Findings are presented according to the four implementations factors, highlighting the enablers and barriers that both managers and carers identify in relation to each factor. As managers’ differ in their assessment of implementing prevention and management measures (11% report that implementing prevention measures is not possible, while this figure reached 19% for control measures), information is are presented separately for each type of measure.
Enablers and barriers to implementation
We identify different elements within each implementation factor that could be classified as barriers or enablers to implementation (Table 1). Managers and carers share similar perceptions on these barriers and enablers, yet carers and managers provided different insights for the same implementation factor (e.g., human capital: quality and quantity). Table 1 summarizes the enablers and barriers identified in each factor, noting whether it was identified by managers (MG) or carers (CR).
Regarding the alignment of goals between the provider, intervention, and recipients, the survey shows that 80.6% and 75.0% of managers have a high degree of knowledge of the COVID-19 prevention (e.g., PPE use and disinfection) and control (e.g., setting an isolation area) measures, respectively. Most managers report that they agree or strongly agree with the prevention measures (94.6%) and control measures (97.2%) in the guidelines and protocols.
Similarly, carers perceive that interventions are important and accurate, indicating an adequate alignment between the goals of implementers and the measures proposed. Fear, uncertainty, and the burden of COVID-19 on LTCF residents, are strong incentives to adopt these measures. The fear of contracting the virus acts as an enabler to implement preventive measures. It motivates carers to implement these measures not only while at the LTCF, but also outside in public spaces or even at home:
“We are following these measures from day one, because we don’t know if there will be another outbreak. We need to do everything to protect older people and ourselves. The hardest thing is fear. Fear to be infected. Even when using the PPE [personal protective equipment]. Fear overcomes me.” (I1)
“The measures are OK. Anything to protect the grandpas is fine.” (I2)
Carers value the quick response from authorities regarding measures aimed at LTCF. They also perceive the need to contribute in the implementation of the measures; they acknowledge that it is both their and the clinical team’s responsibility to protect the residents and themselves. Carers accept the measures and implement them without questioning whether they are the most effective or efficient measures. They recognize that the measures are designed to protect older people and implement them as ordered.
“We have to believe this [the implementation of the preventive measures established in protocols] is the right way [to prevent and mitigate COVID-19].”
“We need to be careful, because we are the ones that go outside, not them [residents].” (I1)
Notwithstanding the enablers identified above, the origin of the protocols is unknown for carers, and rather seen as a top-down measure. This can act as a barrier to implementation.
“I think it was the nurse in charge of the residency who created the protocols, she made the protocol, and then she taught it to us.” (I3)
“I have no idea where they came from [the measures]. Perhaps they were done by the boss or someone else, but honestly I have no idea where they come from.” (I4)
PPE availability enables implementation. First, in terms of Personal Protective Equipment (PPE) availability, around 20% of managers perceive PPE shortage (22.4% and 25% for prevention and control measures respectively). Carers share this perception, although some carers reported problems in accessing specific items. Carers also noted an increase in resources during the pandemic:
“We have been given all the PPE we need.” (I5)
“We changed our aprons every two older adults, because there weren't that many. Now there are more supplies, and we change aprons and gloves." (I6)
Only one participant commented that the LTCF did not provide EPP and she had to pay for the equipment out of her own pocket:
“The goggles, those I had to buy them myself.” (I7)
Infrastructure was a key resource and was rarely capable to meet to the protocols’ requirements. Many of the LTCF physical configurations are difficult to adapt to a pandemic situation, as they were not designed to be adaptable to emergencies of this magnitude. Half of the managers reported that their infrastructure was inadequate to implement the measures; carers made a similar assessment:
“We didn’t have the infrastructure. As I told you, this is new for everyone.” (I3)
“In architectural terms, it is not possible to add more bathrooms.” (I5)
The survey shows that the most frequent barrier to implement the measures was staff availability for prevention (55.5%) and management measures (52.8%). Carers also identified human capital as one of the crucial issues in dealing with the pandemic and implementing the protocols. For carers, however, the critical issue is quality rather than availability. Though carers acknowledge the need to bring new staff to the LTCF, they criticize the lack of adequate training or experience among the newly recruited staff:
“They sent a lot of people, but they were not prepared to work here. They had no experience.” (I3)
Additionally, participants report a lack of technical and psychological support for carers, a key aspect for LTCF staff (WHO, 2020). Carers resent this lack of support as they struggle both with the provision of services and the pandemic on a day-to-day basis, while also dealing with their own fears, and facing the fear and the real possibility of death of the older people they care about:
“I insist. There is a lack of support—psychological, pedagogical, training—for the carers.” (I8)
In general, participants declared that the guidelines and protocols were easy to understand. Surveyed managers perceive no barriers in understanding the prevention (100%) and control (96.8%) measures. However, practically no carers reported having seen the actual protocols (only one did). Carers got the information from posters and relied on LTCF managers and the technical staff indications:
“Our boss, she is a nurse and she knows a lot. We have an advantage there. She anticipates the facts. Something like that.” (I2)
Both managers and carers valued the training. Around 60% of managers felt that staff had adequate training to implement the measures. Carers declared that training was key to know what to do. However, there can be issues with the interpretation and the emphasis on a particular mention when trainers or managers are the sole source of information for prevention and control of COVID-19. As one of the interviewer noted:
“She [carer] listed all the prevention measures but couldn’t say which was the most important (e.g. washing hands) and kept repeating others that were not in the guidelines (e.g. shoes sanitization).” (RI)
Another aspect of the technical requirements in implementing the guidelines and protocols is supervision. Carers acknowledge having received training on the protocols but highlight that there was few to null supervision on the actual implementation:
“They ask us to wash our hands, and they give us the equipment… but honestly, there is no much control.” (I5)
Trust between carers and health professionals working at the LTCF can affect the effectiveness of the intervention:
“The professionals told us there were respiratory problems… but all those were also coronavirus symptoms… we were working with infected people and we didn’t know.” (I4)
Yet, the workplace environment was generally perceived as positive. Most managers reported that the staff agreed and/or strongly agreed with the prevention (94.4%) and management (91.7%) measures. Carers described the job and their colleagues in good terms, reinforcing the idea that they felt part of a group that shared a common goal (esprit de corps):
“We work together in a good working environment; here you feel good… we are a very bonded group and we support each other...” (I9)
However, personnel turnover during the outbreaks altered the perception of this good environment generating tension between the newly recruited carers and those with a longer tenure:
“The new ones. They came here knowing nothing about this...” (I3)
“The old carer, she has years of experience and old habits. She has her own way to do the job. And she wants to impose her style, the old way, and wants to pull down the new.” (I3)
Finally, carers reported they were able to adapt their everyday life routines to the pandemic measures. However, they acknowledged that both the residents and the carers themselves struggled to comply with some of these measures. There are socio-emotional (e.g., wanting to spend time and share a space with others) as well as practical factors (e.g., barriers for communication) explaining this struggle:
“They [some residents] gather anyway. They want to have lunch together, and we have to separate them.” (I5)
“Before, we shared more time with them [residents]. If someone asked for you, you went. Now, we can only see the residents we have assigned.” (I6)
“They [residents] ask me why I’m wearing a costume. They don’t understand why we should use a mask if there is nothing wrong with them. It makes them feel bad.” (I5)
“Using the face mask was difficult, because it gives you a feeling of suffocation.” (I3).