key: cord-0917041-y32fx5ba
authors: Araujo, Odete; Sequeira, Carlos; Ferré-Grau, Carme; Sousa, Lia
title: Nursing homes in Portugal during the COVID-19 outbreak: challenges for the future
date: 2021-10-20
journal: Enferm Clin
DOI: 10.1016/j.enfcli.2021.09.011
sha: ebc610856624713501c00d7cb80219073054f2a9
doc_id: 917041
cord_uid: y32fx5ba

Objective: This study sought to explore the perceptions of experts about the performance of nursing homes during the COVID-19 outbreak. Method: A qualitative study was developed in two stages: (1) a focus group, conducted in May 2020, with 5 experts; (2) a modified e-Delphi, implemented in September 2020 with 22 experts, both in the area of assistance in nursing homes from Northern and Center of Portugal. Results: The results allowed identifying three main areas that influenced the performance of nursing homes during the COVID-19 outbreak: organization models and resources; physical and mental health of residents and; family as a support. Conclusions: Older adults residing in nursing homes are particularly vulnerable to severe disease or death from COVID-19. It is emergent that nursing homes prevent physical and mental frailty in older residents and the loneliness aggravated by the pandemic circumstances. Decision-makers need to recognize that older people living in nursing homes have several health needs, which should determine the implementation of new strategies namely the increase in the number of professionals with appropriate skills.

Nursing homes have been seriously affected by the Coronavirus disease 2019 worldwide (Werner et al. 2020 ). This reality is more dramatic in the USA (1) and Europe reporting higher rates of morbidity and fatality in older persons living in nursing homes as well as high rates of workers' absenteeism (2) (3) (4) (5) . At the beginning of the outbreak, the lack of evidence about the transmission of COVID-19 and the low availability of testing have drastically accelerated spread within these facilities increasing morbidity and mortality rates among older residents (5) . In addition, frail people, with various chronic diseases, reside in nursing homes in common spaces, including the bedroom, making social distance or isolation difficult or impossible, thereby increasing susceptibility to the virus (6).

According to the recent report of the European Centre for Disease Prevention and Control (2020 (5) , the statistics of the impact on older persons living at long-term care facilities (LTCFs), which include nursing homes are tragic. Some examples reporting last May (first wave) show Belgium with 51% of the 9,052 COVID-19 related fatal cases that explained from LTCFs, with just 23% of cases laboratory-confirmed. In Spain, 17,730 fatalities have been reported from 5,400 affected home-care residents, representing 66% of all fatal cases associated with . In Germany 22,071 infections linked to long-term care and nursing homes were reported with a death toll of 2,966 (20%), representing 37% of all 7,914 deaths related to COVID-19 in this country (8) . Portugal has 3,069 LTCFs divided into 2445 general nursing homes, 287 residential homes, and 337 ´mixed LCTs´, and recent statistics show a total of 4,700 older residents infected with COVID-19 and 1,047 deaths from the infection (9).

Unfortunately, social and health weaknesses LTCFs in general and predominantly in nursing homes are not a new reality. For decades, nursing homes have been overlooked, especially considering the frequently unmet health needs of frail people and the reduced number of qualified social and health professionals (6). Just like in Europe, Portugal shares a similar reality concerning well-reported poor care delivery situations, mistreatment of older people, and loss of dignity (10) . Furthermore, the pandemic outbreak has urged the implementation of new procedures in nursing homes with low ratio of professionals to care for older residents, especially for those institutions who have their staff infected by .

The biggest challenges during this pandemic are avoiding early deaths linked to COVID-19 and deliver dignified care to older residents, preventing physical and cognitive decline using less human and material resources (11, 12) . Importantly, preventing loneliness in institutionalized residents is now as much a priority as helping them with personal hygiene (13).

Another important concern relates to managing visits and communication with family. It is well reported that family and friends visitations are crucial to maintaining social relations and contact with the outside, however, in the pandemic context, it is vital to ensure a balance between in-person visitations and the feeling of loneliness (14) (15) (16) . Recent evidence describes additional interventions in reducing the negative health and social consequences by adding, for example, technological alternatives, such as telephone and/or video calls) (17) .

This study sought to explore the perceptions of experts about the performance of nursing homes during the COVID-19 outbreak.

