Medical support is a key point in helping nursing homes face the threat of COVID-19
The COVID-19 outbreak spread rapidly across the world. Nursing homes are high-risk settings and face unprecedented challenges. Various preventive measures were implemented in nursing homes in China, including lockdowns, the restriction of visitors, the prohibition of the entry of the people from Wuhan City, 14-day isolation for returning staff and residents, and symptom monitoring for all of the staff and residents. Despite these strict measures, COVID-19 still found its way into 3 nursing homes in Wuhan Province in China that were included in this survey. We must be aware of the many problems and weaknesses in the management of nursing homes. In this study, the average overall implementation rates of COVID-19 prevention and control measures was 80.0% (143.97/180), which was at the medium level. The staff and residents in nursing homes generally lacked awareness, knowledge, and basic skills for preventing the spread of infectious disease, which made the guidelines insufficient. The study shows that nursing homes that lack medical support had low implementation rates. In particular, the number of medical staff and the establishment of a quarantine room/unit were two critical factors that affected the implementation score. (p<0.05). The finding indicates that medical staff in nursing homes are poised to play a pivotal role in improving the implementation of COVID-19 prevention and control measures. They could provide services to residents directly, be responsible for operating the quarantine room/unit, and provide training to other staff. However, not all nursing homes had doctors and nurses on their staff. The USA’s research also showed similar result that the nursing home with health care worker represents a lower mortality rate compared with facilities without health care worker [25]. In our survey, there were no medical staff (doctors, nurses, or pharmacists) in 19.7% of the nursing homes, as nursing homes tend to strive to create a family environment rather than a medical environment [26]. This scenario leads to preventive measures that cannot be closely followed. Studies in Singapore [27] and Spain [15] suggest that public healthcare workers should be sent into nursing homes to help improve preparedness for and the prevention and control of COVID-19. A study in Canada also reported the experience of the emergency response of an acute-care hospital to a nursing home [28]. Such hospital-nursing home partnerships are a new form of cooperation that has arisen during the COVID-19 pandemic.
A shortage of nurse aides in nursing homes was a significant problem
Nursing homes often face nurse aide shortages, which have been exacerbated by the current pandemic situation. Nurse aides have to work long shifts, perform high-intensity labour and complete a large amount of extra work during the pandemic because the nursing homes are experiencing high levels of absenteeism. The pandemic coincided with the Spring Festival. Some nurse aids who went home to reunite with their families were unable to return. Nurse aide shortages not only directly affect the achievement and maintenance of care quality in nursing homes but also indirectly affect the implementation of COVID-19 prevention and control measures [10]. Most of the implementation measures were implemented by the nurse aides. However, nearly half (47.7%) of the nursing homes reported staff shortages. Even before the pandemic, it was difficult to recruit qualified nurse aides in China. Nurse aides are often described as special groups with low social status, lower education level, insufficient training, and poor wages. Other countries face the same problem [27, 29, 30]. Policies should be designed to ensure that nursing homes are adequately staffed and that infection control protocols are implemented with high quality [17]. Common strategies include having nurse aides live in nursing home, extend their hours, asking nurse aides to sacrifice their rest time and encouraging the staff other than nurse aides to temporarily fill the nurse aide role. However, the execution of these strategies was difficult. It required a high level of leadership of the nursing home’s manager. In our study, the three dimensions of transformational leadership, included intellectual stimulation, individualized consideration, and idealized influence, affecting the prevention and control implementation. The transformational leadership of the nursing home’s manager was different from other types of leadership. It built the relationship between managers and staff based on loyalty, trust and respect [31]. Idealized influence played an important role. Manager elevated the moral level of staff with personal integrity [32]. It encouraged them to consciously prolong the work hours, increase workload, and implement prevention and control measures for making up for the shortage of staff.
