key: cord-0913327-bleqf2bz authors: McGilton, Katherine; Escrig-Pinol, Astrid; Gordon, Adam; Chu, Charlene H.; Zúñiga, Franziska; Sanchez, Montserrat Gea; Boscart, Veronique; Meyer, Julienne; Corazzini, Kirsten N.; Jacinto, Alessandro Ferrari; Spilsbury, Karen; Backman, Annica; Scales, Kezia; Fagertun, Anette; Wu, Bei; Edvardsson, David; Lepore, Michael J.; Leung, Angela Y.M.; Siegel, Elena O.; Noguchi-Watanabe, Maiko; Wang, Jing; Bowers, Barbara title: Uncovering the Devaluation of Nursing Home Staff During COVID-19: Are We Fuelling the Next Health Care Crisis? date: 2020-06-11 journal: J Am Med Dir Assoc DOI: 10.1016/j.jamda.2020.06.010 sha: 4c50a80422d16092a907159eb9b5ac6adc13e9b7 doc_id: 913327 cord_uid: bleqf2bz nan As the COVID-19-related mortality rate of nursing home residents continues to rise, so too will 3 the rates of mortality and morbidity of staff who care for them, 1 a problem we must address now 4 to avoid another health care crisis once this pandemic recedes. Currently, a significant 5 proportion of deaths are attributed to persons living in nursing homes, ranging from 42-57% in 6 European countries reporting data 2 to as high as 82% in several U.S. states and in Canada 7 reporting data. 2, 3 However, there is a concern that many countries are not including nursing 8 home deaths in the death toll. While not reported globally experts predict, the majority of health 9 care workers who will die from COVID-19 are nursing staff (nurses and nursing assistants) 10 working in nursing homes. 1 Most residents in nursing homes are over the age of 80 and have multiple chronic conditions and 12 are at risk of COVID-19. However, several factors unrelated to the residents themselves increase 13 their vulnerability to COVID-19 as well as members of nursing home staff. The pandemic has 14 laid bare long-standing structural deficiencies affecting the nursing home sector. Chronic 15 understaffing in nursing homes is a global concern, which makes providing basic care a 16 challenge, and has made monitoring residents for COVID-19 symptoms even more difficult. 4 Understaffing also undermines a staff's ability to follow protocols to keep residents physically 18 distant, as public health measures to reduce the transmission of the virus including isolating 19 residents when COVID-19 positive can exacerbate behaviors in residents with dementia who 20 may not understand or follow the procedures. 5 Staffing levels in nursing homes continue to be a 21 concern globally. 6 Precarious work conditions characterized by part-time employment, heavy have tested positive for COVID-19 symptoms. 1 At the same time, some countries report 28 significant rates of staff absenteeism or abandonment of their work due to fear of getting the 29 virus or transmitting it to their loved ones. 8, 9 This fear is not unfounded, as many staff providing 30 the most hands-on, direct care in nursing homes (e.g., bathing, assisting with meals, etc), are 31 women, who have double or triple caregiving responsibilities 7 , with a low socio-economic status 32 that cannot risk income loss regardless of working conditions, and are at high risk for poor health 33 outcomes if infected. Also, it is known that staff are most likely spreading the virus within 34 nursing homes 10 especially because many who are subject to low wages and the part-time 35 employment culture are forced to work at multiple nursing homes in order to earn a livable wage. The expected grief, guilt and moral distress of losing residents they have cared for over many 37 years, the moral injury related to working under high pressure and possibly violating their own 38 ethical or moral codes 11 -coupled with the potential guilt of their own role in transmission -will 39 need to be addressed. The COVID-19 pandemic has also revealed and accentuated the ageism and devaluing of older 41 people pervasive in many societies. 12 By association, the nursing home staff workforce also 42 experiences devaluing, a long-standing reality which has become more apparent as the pandemic 43 expands globally. The public campaign 'clap for medical staff' worldwide 13 and 'clap for those 44 in the National Health Service' in the UK 14 initially appeared to ignore staff in nursing homes. Shortly after, the slogan was changed in many countries to 'clap for carers or health care 46 workers.' While anecdotal, the initial messaging implies that nursing home staff are often an 47 afterthought, frequently ignored in health care system conversations. We, as a global society, have failed our nursing home community, residents, relatives and staff. Given that this pandemic has publicly revealed and aggravated the long-standing age-old 76 precarious working conditions in nursing homes, it can be reasonably expected that future 77 recruitment of staff will be an even greater challenge in the future. The current crisis highlights 78 the ingrained poor status of a workforce that is taken for granted and ignored, despite supporting 79 the health and well-being of some of the most vulnerable older adults in society. As concerned advocates and researchers, it is our opinion that we need to better protect and 81 support the frail older adults residing in nursing homes, their relatives and the workforce (staff 82 and leadership) that provide care in these settings. Relatives in lockdown not only need to be 83 protected from the infection, but also the grief of being isolated from their family members. We researchers and points to several strategies that could be adopted (Table 1) Epidemiology of Covid-19 in