported providing direct care to 1 or more residents with COVID-19 in the prior month.
We identified 7 themes from respondents’ written responses to the open-ended questions.
Theme 1: Constraints on Personal Protective Equipment (PPE) and Testing
Earlier in the pandemic, access to adequate PPE was a serious concern. However, on the whole, respondents described PPE availability as comparatively better when completing the survey in May or June 2020.
“When everything first hit, nothing was in place. There was no COVID unit, there [were] no COVID swabs available, there was no staff. After the crisis was in full tilt, then we started getting things we needed.”
(Advanced Practice Clinician)
“We now have enough of everything… Stress occurred when staff had to use garbage bags etc. to protect themselves... using N95s that you knew were not acceptable.”
(Advanced Practice Clinician)
At the same time, respondents in management roles reported going to great lengths to procure PPE, including spending a great deal of time, money, and effort to obtain sufficient quantities.
What are your biggest challenges? “Obtaining needed supplies from unconventional suppliers. Actually leaving the building to go pick up supplies [from places] such as distilleries and plastics manufacturers.”
(Administrator)
“Not nearly enough financial assistance for actual workers or the facilities that had to buy massive supplies….”
(Administrator)
What could be going better? “Availability of PPE and always trying to locate some takes a lot of time.”
(Registered Nurse)
They also described continued reliance on crisis standards for extended reuse of gowns and masks.
“[We are] reusing…gowns and going in and out of rooms with the same gown. The face masks [are] being reused for a week.”
(Certified Nursing Assistant)
“[We need] access to PPE. Enough so we could use it properly, as we were trained, and not the crisis level of acceptable use…”
(Administrator)
“Having to reuse PPE is not ideal, but it is the best we can do right now.”
(Administrator)
What could be going better? “Having the supplies you NEED to do your job without having to reuse what we have which is a huge concern as far as infection control goes!”
(Certified Nursing Assistant)
Testing was cited as an ongoing challenge, particularly by physicians and advanced practice clinicians, with many respondents commenting on the need for “more tests” or “more testing.” Others detailed improved access compared with the beginning of the pandemic, but highlighted the competing priorities to identify and quarantine staff and resident cases.
“We now have enough tests, but cannot test all staff because we would go from critical staff shortage to [an] untenable staff shortage... We cannot sweep test all residents, as our 46-bed isolation unit is full and [we have] no place to isolate the asymptomatic positives.”
(Physician)
What are your biggest challenges? “Lack of assistance from [the Department of Health and Human Services] and local government sectors. It took a great length of time to allocate testing and a lab to deal with the size of our building.”
(Registered Nurse)
“During the height of the outbreak, outside services- lab, x-ray, and IV services were… strained and response times were inconsistent and often slow.”
(Advanced Practice Clinician)
Theme 2: Burdensome Regulations and Guidance
Administrators and other respondents working in management roles discussed the challenges of navigating frequent changes in regulations and guidance. They commented that direction from multiple local, state, and federal agencies was at times not only confusing but also contradictory. They also cited the time and attention required to monitor numerous communications and continually update internal policies, procedures, and operations to remain in compliance.
“Keeping up with all the changing regulations is challenging... that is, federal, state and local health departments. And many times the guidance conflicts.”
(Administrator)
What are your biggest challenges? “Constant changing regulations. Spending too much time reading, researching, typing, and re-typing policies and procedures to be current and educating staff and residents... Constant reporting at the county, state and federal levels and trying to learn how and where to report (their systems).”
(Administrator)
“Guidance has been spotty and unrealistic.”
(Physician)
Theme 3: Concern for Self and Family
Many respondents, particularly certified nursing assistants, commented on the fear and stress associated with possibly being infected and infecting family members. Several remarked that they or their family members were in high-risk groups due to age or chronic illness.
“I am one of the vulnerable population, as I am 64, I have asthma, and I am morbidly obese.”
(Certified Nursing Assistant)
What are your the biggest challenges? “That I don't get it. My age and I'm a smoker play a big part.”
(Certified Nursing Assistant)
“I am also a caregiver to my immunocompromised mother so there is a HUGE fear of contracting the virus and being unaware, possibly infecting my mom.”
(Certified Nursing Assistant)
Theme 4: Concern for Residents
Respondents cited the ongoing challenges of trying to protect the residents under their care, while worrying about the impact of social distancing and isolation on residents, particularly those with dementia and those used to seeing their families regularly.
“We have had increased numbers of deaths in otherwise stable residents, typically showing signs of failure to thrive… These changes seemed to have started 4–6 weeks after… visitation/activity restrictions and all had families that regularly visited prior to the pandemic.”