Little preparation for the pandemic
COVID-19 has exposed long-standing problems in nursing homes. Given the shockingly high rates of infections and deaths in nursing homes, it is crucial for nursing homes to prepare. However, little planning for infectious disease pandemics has been undertaken in nursing homes. There was no absolute requirement for such planning in the previous policy. Furthermore, in terms of the management system, there is a lack of emergency response plans, emergency leadership committees and emergency supply reserve mechanisms in nursing homes. This is similar to the situation in other countries, such as Ireland [33] and the USA [17], where there is little preparation for pandemics in nursing homes. Even more troubling is that most nursing homes lack the essential materials to protect their residents and staff. In our survey, 69.8% (332/461) of nursing home managers reported they had serious resource problems, 72.0% of nursing homes reported their primary problem was inadequate protective supplies. They could not obtain access to the necessary supplies for prevention at the beginning of the pandemic. The shortage of protective supplies is still a problem in many countries [34]. 70% of American nursing homes were unable to provide sufficient supplies for their staff [10]. In this light, nursing homes should reserve protective material for emergency use, intensify their efforts to acquire protective supplies during epidemics, improve access to essential resources, and develop optimal distribution strategies for when supplies are insufficient. During the pandemic period, there may be considerable pressure on nursing homes to maintain operation; 43.8% of the nursing homes reported having difficulties operating, and 25.6% of nursing homes reported an inadequate supply of daily necessities in this study. Given the similar lack of preparation and reserves in the nursing home sector during many other natural disasters [33], the COVID-19 pandemic raises questions regarding whether nursing home managers have learned from this experience. We found nursing homes those located in urban, had more than 200 beds, had hospital-nursing home cooperation, and higher transformational leadership of managers had a lower risk of involving serious resource problems. It indicates that the better the nursing home’s comprehensive conditions, the stronger their ability to resist the risk of resource problem caused by the COVID-19 epidemic. A similar result from nursing homes in the USA showed that the nursing homes with higher quality ratings could control the spread of COVID-19 and decrease the death rate [35]. Because both the human resources and material resources of the high-quality nursing homes were relatively sufficient [36]. Nursing homes of China had to prepare enough human resources and material resources, making emergency response plans to avoid future crises.
Access management should be strengthened
COVID-19 is an ongoing pandemic that is challenging nursing homes due to its high infectivity. It is forcing the implementation of drastic measures in nursing homes [37]. Nursing homes have adopted strict access and visitation restrictions according to the provided guidelines [38]. Overall, the rate of adherence to the guidelines for access management among nursing homes in this study was 78.7%. However, it is uncertain whether the level of adherence can be maintained throughout the pandemic period. Staff are most likely to cause imported transmission [39]. Staff movements between their homes and nursing home facilities could transmit the disease. A survey of Chinese nurse aides showed that 81% of nurse aides from a rural area with low educational level and low adaption of other work. 92% of nurse aides were inter-city migrants, and 62% of nurse aides were inter-provincial migrants. Unlike in other countries, Chinese nursed aides always worked for only one facility and did not have a second job. So 85% of nursing homes accommodated nurse aides [40]. However, in our survey, only 78.8% of nursing homes can provide staff accommodations in nursing homes. Therefore, 21.2% of nursing home staff have to go home. To decrease the risk of the spread of COVID-19, one infection control measure is to house the staff in the nursing homes, which might mitigate the risk associated with staff moving between their homes and the facilities during the pandemic. If there is no living space in the nursing home, the staff should be centrally managed in an accommodation site without having contact with others. The staff responsible for purchasing should not contact staff who provide services to the residents. Access management is the key form of management; if not strictly implemented, nursing homes will be placed at great risk.
During the COVID-19 epidemic, most nursing homes in China have been completely closed and had little contact with the external environment, with nobody entering and nobody exiting. In the early stage of the epidemic, nursing homes prohibited any visitors unless it is for “an end-of-life situation.” Item 2.2 and Item 2.3 showed the strict visit policy. However, the average implementation rate of Item 2.2 and Item 2.3 were not high, with 73.2% and 58.8%, respectively.
