key: cord-1022914-limlf73r
authors: Sunner, Carla; Giles, Michelle; Parker, Vicki; Kable, Ashley; Foureur, Maralyn
title: COVID‐19 preparedness in aged care: A qualitative study exploring residential aged care facility managers experiences planning for a pandemic
date: 2021-07-12
journal: J Clin Nurs
DOI: 10.1111/jocn.15941
sha: b6810c0291c7233fccee4364a6ddb4f220f77629
doc_id: 1022914
cord_uid: limlf73r

AIMS AND OBJECTIVES: The study aims to understand the changing context of RACFs and the role of RACF managers in preparing to confront the COVID‐19 pandemic and to provide insights into how the use of visual telehealth consultation might be incorporated to assist with managing whatever might arise. DESIGN: An interpretive descriptive study design was employed, and data were collected using semi‐structured interviews conducted via telephone or videoconference. Purposive recruitment targeted clinical managers responsible for the COVID‐19 response in RACFs. METHODS: RACF clinical managers were invited to discuss their responses to COVID‐19 including the management of RACF and staff. Semi‐structured interviews explored the COVID‐19‐related challenges, the response to these challenges and how telehealth might assist in overcoming some of these challenges. This study followed Thorne's (2008) three‐stage process of interpretive description. The COREQ checklist was used in preparing this manuscript. RESULTS: Two main themes were identified. The first theme ‘keeping people safe’ was comprised of three subthemes; fear and uncertainty, managing the risks and retaining and recruiting staff. The second theme was ‘keeping people connected’, had two subthemes; being disconnected and isolated and embracing technology. CONCLUSION: Findings from this study provide valuable insight into understanding the context and the challenges for RACFs and the staff as they attempt to keep residents safe and connected with healthcare providers and the outside world. RELEVANCE TO CLINICAL PRACTICE: Understanding the experiences of RACF managers in preparing to respond to the pandemic will better inform practice development in aged care in particular the use of telehealth and safe practices during COVID‐19. Increased awareness of the challenges faced by RACFs during a pandemic provides policymakers with valuable insights for future planning of pandemic responses.

The World Health Organisation declared COVID-19 a pandemic on 11 March 2020 and by September 2020 there were over 30 million confirmed cases, with just under a million confirmed deaths (WHO, 2020) . Internationally, governing bodies are warning older people that they are at greater risk of contracting a COVID-19-related illness, leading to poor outcomes (Brooke & Jackson, 2020; Fisk et al., 2020; Werner et al., 2020) . Deaths occurring in residential aged care facilities (RACF) have been reported to comprise almost 80% of Canada's COVID-19-related deaths, with 50% in Switzerland (Faghanipour et al., 2020) , 42%-57% in European countries (McGilton et al., 2020) and 66% of deaths in Australia. Consequently, it is important to understand the many challenges faced by RACFs whilst they were responding to the COVID-19 pandemic, and to explore ways they may be supported through this difficult time.

Regrettably, RACFs were caught unaware by the COVID-19 pandemic. The speed with which the virus took hold left vulnerable older people and RACF residents susceptible to illness and premature death. Most cases of COVID-related deaths in RACFs have been reported to be because of poor preparedness plans and RACF organisational deficiencies in Australia (Marozzi, 2020) and globally (Faghanipour et al., 2020) . Prior to the pandemic it was already well recognised that there was a need to address systemic failures in facility design inadequacies and infection control practices given the high rates of transmission of infectious disease in RACFs (Davidson & Szanton, 2020) . The importance of pre-emptive pandemic planning for RACFs cannot be understated.

Managers had crucial decisions to make regarding the safest location for residents during the pandemic. Chronically understaffed RACFs now had to face the prospect of the existing workforce contracting COVID-19 and being unable to work (McGilton et al., 2020) .

Managers of RACFs had very little option but to try to meet the high care needs of RACF residents with a depleting workforce. One option was to transfer residents to acute hospitals for care. There were concerns that if the only plan was to move RACF residents into the hospital system, capacity would be reached within a couple of weeks (Daly & Wearing, 2020) . Additionally, Australian and international studies have revealed it is not in the best interests of RACF residents to spend time in emergency departments due to the risk of further injury, unnecessary discomfort and distress (Dwyer et al., 2014; Hullick et al., 2016; Marsden et al., 2018) . This strategy would have left the vulnerable RACF resident in a dire situation, unsafe at home and unsafe in hospital, but with no alternative if the RACF could not safely manage their care.

