key: cord-264479-s20oacr9
authors: Bern-Klug, Mercedes; Beaulieu, Elise
title: COVID-19 Highlights the Need for Trained Social Workers in Nursing Homes
date: 2020-05-25
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2020.05.049
sha: 
doc_id: 264479
cord_uid: s20oacr9

nan

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 needs 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 service 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 COVID 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.

While 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 one FTE social services staff member, and that person does not have to hold a degree or license in social work 3 . The unrealistic staffto-resident ratio and the disregard of professional standards has been a problem for decades. The inadequacy of this lax regulatory stance toward the credentials of the key onsite 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 one contracting COVID and about the impact of social isolation.

Families have a lot of questions. Some questions have no answers. Families wonder why the nurse hasn't called them back in two days and why no one picks up the phone.

Suspicion brews. Families hold themselves responsible for being there for their loved one 4 . This sense of responsibility is heightened during a crisis. Families want their mother/brother/sister to know they are not forgotten and have not been abandoned. the nursing staff to provide resident care. One social worker disclosed that while 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 deescalation, 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, 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 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 one 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 don't have the staff capacity for that, even if they have a spare laptop or tablet. From the family's perspective it doesn't seem to be asking much for a ten-minute daily face-time session, yet from the staff perspective it requires much more than ten minutes to organize, prepare and safely deliver a phone or internet session. 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 relative is 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 don't 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-sight morgue and many lack sufficient storage space for decedents' possessions. 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.

• 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/2019ncov/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 .

Resilience as effective functional capacity: An ecological-stress model

Psychosocial crisis management: The unexplored intersection of crisis leadership and psychosocial support. Risk, Hazards, & Crisis in Public Policy

Code Title 42 Section 13951. Requirements for, and assuring quality of care in, skilled nursing facilities

Family members' responsibilities to nursing home residents

Standards for social work services in long-term care facilities

Psychosocial assessment of nursing home residents via MDS 3.0: Recommendations for social service training, staffing, and roles in interdisciplinary care

Transforming palliative care in nursing homes: The social work role