Pandemic Nursing Framework for Nursing Homes During COVID-19

Version	Summary	Created by	Modification	Content Size	Created at	Operation
1		Hongli Sam Goh	+ 1493 word(s)	1493	2021-12-23 04:00:55	\|
2	Done	Jason Zhu	-2 word(s)	1491	2021-12-29 02:59:48	\| \|
3	Done	Jason Zhu	-2 word(s)	1491	2021-12-29 03:00:42	\|

This entry is adapted from the peer-reviewed paper 10.3390/ijerph19010075

Nurses have played a vital role in the fight against COVID-19 by ensuring continuity in patient care and demonstrating clinical leadership in pandemic efforts. The pandemic nursing measures can be broadly classified into four groups: (1) infection surveillance and containment measures; (2) ensuring continuity in clinical care and operational support; (3) resource and administrative coordination; and (4) staff training and development.

long-term care community nursing COVID-19 coronavirus

1. Introduction

In December 2019, a novel coronavirus, COVID-19, emerged and resulted in a pandemic affecting over 215 countries worldwide within a short span of five months. As of 30 June 2021, 181,521,067 people have been infected globally, with 3,937,437 deaths ^[1]. Singapore reported its first COVID-19 case on 23 January 2020. Due to rapid local community transmission, the country raised its Disease Outbreak Response System Condition (DORSCON) alert level to orange on 7 February 2020. On 7 April 2020, the country introduced “circuit breaker” measures to stamp the sharp rise in COVID-19 cases within the community ^[2]. Due to the unknown pathology of the disease, its high transmission rate, and asymptomatic infections, this pandemic sparked a flurry of clinical guidelines put forth by governments and healthcare organizations worldwide to contain its spread and impact ^[3].

Long-term care facilities are especially vulnerable to infectious diseases due to their residents’ profile, infrastructure constraints, manpower and resource shortages, and limited government funding ^[4]. These systemic challenges have contributed to reports of COVID-19 transmission within nursing homes in the United States, the United Kingdom, and Singapore ^[5]^[6]^[7]. In Singapore, the majority of the nursing homes resemble dormitory-style residential conditions with shared communal facilities and close proximity among residents ^[8]. The physical layout, coupled with the systemic challenges nursing homes face, could provide the impetus for the COVID-19 outbreak. Tan and Seetharaman reported high rates of acute respiratory symptoms among nursing home residents, making it difficult for clinicians to differentiate COVID-19 cases from non-COVID-19 ones ^[9].

Management guidelines for the COVID-19 outbreak can be more complex for nursing homes than acute hospitals due to differences in physical layout, resources, and residents’ disease profiles ^[9]. In a local news report, a nursing home operator had to resort to seeking assistance and additional manpower from the Ministry of Health (MOH) to support its daily operations when several of its staff and residents were infected with COVID-19 and required to quarantine. Staff shortages and lean resources have been identified as contributory causes ^[10]. Although governmental bodies have been swift in introducing pandemic guidelines, success is contingent on nursing homes' extent and pace of implementation. While there have been several published reports on COVID-19 pandemic measures taken by acute hospitals and primary and tertiary care centers ^[11]^[12]^[13], little has been reported about measures taken in the long-term care sector. Therefore, there is a need to shed light on the efforts and measures taken by nursing leaders to manage COVID-19 within nursing home settings. This article proposes a pandemic nursing framework that has provided the nurse leaders with a highly efficient approach to handle the COVID-19 situation at the nursing home.

2. Infection Surveillance and Containment Measures

When COVID-19 was first reported in China in January 2020, the nursing home quickly set up a nursing taskforce committee to monitor the situation. At that time, two key challenges emerged for the nursing taskforce committee: (1) the exigency of data collation for the real-time monitoring of suspected/confirmed cases; and (2) the review of multiple COVID-19 reports of pandemic responses.