Residential Aged Care Facilities were already grappling with systemic failures prior to the COVID-19 crisis (Davidson & Szanton, 2020) . Due to the pandemic, care of the aged in RACFs has now become a public health issue (Davidson & Szanton, 2020) , rather than the sole responsibility of the RACF itself. Four public health solutions have been proposed to address the RACF systemic failures including increasing aged care funding (Werner et al., 2020) ; increasing staffing (Davidson & Szanton, 2020; Faghanipour et al., 2020; Gaur et al., 2020; McGilton et al., 2020) ; making aged care employment more attractive (McGilton et al., 2020) ; implementing more helpful technology (Siette et al., 2020) . Together, these four solutions present a sound plan but will come at a price. For example, the expected cost of restructuring and fortifying aged care in the USA has been estimated to amount to $US15 billion (Werner et al., 2020) .

One of the potentially less expensive solutions is to consider the implementation of more helpful technology such as visual telehealth to beam expert clinical support care into RACFs. Visual telehealth is a timely and cost-effective means of providing care for RACF residents and supporting RACF staff in clinical decisionmaking during the COVID-19 pandemic (Davidson & Szanton, 2020; Edelman et al., 2020; Fisk et al., 2020; Gillespie et al., 2020; Hoffman et al., 2020) . To date, little has been reported of the way in which pandemic preparedness affects clinical decision-making in RACFs and how visual telehealth has supported or can support this process.

In early 2020 we had commenced a large, funded study focusing on the use of visual telehealth consultation in supporting clinical care decision-making between RACFs and emergency departments. This study was temporarily suspended due to COVID-19 visitor restrictions (Sunner et al., 2020) . The research team saw this temporary suspension period as a unique opportunity to engage with as many RACF managers as we could, to understand the pandemic response through their eyes. We wanted to discover what their key issues and concerns were, and to explore with them whether visual telehealth would be of assistance to them as they were preparing for and responding to COVID-19. It is important to increase understanding of the challenges faced by RACF managers in the situation of a pandemic in order to identify strategies they employed in this unique situation to future proof facilities against pandemics. Increasing understanding of their pandemic response may also identify useful What does the paper contribute to the wider global clinical community?

• Insights can be used to inform the development of strategies for RACF managers who are actively trying to manage risk and maintain communication during a pandemic • Information to strengthen the development of policy and procedure in the areas of communication and safe practices in RACFs • Better understanding of the current challenges in responding to the COVID-19 crisis for RACF managers to future proof facilities against new pandemics strategies they developed that may also improve current practices in RACFs.

The study aims to understand the changing context of RACFs and the role of RACF managers in preparing to confront the COVID-19 pandemic and to provide insights into how the use of visual telehealth consultation might be incorporated to assist with managing whatever might arise.

A qualitative study design was employed, and data were collected using semi-structured interviews conducted via telephone or videoconferencing. Thorne's interpretive descriptive methodology was used to guide this study owing to its focus on practice to uncover what is not known about a phenomenon (Thorne, 2008) . The Consolidated Criteria for Reporting Qualitative Studies (COREQ) (Tong, Sainsbury, & Craig, 2007) has been followed in reporting this study (File S1).

RACFs (n = 100) that utilised the aged care emergency service of one Local Health District (LHD) in New South Wales, Australia were targeted for this study. The RACFs were located in metropolitan, rural and remote areas. RACF managers (and relieving managers) contacted for this study were identified from a local database nominating the key managerial contact for each RACF, and/or the most senior role onsite. A purposive sample of RACF managers was selected as the most appropriate key informants as they would have the greatest organisational knowledge of the RACFs' response to COVID-19. Interviews were conducted in early 2020 when all RACFs were in varying states of lockdown that occurred towards the end of the first COVID-19 wave in Australia.

Invitations were sent via email to the managers of 100 publicly funded or privately owned RACFs within the LHD. The decision to invite 100 RACF managers to participate was a pragmatic decision based on the potential number of interviews one researcher could manage within the shortest possible timeframe in a dynamically unfolding COVID-19 situation. Twenty-eight RACF managers responded, with three RACFs electing to have more than one manager participate in the interview. Emails were resent three times, one week apart to encourage participation. This resulted in 28 individual and two group interviews (consisting of 2-3 participants), totalling 31 participants (4 male and 27 female) from 18 RACFs located in metropolitan areas and 10 from rural areas, see Table 1 .

Semi-structured interviews were guided by key questions (see Table 2 ) exploring the participants' experiences with RACF preparation and the challenges encountered or anticipated. Interviews were conducted between May and June 2020.

Due to pandemic social distancing restrictions at the time, interviews were conducted over a secure videoconferencing platform that included a recording device. Interviews were also recorded on a digital recording device as a backup in case of equipment failure on the videoconferencing platform. Only the researcher (CS) and the consenting participant(s) were present during the interviews, which were conducted in private workplace environments at each location.