a Long-Term Care Facility 180 in King County, Washington Mortality associated with COVID-19 outbreaks in 182 care homes: early international evidence. International Long-Term Care Policy Network One-Third of All U.S. Coronavirus Deaths Are Nursing Home 185 Residents or Workers. The New York Times Las muertes en las residencias catalanas se disparan tras registrar 338 189 fallecidos desde el fin de semana Ediciones El País Dementia care during COVID-19 Essential long-term care workers commonly hold 197 second jobs and double-or triple-duty caregiving roles Residencias, la trampa mortal de los más vulnerables 199 SP: Ediciones El País It hurts our soul': Nursing home workers struggle with thankless position New York: WebMD LLC Presymptomatic SARS-CoV-2 infections and 206 transmission in a skilled nursing facility Managing mental health challenges faced 208 by healthcare workers during covid-19 pandemic Ageism and COVID-19: What does our society's response 210 say about us? Coronavirus: Worldwide applause for front-line medical staff. Al Jazeera. Al Jazeera 212 Media Netword National salute to NHS staff as thousands take to balconies to express thanks United Kingdom: MNA Matt Hancock sparks outrage by offering care workers a badge as they 220 plead for PPE. Mirror. London: MGN Limited Nursing home workers demand PPE on National Day of Action. SEIU HCII. Chicaco, IL: 224 SEIU HCII More than 70% of providers lack PPE as U.S. COVID-19 death toll passes 50,000, AHCA 227 chief says. McKnight's. Long Term Care News Toward common data elements for international 231 research in long-term care homes: Advancing person-centered care The pivotal role of the director of nursing in nursing 236 homes A comprehensive approach to reablement in dementia Promote daily huddles with staff to provide updates and address concerns. 2. Provide more 1:1 engagement between supervisors and staff with an emphasis on appreciation of the work being done Develop a leadership group that is available 24-hours a day to communicate information and provide hands-on support to staff national and multiple regional WhatsApp group) to efficiently disseminate guidelines to managers and staff in a timely manner. 5. Encourage managers to prioritize the ongoing communication with infection control officers. 6. Curate useful and clear resources for staff, residents and their families Keep Staff Healthy 8. Pay close attention to the emotional health and well-being of staff and offer stress management as well as grief support services without cost to staff Provide daily meals and snacks to staff, as well as open a 'quick market' so staff can buy food before returning home Keep staff motivated and support staff morale by displaying letters of gratitude from families and the public in walkways Maintain weekly virtual rounds between medical care providers, consultants and nursing home staff to discuss clinical care issues Assure staff appropriate hours including no overtime and provide rest periods to avoid burnout. Implement Human Resource Policies 13. Optimize the use of health sciences students. 14. Implement hazard and sick leave pay and offer full-time employment and staffing flexibility. 15. Increase staffing by redeploying and educating staff from other healthcare facilities, such as hospitals, to work in nursing homes Implement New Clinical Practices Human connectedness strategies to minimize resident isolation. 18. Policies regarding transfers to and from hospitals of COVID-19 residents Decision-making guidelines for developing infection control and isolation care plans. * * Ethical guidance for people who work in long-term care: What is the right thing to do in a pandemic? We would like to acknowledge the contribution of Lydia Yeung and Constance lrwin in assisting with the collation of the information provided by the co-authors. Education and Training 1. Encourage staff to stay at home if they are experiencing any signs or symptoms, and ensure alignment with human resource policies. 2. Provide weekly preparedness training with staff so they are confident in their ability to respond. 3. Prepare and distribute updated videos and other resources for staff on how to use and dispose of Personal Protective Equipment (PPE). 4. Redeploy experienced nurses to ensure that staff follow PPE guidelines and assist with the donning and removing of PPE. Promoting Protective Practices (Guidelines now available in many countries which continue to be updated: See below for examples)* 5. Maintain visiting restrictions within the nursing homes, limiting and screening anyone entering the home. 6. Screen nursing home staff and essential care partners for COVID-19 on a routine basis. 7. Provide education for anyone in nursing homes which includes hand hygiene, respiratory etiquette and the promotion of physical distancing between everyone, including during break times. 8. Consider encouraging staff to reduce the transmission risk by staying in nursing homes for extended periods of time, or other accommodations, if possible. 9. Practice inclusive surveillance protocols for residents under investigation which include assessment twice daily for possible signs and symptoms of COVID-19, including fever, cough, shortness of breath, and other atypical symptoms, such as hypoactive delirium, deterioration in activity, and loss of appetite.10. Implement the universal use of face masks for all health care staff and visitors in long-term care facilities. 13. Request PPE from national stockpiles. 14. Campaign to public and private donors to obtain necessary PPE.