At that point, the nursing home lacked a dynamic pandemic response system. Hence, the Nursing Director and Infection Control Nurse (ICN) assumed the infection surveillance and containment measures function by directing the overall pandemic efforts with the command center. They managed the setup of screening counters, surveillance system for staff/visitor traffic movement and served as the subject matter expert for the command center. The ICN's role involved reviewing national pandemic guidelines; drafting department-specific organizational directives; and liaising with experts, government agencies and other healthcare organizations. Other infection surveillance and containment measures included: (1) conducting mask-fitting and personal protective equipment training for over 400 nursing and non-nursing staff; and (2) mobilizing necessary resources and support from the nursing workforce at short notice for any government-directed pandemic measures. Their role proved pivotal in enhancing the nursing home’s capability to respond to the ever-changing pandemic measures that were issued at short notice.

3. Ensuring Continuity in Clinical Care and Operational Support

In February 2020, Singapore reported a growing number of COVID-19 clusters within the community, leading to an escalation of DORSCON alert level. As a result, the nursing home had to intensify manpower and resource planning efforts to ensure continuity in clinical practice care and operational support. To ensure sufficient manpower, the nurse managers informed all frontline staff to defer non-essential overseas trips and explored alternative staffing arrangements, such as a split-team/split-site arrangement, a 12-h shift rotation, and work hours extension. A ward-specific staffing threshold was also set for the possible activation of additional staffing in the event of high work absenteeism. To sustain adequate resources for clinical operations, nurse managers projected ward utilization rates for essential resources, such as personal protective equipment (PPE). Areas for the consolidation of services were also identified, resulting in the delegation of non-essential tasks to non-clinical staff and the suspension of certain services.

The nurse managers played a crucial role in ensuring continuity of care for the residents. They increased ward round frequencies and kept close communication with staff. They also had to monitor vulnerable residents for signs of acute respiratory symptoms, prioritize residents’ outpatient appointments, and reschedule non-essential ones to minimize residents’ movement out of the nursing home. The constant presence of the nurse managers at the frontline helped ensure rapid information dissemination, staff compliance to prevailing pandemic directives, and the monitoring of staff safety and welfare during this trying period.

The nursing team also leveraged information and communication technology to substitute face-to-face family visits with remote visitation. These measures helped residents to keep constant communication with their next of kin and friends during the pandemic.

4. Resources and Administrative Coordination

Two non-nursing administrative staff members assisted the nursing taskforce committee in logistics and administrative and manpower support functions, which centered on inventory management, organizational and documentation support, and data collation required for government reporting. The administrative staff assisted the Nursing Director in conducting business continuity planning for the entire nursing home, such as split-site and split-team work arrangements and identifying areas for service consolidation. They also assisted the ICN in data collation for mandatory reporting to the MOH. As data were primarily in hardcopy format, collating such information can be challenging and time-wasting. The administrative staff proved valuable in supporting the clinicians with mundane tasks, allowing them to focus on coordination and communication efforts with various governmental agencies.

Other than operational and administrative support, the administrative staff also supported the nurse managers in overseeing human resource matters, such as staff welfare and lodging. For example, when workplace segregation was instituted to minimize staff movement within the 624-bedded facility, the administrative staff coordinated with the human resource personnel to ensure similar living arrangements within the nursing home dormitory for the foreign staff to minimize risks for cross-cluster transmission. Temporary accommodations were also arranged if foreign staff were issued quarantine orders or evicted from rental housing by their landlords. Other resources, such as a helpline for psychological support and food catering, were also arranged to ensure staff welfare and mental well-being.

5. Staff Training and Development

The last function pertains to the staff training and competencies in pandemic measures. The Nurse Educator assumed this function by coordinating and conducting essential training to enable the nurses’ competencies in pandemic management. The Nurse Educator also participated in joint government efforts to conduct sector-specific training courses for nursing homes or healthcare professionals who might not possess the capabilities to conduct their training.