An exploratory study was developed in two stages. In the first stage, a focus group was recruited. This is a qualitative technique of data collection, used to gather/discuss opinions about a certain subject, through group meetings including 5 to 12 experts in the area under study. The organization of the focus group must include a semi-structured script and the number of meetings should not exceed 5 per study (18).

In this study, an exploratory focus group was conducted in May 2020, with 5 experts in the area of assistance to older people, namely in the context of LTCFs from Northern and Center of Portugal. Participants were selected through convenience sampling. The selection criteria were experts recognized in the area of assistance to older people, the management of LTCFs, and to have at least 5 years of experience in the area. The focus group included the principal investigator who conducted and facilitated the intervention, and an assistant investigator, who worked as a non-participating observer, text and sound recording the intervention.

The focus group started with the socio-demographic characterization of the experts by filling in a data table (age, gender, academic degree, professional occupation, length of professional practice, and region of the country where they worked). Then brainstorming took place, with a set of 3 open questions for discussion by the experts: 1) What are the main needs/difficulties of LTCFs in the context of the pandemic outbreak?, 2) Concerning the physical and mental health, how were the residents' needs met?, and 3) What is the role of the family in the process?.

In the second stage of the study, a modified e-Delphi was employed to validate the results obtained in the focus group. The modified e-Delphi followed the recommendations of Justo (19): 1. Composition of an expert panel using the following inclusion criteria: to have experience of at least 3 years in collaboration/management/direction/consulting of LTCFs. The experts were identified through convenience sampling.

2. The number of participants -22 experts agreed to participate in the study.

3. Formulation of the questionnaire -The main results obtained in the focus group were adapted to an online questionnaire, using the Google Docs application. The electronic questionnaire was composed of an introduction describing the context and objectives of the study, followed by a group of questions of sociodemographic characterization. Then, the experts were invited to rate their degree of agreement, using a Likert scale (from 'totally disagree' to 'totally agree'), with some statements addressing the issues: 1) What are the main needs/difficulties of LTCFs in the context of the pandemic outbreak?, 2) Concerning the physical and mental health, how were the residents' needs met?, and 3) What is the role of the family in the process?. The questionnaires were sent by email during May and June 2020 and were to be completed within one month.

4. Consensus formation process: for this work, consensus criteria were established based on the positive agreement level of the experts' answers to each item of the questionnaire. Thus, the positive agreement was defined as a rate equal to or above 50% (Scarparo et al., 2012) , with positive agreement defined by the sum of the percentage of answers 'agree' and 'totally agree'. For positive agreement, three levels of consensus were established (perfectpositive agreement = 100%; strong positive agreement = 79% to 99%; moderatepositive agreement = 50% to 79%).

Since in this study, the positive agreement was reached directly in the first round, we proceeded with the presentation and analysis of the results.

Throughout the stages of the study (focus group and modified e-Delphi), all ethical principles were observed. The experts freely agreed to participate in the study and gave their informed consent. Participants were ensured of the anonymity and confidentiality of their responses and the use of the study results only for scientific publication. In the focus group, all experts consented to record the meeting.

In the first phase, Focus Group, data were analysed using the content analysis, according to Bardin (2015) and included different phases: 1) pre-analysis, 2) exploration of the material and 3) treatment of the results obtained, inference and interpretation. Pre-analysis aims to organize and systematize ideas, making them operational, in order to guide a precise scheme for the development of the following operations. The exploration of the material, followed by the pre-analysis, consists in the systematic application of the decisions taken through operations of codification, decomposition or enumeration, according to the previously formulated rules. The treatment of results, inference and interpretation concern the treatment of raw data so that they are meaningful and valid, a stage where the researcher can make inferences and advance interpretations. All interviews were transcribed verbatim after data collection. Analysis initiated with repeated listening of the recordings and reading of the interview transcriptions.

For the second phase (e-Delphi study), we carry out a statistical processing of the answers: analysis of the responses was performed through descriptive statistics, namely by distribution of frequencies (absolute and relative frequency) and measures of central tendency (median) with the use of the Microsoft Excel 2013 program and data analysis operative system Google Docs.

The sample comprised five participants in first phase (focus group) and twentytwo in the second phase (e-Delphi), the overall mean age was 42.2 years (sd=3.4 years) and 32.7 (SD=7.9), respectively. Three men participated in the focus group phase and fifteen in e-delphi phase. Most of participants who participated in the first J o u r n a l P r e -p r o o f 8 phase were technical director (n=3) and nurses (n=11) in the second phase. The sociodemographic characterization of the experts who integrated the two phases of the study is displayed in Table 1. <insert Table 1 about here>

The three themes identified were (a) Main needs/difficulties of LTCFs in the context of the pandemic outbreak (COVID-19), (b) How the residents' physical and mental health needs were met, (c) How the family was involved in pandemic response strategies. While described separately, as illustrated in Table 2 the themes were interrelated demonstrating the complexity of analysis.