One repeat interview was attended. The interviews ranged from 15 to 45 minutes in duration. Brief field notes were made by the interviewer to document key points identified in the interviews. The interview recordings were fully transcribed, and participants were offered the opportunity to receive a copy of the transcript.

Committee, approval number 2019/ETH12853. Following approval, an information statement outlining the study purpose and a consent form were sent via the work email of the RACF managers.

RACF managers who replied to the invitation email and returned a signed consent form were sent an appointment to participate in an interview. Participation and consent were voluntary. Interviews were transcribed and the demographic details were de-identified to ensure confidentiality and each participant was allocated a pseudonym.

NVivo software (QSR International, 1999 ) was used to manage the data. An inductive approach to data analysis was used according to the three steps outlined by Thorne (Thorne, 2008) .

The transcripts were coded independently by three researcher's CS, VP and MG, who then collaborated in the development of representative themes (CS is a PhD in nursing student, VP and MG are experienced nurse clinicians and researchers). Open codes were developed inductively and iteratively by the three coders (CS, VP and MG) reviewing three transcripts each independently. Thorne's (2008) three-stage interpretive descriptive method of data analysis allowed the researchers to check, test, compare and contrast whole components of the data to identify differences, similarities, relationships and patterns to gain an understanding of the RACF managers' experiences responding to a COVID-19 pandemic.

Codes were further refined, and common emerging themes recognised and put through the 'thoughtful practitioner test' (Thorne, 2008, pp. 92-93) , where insights from the three coders, who were expert experienced clinicians from three different clinical backgrounds, were able to provide rich, critical reflection on the data.

The coders identified a coding tree consisting of 25 initial codes derived from the data with 11 sub-codes. Themes were then worked through a process of reflection and inference to create an emerging understanding and qualitative description of participants' contributions (Sandalowski, 2010) . Transcripts were then re-read several times by the researchers (CS, VP and MG) and were discussed until a consensus was reached, finally resulting in two main themes and five minor themes as outlined in Table 3 .

Transparency and trustworthiness of the findings were ensured through; keeping an auditable record of how the findings were derived, grounding of the findings in the data and member checking (Bazeley, 2013) . Credibility was assured as all interviews were TA B L E 1 Demographic characteristics of the participants 

Tell me what you have in place in response to the COVID-19

What are the challenges that you foresee?

How do you think the Visual Telehealth Consultation can assist you with these challenges?

Probing questions, such as 'could you please provide an example' or 'please tell me more', were used to encourage the participants to elaborate and deepen their answers, when needed conducted by CS who has interpretive authority (Thorne, 2008) and extensive experience in the aged care sector in the community and in emergency department care of the older person. At the time of the study, CS was employed as a project manager for the PACE-IT project (Sunner et al., 2020) and was closely mentored, supervised and supported by her research team, who are all experienced qualitative researchers and co-authors on this paper. 

The sudden and unheralded arrival of the COVID-19 pandemic meant that there was an imminent and urgent heightened risk for RACFs resulting in escalating fear and uncertainty. Managers were confronted and challenged by a situation that they had not previously encountered and the path ahead for them was not clear.

In keeping people safe, there were three subthemes identified;

Fear and uncertainty, Managing the risk and Retaining and recruiting staff.

In the context of COVID-19, participants were concerned that staff were unwittingly bringing the virus into the RACF and also taking it home, potentially exposing residents and their families to harm, as Chloe expressed;

A lot of the staff are saying, the hardest thing is the thought that we might actually be a carrier and not know (Chloe)

All participants described a perception that staff felt they were in some sort of danger, verbalising that they were also personally feeling nervous, frightened, fearful and scared. 

Managers were dealing with fear from staff residents and families, residents wanting to see their loved ones but being isolated from them, so managers had to think about how they could use technology to assist them addressing this. The second theme is Keeping people connected, consisting of two subthemes; Being disconnected and isolated and Embracing technology.

Some participants voiced concern about the disconnection that the mandated 14-day isolation caused for a resident's mental health. For example, Chloe told of the following situation;

We had one lady who did go to hospital a couple of weeks ago and she does suffer from mental health problems and I was quite concerned about her being in her room because she didn't want to get out of bed and it took a few days before she would allow the staff to actually get her up and, "come on let's get you in a chair, let's get you", you know, and sort of perk her up and she's out of her room now and she's really happy but, you know, just the mental challenge for that (Chloe) It was noted that the use of telehealth was now more widely accepted amongst the residents when they were talking to the GP or family via video technology. Several participants reported the resident's response to the use of telehealth as;

We have one lady, she's 103 and we tried to explain to her that she would be able to talk to people on this funny looking thing and she said 'I really didn't think I'd be able to say anything, I thought I'd clam up, but once I got on I couldn't shut up' she said. 'I couldn't stop talking'