(Advanced Practice Clinician)
“Our [Memory Care] residents are not able to follow instructions easily and have poor safety awareness, limited potential to retain new education, [and are] unable to social distance due to advanced dementia. The wander, touch each other, touch each other's things, etc.”
(Licensed Practical Nurse)
“At times I feel like we are killing the residents with the cure [the isolation].”
(Certified Nursing Assistant)
What could be going better? “Emotional support and activities for residents. They are bored and depressed and don't always understand why we have so many restrictions.”
(Advanced Practice Clinician)
Theme 5: Burnout
Respondents remarked on the mental and physical exhaustion of working during the pandemic due to staffing shortages, increased workloads, and new responsibilities. The emotional burden of caring for residents experiencing distress, illness, and death was also cited as significant.
“I have to work 16 hours on the weekends and I wear a mask all the time… and I have a headache most of my shift! ... I feel so drain[ed] when I get off work.”
(Certified Nursing Assistant)
“Too many [patients] with COVID, not enough time to call families and discuss goals of care… Also, burnout. I have been taking care of only COVID patients for 8 weeks… losing this many residents and keeping going is tough.”
(Physician)
“We are short of help, which means I must care for 20 residents alone.”
(Certified Nursing Assistant)
What are your biggest challenges? “Having a burnout of aides due to ... working 12 hours for as many as 10 days in a row, unable to leave.”
(Certified Nursing Assistant)
Theme 6: Teamwork, Communication, and Flexibility
Many respondents, particularly those in leadership roles, commented with pride on how staff were working together and fulfilling multiple roles to care for residents.
“We work as much as possible as a TEAM to provide the best quality of care than we can for the residents!”
(Certified Nursing Assistant)
What is going well? “Teamwork. Sharing common goals of caring for these patients.”
(Advanced Practice Clinician)
“The cooperation of the staff, residents, and families has been absolutely wonderful and has made these difficult circumstances tolerable.”
(Administrator)
“Our staff are filling multiple roles while we fight this virus: they are caregivers, entertainers, spiritual companions, family members... They really have been heroes.”
(Administrator)
Communication from management was also cited by multiple respondents as an important factor influencing their ability to perform their jobs, although some noted that communication had been effective, whereas others commented that it had been lacking.
What are your biggest challenges? “Breakdown of communication and lack of PPE ... changing things daily and not keeping us informed.”
(Certified Nursing Assistant)
“We have an extremely strong management team that has supported the floor staff through the whole process. [Our] managers have worked in every department to provide assistance [and] reassurance. We began planning early.”
(Licensed Practical Nurse)
Theme 7: Public Blame and Lack of Recognition
Poignantly, respondents contrasted the level of public support for hospitals and hospital workers, who are often referred to as heroic, with a lack of recognition and even vilification of nursing homes and their staff.
“We would all love it if the general public, media, and government showed the same respect for nursing homes as they do for hospitals.”
(Social Worker)
“It is very frustrating that hospitals receive praise for what they are doing. [Nursing homes] and their leaders are an amazing group of providers and we get no credit, we are left as the scapegoats, the government adds tons of requirements, additional punitive surveys, and unrealistic guidelines.”
(Administrator)
Is there anything you would like to share? “The standard we are held to compared to any other health care providers. The vilifying of people risking their lives while trying to save others. The mere fact that we have been turned into criminals for not being able to keep up with an event that the entire world could not manage, but somehow nursing facilities should have done better than world leaders.”
(Administrator)
Many respondents described the burden of public scrutiny and blame on the industry.
“[Nursing home] staff are treated as if they are the cause of the deaths, not the unseen virus… No one tells all the positive things [staff] have done to protect the residents they love. That is very sad to me.”
(Registered Nurse)
“The other thing that has taken an emotional toll is the amount of negative media…[Our] profession has done an unbelievable job in preparing for and fighting this invisible enemy. You can do everything right and still be negatively impacted.... then there is fault [implied].”
(Administrator)
“My patients' deaths are being politicized.”