During the first outbreak the institutions needed to face with several challenges including difficulties to attract workers specialized in social and health fields.

"It is very difficult to attract professionals to work in nursing homes because, in addition to being a very difficult job from a physical and emotional point of view, the working conditions are not very appealing" (Maria).

The physical and mental health activities were cancelled or reorganised as a consequence of maintaining COVID-19 prevention measures, including distancing, respiratory etiquette.

"Group social and recreational activities such as music or exercise were cancelled. We tried to maintain the physical and cognitive stimulation of the older persons, but the measures to prevent COVID-19 were maintained and limited group activities" (João).

The physical presence of the families in nursing homes was compromised by the requirement of compliance with the rules imposed by the government. To mitigate the lack of visits, the institutions involved, through their staff members, made crucial efforts to establish connections by videoconference or through social networks in order to establish communication and maintain family ties.

We kept in touch with families and closes relatives through videocalls. We organized and deployed a staff member to ensure that everyone (older persons) could see and talk with their loved ones.

<insert Table 2 about here> Regarding the results obtained in the second phase of the study -modified e-Delphi technique, a positive agreement level was found in all items in the first round of the 22 experts' responses, ranging between moderate and perfect level of consensus, as described in Table 3. <insert Table 3 about here>

Older people and their care workers in nursing homes have been seriously impacted by the COVID-19 pandemic. The worldwide pandemic has particularly affected older persons due to their increased frailty condition combined with potential chronic illnesses and a higher risk of dying from COVID-19. The OECD (12) has shown that more than 60% of older persons living with chronic conditions, worsened by the pandemic outbreak, and under social restrictions were more likely to suffer from increased physical and mental health problems.

The results of our study highlighted three main priority areas. First, these study results showed that the main needs and difficulties felt by nursing homes regarding the available material and human resources during the first wave of COVID-19 were not necessarily new and continued to stop the attraction of care workers with the right competencies. This means that there are still difficulties in hiring and maintaining care workers specialized in social and health fields (12).

Furthermore, during the pandemic outbreak, organizations from the social sector felt a lack of support from other organizations. This did not allow nursing homes to share experiences, procedures, and ways to mitigate the impact of COVID-19 on older residents and staff members (20). The management model established not considering middle management has led to inadequate organization and management of decision-making in complex situations (20, 21) .

At the beginning of the COVID-19 pandemic, particularly during the first wave, countries across the world faced common challenges including the scarcity of individual protective equipment and lack of national guidelines from the Portuguese Ministry of Health specially directed at nursing homes (22). All these factors have largely contributed to care workers' burnout. On the one hand, these professionals had to consider new individual procedures and explain the procedures to nursing homes older residents, many of them with cognitive decline, and managing the communication with families. It is well known that people with cognitive decline have serious difficulties to adhere to social distancing recommendations compared to other residents without cognitive illnesses. Furthermore, the social restrictions had a negative impact since they were found to increase mental confusion and agitation mostly caused by additional measures, such as the use of masks (16) . On the other hand, the professionals that tested positive for the infection had to be replaced by other workers ensuring the continuing of care to the residents. In several Portuguese nursing homes, many professionals had a 24 to 24-hour shift work during several days to mitigate the lack of staff (9). Within this scenario, higher levels of uncertainty, anxiety, and depression were identified among care workers (23) .

Concerning the second area -health of residents -the results showed that all external activities were suspended, but internal activities were reorganized to encourage interaction among the residents and avoid contagion between the older persons and care workers. In particular, physical and cognitive activities were promoted to prevent the worsening of physical and mental fragility and dependency in residents whenever possible. However, other ways to promote physical (24) and

cognitive activities (25) should be implemented, such as, for example, including an individual and personalized plan to avoid contact between residents. Unfortunately, the low ratio of health professionals working in nursing homes still hinders the implementation of such measures.