Participants also reported far greater acceptance of telehealth use by themselves and the staff, and the many benefits that had been realised;

I love telehealth … I'm quite happy to keep everyone out of here and dial in to everyone, it'd be great. (Good assistance with) Supra public catheter reinsertion

Used with a PEG (percutaneous endoscopic gastrostomy) tube it would have been good to talk through that… the resident had to go to hospital

The benefits of using telehealth for residents included the reduction in transport to another facility for consultation or treatment and associated costs, assistance in attending difficult clinical procedures, outpatient appointments, educational webinars and videoconferencing for staff meetings. As Tahlia states;

Transport costs to get our residents to and from an appointment is difficult, in particular, a lot of my residents don't like to leave the building, with the dementia, or if we get them out, we can't get them back in. So, I think telehealth has a potential to be very useful in be- Participants reported that the facility used telehealth as an alternative to face to face visits, using a variety of different platforms, and that this raised data security and privacy issues.

I think one's using Facetime, which is a bit strange, because they won't send anything via email because of

[security] things, but they're using Facetime to do their Telehealth (Amelia)

The decision to use telehealth was often driven by the GP. However, some GPs did not attempt to adopt telehealth at all, and in fact reduced their contact, opting for no visits or just telephone calls.

GPs were providing wound advice consultations based on emailed photographs and a telephone call. Others physically visited the RACF but did not personally visit or view the resident.

Participants shared their experiences of GPs who really 'stepped up to the mark' by ensuring residents were able to avoid hospitalisation with the adoption of telehealth or by increased telephone consultations. One participant spoke of a particular GP who engaged fully with visual telehealth consultation, doing a weekly round for all her residents;

We embraced Zoom which was wonderful, so with her iPad and my iPad we could walk round the facil-ity…and she could actually talk to her residents (Brooke) In contrast, some participants voiced their frustration that several

GPs had not adjusted their communication techniques at all, continuing to telephone as they usually would.

The use of telehealth appeared to have a good level of acceptability and the rate at which it was being embraced differed throughout the participant's facilities. However, the common thread was that it was a useful tool to address the communication restrictions thrust upon RACFs in the time of COVID-19.

The events that unfolded following the completion of this study in

March 2020 were unprecedented in Australia and the world. The many fears and concerns that managers in this study were experiencing became reality for some. Maintaining a safe level of staffing in RACFs was a major challenge for RACF managers during ordinary times (Quigley et al., 2020; Royal Commission, 2011) . During COVID-19 staff shortages have been exacerbated, with already struggling RACFs losing some of the staff to illness, burnout or mandatory quarantine during the pandemic.

Some workers have left the job due to unsafe working conditions (Faghanipour et al., 2020) , leaving RACFs critically understaffed and unable to deal with the increased needs of residents (Quigley et al., 2020 (Sunner, 2020) , has shown that it can support RACFs in many ways and was highlighted in the two major themes; keeping people safe and connected.

The strength of this study is that it was undertaken in real time as RACF managers confronted a major threat to the health of residents and staff due to the COVID-19 pandemic. They generously gave of their time to participate in this study in order to share their experiences and solutions with other RACF managers who found themselves in similar situations. However, the findings from this study may not be transferable to RACFs in other areas of Australia or internationally as the RACF challenges and responses were context specific, and significant differences in the severity of the COVID event across facilities. It is important to acknowledge that there was a time constraint to undertake the interviews in the peak of the first wave of COVID-19 to understand managers' experiences in real time.

These unprecedented times have identified a gap in the aged care sector in terms of protection of vulnerable residential aged care residents. COVID-19 has highlighted the urgent need for better planning and management. Findings from this study provide valuable insight into the most pressing challenges for RACFs and the staff as they attempt to keep the residents safe and alive, maintain and upskill the workforce, keep up with rapidly generated guidelines and introduce new technologies to keep the residents connected with healthcare providers and the outside world.

Understanding the experiences of RACF staff and residents during the COVID-19 will assist facility managers and policymakers effectively plan, develop and implement strategies to overcome many of the challenges identified. Findings from this study identify a clear need for further support RACFs during the pandemic and beyond.

Better awareness by external governing bodies will assist in managing future pandemic responses in RACFs and contribute to keeping these vulnerable Australians safe. In addition, telehealth has been identified as a useful strategy to overcome many of the challenges RACFs experienced during pandemic lockdown.

We would like to thank the RACF managers who participated willingly in this study. They gave up their time to share their stories during a stressful and prominent time in global history.

No conflict of interest has been declared by the authors. Maralyn Foureur https://orcid.org/0000-0002-0454-0165

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