(Physician)
Discussion
In May and June 2020, front-line nursing home staff described working under complex, challenging, and evolving conditions during the COVID-19 pandemic. Data collection for the survey took place more than 3 months after a nursing home in Washington became the initial US epicenter of COVID-199 and at a time when there were already more than 50,000 cases and 10,000 deaths among nursing home residents.10 Yet, respondents reported that needed resources, including testing and PPE, were still lacking, and that many facilities were still relying on extended use and reuse procedures for PPE. More recent evidence has shown that many nursing homes are still experiencing PPE shortages,11 a concerning finding given the more than 322,000 nursing home staff infections and 1100 staff deaths as of late October.2
Administrators described going to great lengths to source PPE and other supplies from at times unconventional suppliers, and to coordinate testing for their facilities, particularly in the earlier months of the pandemic. This administrative burden has continued to grow in recent months. Staff working in leadership roles have had to navigate frequently changing and at times contradictory guidance from multiple local, state, and federal agencies; build data systems to meet weekly and lengthy federal reporting requirements; manage staffing shortages; build systems for point-of-care testing and reporting; coordinate complex cohorting protocols for admissions and new cases; maintain communication with residents’ families and implement new visitation procedures; navigate state and federal survey processes; and manage significant additional operating expenses.
A number of the themes elicited raise significant concerns for the long-term effects of the pandemic on the nursing home workforce. Respondents reported experiencing burnout, and described the physical, mental, and emotional burden of taking on heavier caseloads and learning new roles and processes. In addition, they expressed sincere concern and empathy for their residents experiencing isolation, illness, and death. The nursing home environment is unique in that staff often work with their residents for months or years at a time, getting to know them and their families well. This added familiarity can make the emotional toll of caring for residents in these circumstances all the more challenging.
Direct-care staff, nursing assistants in particular, cited fears of becoming infected and of possibly infecting their families. These fears are not unfounded; a recent report found that roughly 43% of health care workers hospitalized with COVID-19 were nurses or nursing assistants.12 Nursing assistants in nursing homes are particularly vulnerable because of the high level of personal care required in this setting, putting them in regular prolonged close proximity with residents. Their vulnerability is only amplified if they do not have comprehensive health insurance or paid sick leave to protect themselves in the event of illness.13 , 14
Poignantly, despite there being no specific question on the topic in the survey, a number of respondents commented on the demoralizing impact of negative media coverage and public scrutiny of nursing homes, contrasting the praise and resources given to hospital workers with a lack of recognition and even blame directed at nursing home staff. The federal government has been criticized as taking an overly punitive approach to nursing homes during the pandemic,15 despite significant evidence that both high- and low-quality facilities are vulnerable when there is high community virus prevalence.16, 17, 18, 19 This has been coupled with extensive national and local news coverage of hard hit nursing homes that has often portrayed them negatively20, 21, 22; for example, referring to nursing homes as “death pits” in one high-profile article.22
Combined, these factors bode poorly for long-term staff retention in an already vulnerable and strained workforce. Burnout is an important contributor to staff turnover,23 a chronic problem in nursing homes,3 , 24 and is likely only to worsen as a result of the pandemic. Past evidence has shown consistent relationships of high turnover and staff burnout to poor resident outcomes and missed care.5 , 25, 26, 27, 28 Strong organizational leadership is critical in crisis situations, and nursing home owners and administrators must maintain regular lines of communication with staff to keep them informed of policy changes, local conditions, safety protocols, and available resources. Short-term interventions, such as hazard pay and paid sick leave, have been highly variable across states and facilities. However, such measures are particularly important for nursing assistants and other low-wage staff, many of whom experience significant financial vulnerability.13 , 14 With nursing homes facing considerable added costs and operating losses due to the pandemic,29 state and federal investment in such initiatives, in addition to PPE supply chains and testing capacity, will be critical in the coming months and years to support and sustain this workforce.
We note a number of limitations. First, this was a convenience sample of nursing home staff recruited via social media and professional networks who may not be representative of a broader population of nursing home employees, and could be subject to response bias. Understanding these limitations, we chose this approach so that we could quickly disseminate the survey and document the experiences of long-term care staff in as close to real-time as possible, given the rapidly evolving nature of the pandemic. Second, we were unable to validate respondent employment or position because we did not collect licensure or certification details, or the names or addresses of employers. We instead relied on respondents to self-report their professional discipline and employer type. Finally, because we relied on open-ended survey questions, we were unable to ask clarifying questions or follow-up to validate our interpretation with respondents. We did, however, have 4 investigators review the raw transcripts independently before meeting to compare interpretations, validate findings, and reach consensus on themes.
Conclusions and Implications
Nursing home staff described working under complex, evolving, and stressful circumstances during the COVID-19 pandemic. These challenges have added significant burden to an already strained and vulnerable workforce and are likely to contribute to increased burnout, turnover, and staff shortages in the long term.
Acknowledgments
We thank the National Association of Health Care Assistants; AMDA the Society for Post-acute and Long-term Care Medicine; and our other professional contacts for their assistance in disseminating the survey.
Footnotes
The authors declare no conflicts of interest.
This work was funded by COVID-19 seed funding from the Office of the Vice President for Research at Brown University (GR300199).
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