The third area -the contact with the family -, including visitations, was suspended but other communication channels, such as videoconference, social networks, and telephone calls were promoted. This was a common reality in several countries (16, 17, 26, 27) . According to Sengupta and collaborators (28) about 72% to 85% of all residents had contact with families at least twice a month, and considering the current restrictions, telephone calls and other internet options were more frequently adopted (e.g., texting, FaceTime, Skype) for independent residents and communities.

Staff members had a crucial role in encouraging and helping those residents with lower technological readiness to use technological equipment (16, 26) .

The involvement of families on response strategies to the pandemic, particularly to providing information and adaptive behaviour was well accepted by most families who understood the isolation measures needed to protect their relatives. However, a recent publication by Lynn (29) has shown that many nursing home residents and their relatives preferred taking risks rather than enduring an emotionally painful existence. It would be important to discuss preferences and expectations with residents and their families before imposing severe isolation measures indefinitely.

Older adults residing in nursing homes are particularly vulnerable to severe disease or death from COVID-19. The pandemic highlighted already existing weaknesses of nursing homes including lack of care workers and clear guidelines/procedures. These study results showed three priority areas regarding the needs of organizations in the provision of care to older persons including material and human resources, the health of older residents, and the importance of family. In Portugal, nursing homes were established to mitigate the social problems of older persons with high levels of dependency, because culturally families have the responsibility to take care of older persons at home, and institutionalization is seen as the last resource. However, the increase in average life expectancy means that now people live longer, despite physical and mental impairments. In this way, it would be important to carefully address the lack of preparedness of residential structures in the response to residents' health care needs. It should also be noted that most nursing homes in Portugal do not have full-time health professionals, specifically nurses to answer the health needs and anticipate and often mitigate the physical and cognitive frailty of their residents. A new paradigm is needed in current policies since in Portugal the Ministry of Solidarity and Social Security is the head responsible for nursing homes, but we strongly believe that this should be a joint responsibility with the Portuguese Ministry of Health, which has specific competencies assessing health needs. It is also our conviction that the major priority is to avoid high levels of infection among older residents because of the related high mortality rates in this population group. However, in view of the current context, urgent measures are needed such as establishing adequate ratios of health professionals that could be more attractive to nurses and promote quality health care delivery. The rapidly changing demographic characteristics of populations in OECD countries urge enhanced competencies of nursing homes workforce, and it is cardinal that governments address several challenges as priorities.

Nurses are at the frontline when caring for older people living in nursing homes and play a pivotal role in the early diagnosis of cognitive and physical decline as well as preventing loneliness and dignifying the last stage of a person's life cycle. 

1. The attraction of professionals (with specific skills). 2. The lack of professionals specialized in the health area (difficulties in recruiting and retain these professionals in the health area). 3. The organization and management models of institutions (lack of middle and top management). 4. The lack of material resources (Personal Protective Equipment). 5. The lack of guidance from government health entities (difficulties in implementing the contingency plan). 6. The lack of solidarity in the social sector (between institutions). 7. The management of professionals' physical and emotional overload. 

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We would like to express our deepest gratitude to the experts who participated in the focus group and the e-Delphi techniques during the first wave COVID-19 outbreak.

None of the authors has any personal or financial conflicts of interest to declare.

 Table 3 . Results of modified e-Delphi (n=22)

AL CL The difficulty in attracting and retaining professionals with specific skills in gerontogeriatrics.

A -14 (64%) SA -6 (27%)

The lack of professionals specialized in the health area.SD -3 (14%) D -3 (14%) A -11 (50%) SA -5 (22%)

The inadequate organization and management models of institutions.SD -3 (14%) D -4 (18%) A -10 (45%) SA -5 (23%)

The lack of material resources, namely personal protective equipment.The lack of guidance from government health entities. SD -1 (4%) D -6 (27%) A -15 (69%)

Difficulties in implementing the contingency plan.The lack of solidarity in the social sector (between institutions).The management of the professionals' physical and emotional overload.D -2 (9%) A -9 (41%) SA -11 (50%)

How the residents' physical and mental health needs were met AL CL The reorganization of recreational/social activities (e.g. maintenance of activities in the classroom and reorganization of the physical space).

A -11 (50%) SA -10 (46%)

The cancellation of outdoor activities.SD -1 (4%) A -9 (41%) SA -12 (55%)

The promotion of contacts with the family (e.g., scheduled video calls and/or frequent telephone contacts with the institution).A -13 (59%) SA -9 (41%) 100% Perfect Information to residents (with cognitive conditions for this) about the need for adaptation.