When Singapore experienced a spike in COVID-19 cases and entered the “circuit breaker” phase with a tighter set of safe distancing measures in April 2020, many training courses ceased temporarily. This courses include essential ones, such as cardiopulmonary resuscitation and personal protective equipment training. These measures prompted the nursing home to revamp its entire courseware for online delivery. The Nurse Educator worked quickly with the training department to establish an online training infrastructure —— a learning management system and web-based communication platform. At the same time, she had to convert her training materials and content swiftly into electronic format for online delivery.

6. Implication for Practice

Being the largest workforce in healthcare, nurses have played a vital frontline role in the fight against COVID-19. They have demonstrated clinical leadership by maintaining care continuity, directing pandemic efforts, and building organizational capabilities to handle the crisis. This article proposes a useful nursing pandemic structure that outlines a set of functions and measures required for managing a pandemic and can be applied to various medical emergencies and contingencies. The structure can also be used to guide the curriculum and develop core competencies in pandemic management for nurses in the long-term care sector. Nurse educators can also utilize the framework to create training materials to improve the staff's capability in handling pandemics in the future.

References

World Health Organization (WHO). Standard Precautions in Health Care; World Health Organization: Geneva, Switzerland, 2021.
Chen, P.; Yap, J.C.-H.; Hsu, L.Y.; Teo, Y.Y. COVID-19 and Singapore: From early response to circuit breaker. Ann. Acad. Med. Singap. 2020, 49, 561–572.
Peeri, N.C.; Shrestha, N.; Rahman, M.S.; Zaki, R.; Tan, Z.; Bibi, S.; Baghbanzadeh, M.; Aghamohammadi, N.; Zhang, W.; Haque, U. The SARS, MERS and novel coronavirus (COVID-19) epidemics, the newest and biggest global health threats: What lessons have we learned? Int. J. Epidemiol. 2020, 49, 717–726.
Davidson, P.M.; Szanton, S.L. Nursing homes and COVID 19: We can and should do better. J. Clin. Nurs. 2020, 29, 2758–2759.
Barnett, M.L.; Grabowski, D.C. Nursing Homes Are Ground Zero for COVID-19 Pandemic. JAMA Heal. Forum 2020, 1, e200369.
Morciano, M.; Stokes, J.; Kontopantelis, E.; Hall, I.; Turner, A.J. Excess mortality for care home residents during the first 23 weeks of the COVID-19 pandemic in England: A national cohort study. BMC Med. 2021, 19, 71.
Tan, L.F.; Seetharaman, S.K. COVID-19 outbreak in nursing homes in Singapore. J. Microbiol. Immunol. Infect. 2021, 54, 123–124.
Wong, G.H.Z.; Pang, W.S.; Yap, P. A paradigm shift in regulating and running nursing homes in Singapore. J. Am. Med. Dir. Assoc. 2014, 15, 440–444.
Tan, L.F.; Seetharaman, S. Preventing the spread of COVID 19 to nursing homes: Experience from a Singapore Geriatric Centre. J. Am. Geriatr. Soc. 2020, 68, 942.
Lai, L. All Staff, Residents at Homes for the Elderly to be Tested for Covid-19. The Straits Times, 8 May 2020. Available online: https://www.straitstimes.com/singapore/all-staff-and-residents-at-nursing-homes-to-be-tested-for-covid-19-starting-with-those-who(accessed on 1 November 2021).
Lee, C.C.M.; Thampi, S.; Lewin, B.; Lim, T.J.D.; Rippin, B.; Wong, W.H.; Agrawal, R.V. Battling COVID-19: Critical care and peri-operative healthcare resource management strategies in a tertiary academic medical centre in Singapore. Anaesthesia 2020, 75, 861–871.
Lim, W.H.; Wong, W.M. COVID-19: Notes From the Front Line, Singapore’s Primary Health Care Perspective. Ann. Fam. Med. 2020, 18, 259–261.
Mason, D.J.; Friese, C.R. Protecting Health Care Workers Against COVID-19—and Being Prepared for Future Pandemics. JAMA Health Forum 2020, 1, e200353.

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Hongli Sam Goh

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