Lockdown and isolation are appropriate policies to limit the spread of COVID-19, but these measures impact people’s mental health [3]. Some residents and staff often feel lonely, anxious and depressed, and they struggle with the absence of relatives. In our study, 38.0% of elderly residents and staff needed psychological intervention during the lockdown period. It was unclear how long isolation will last by the time we finished our survey, but the situations may worsen as enforced isolation continues. Strictly lockdown policy made the family members and other volunteers’ support care impossible, further exposing the vulnerabilities associated with staff shortage [10]. Manager’s leadership might play an irreplaceable role in maintaining the stability of the nursing homes. Transformational leaders changed their staff and encouraged them to consider organizational goals over personal interests [41]. It made staff regard fighting the COVID-19 as a battle, making them view staying in the nursing home as heroic behaviour to guard the safety of nursing home.
Problems with environmental disinfection management
Environmental cleaning and disinfection are important precautionary measures to prevent indirect COVID-19 infections. Kampf et al [42] reported that coronaviruses can live on surfaces for up to 9 days. Adopting environmental cleaning and disinfection measures has proven to be beneficial in containing the virus [43]. Therefore, the regular cleaning and disinfection of surfaces and objects are essential to control spread. However, the implementation rate of environmental disinfection management was only 79.0% in this study. The frequency of the cleaning and disinfection of residents’ bedrooms and office areas and service places was insufficient (Item 3.2 to 3.5). Although most of the nursing homes had established infection disease prevention and control standards, the staff were insufficiently trained in infectious disease prevention and control skills. The local CDC should be responsible for providing training to the staff in nursing homes regarding disinfection knowledge, including information about what kinds of disinfectants are effective and how to disinfection can be performed effectively [44]. Sanitation and environmental disinfection should be carried out scientifically based on the recommended procedures [45]. Enhanced environmental cleaning and disinfection in nursing homes is important; it should be not a temporary task but should be routine work.
Risk in Hygienic Behaviour Management
Hygienic behaviour management is central to the transmission of COVID-19, and changing behaviour is crucial to prevent transmission. In our survey, the average implementation rate of hygienic behaviour management was only 75.3%, which was the lowest rate among the four aspects of the implementation of COVID-19 prevention and control measures, indicating that hygienic behaviour management is the weakest point in nursing homes. In addition, the implementation rates of measures involving residents, such as having them wear face masks, providing them with education and maintaining physical distance, were extremely low, which may be related to the cognitive decline of some residents. Aktinson et al[46] reported that the size of respiratory droplets from humans typically range from 0.5 to 12 μm and that droplets sized <0.5 μm can remain airborne for significant periods of time. Van Doremalen et al [47] found that COVID-19 remains stable in airborne aerosols for at least 3 hours and can persist on inanimate surfaces for 48 to 72 hours. Based on the above, personal protection in the form of improved hygiene behaviour [44], such as the appropriate utilization of face masks in public areas, may mitigate future COVID-19 transmission in nursing homes. Among the many considerations, forty-two percent of the elderly have dementia or cognitive decline in nursing homes [48], making the enforcement of mitigation strategies such as face mask wearing a major challenge [12]. Therefore, items related to wearing face masks as appropriate (Item4.6 to 4.8) showed lower average implementation rates. It has been a controversial issue whether residents must wear masks in nursing homes that are already completely closed. Given that elderly residents often have respiratory diseases [6], wearing face masks will affect their respiratory function, which can lead to decreased compliance.
Effective risk communication and knowledge education in the early stage of the COVID-19 outbreak is critical for promoting behavioural compliance. These strategies have proven to be useful for the general public [3] but have not been effectively adopted in nursing homes. The implementation rate for the item “Provide knowledge education to the residents about COVID-19 prevention and control” (Item 4.4) was also very low (64.0%). For example, understanding why face masks should be used, why visitors are not coming to see them, and why they should keep distance from others is difficult for residents with dementia. It is also a major challenge for staff to provide education to these residents. The recommendation to “maintain physical distance” (Item 4.3) was also difficult for most elderly and staff. The implementation rate for this measure was 77.0%. In China, residents who live in nursing homes have chronic underlying medical disorders; they usually have considerable personal care needs, including bathing, dressing, and toileting, which make maintaining physical distancing nearly impossible. Considering the characteristics of the residents, there are few strategies that can be used to improve the hygiene behaviour of residents. The best strategy is to prevent COVID-19 from invading nursing homes.