Demographic profile - staff survey
Seventy-six people who work in residential care settings for older people took part in the survey. The profile of the sample was as follows, manager/person in charge (PIC) (n = 22), owners/PIC (n = 5), owner & manager (n = 1), and staff members (n = 49). The profile of the staff members who completed the survey was as follows, nurse managers (n = 12), staff nurses (n = 10), student nurses (n = 2), health care attendants (n = 11), 5 were categorised as other (this included CNS, Intern nurse and clinical advisor), cleaning and catering (n = 2) and administrator (n = 1).
The health care facilities who responded were as follows - HSE facilities (n = 34, 49%) privately owned facilities (n = 30, 43%) and other types of facilities i.e., Sect. 38 and voluntary (n = 5, 7%).
Geographically most of these facilities were based in Dublin (n = 47, 67%), 13 other counties (Cavan, Cork, Donegal, Kerry, Kildare, Laois, Limerick, Louth, Mayo, Meath, Waterford, Westmeath and Wexford) in the Republic of Ireland were also represented. There are 576 facilities in Ireland (meaning we heard from 1 in 7.5 residential settings). Forty-five of the respondents said they worked at a multi-site facility. Almost 70% of staff had worked at their facility for over 2 years.
Residents/family members
Twenty-eight family members completed the online survey (15 daughters, 3 sons, 1 husband, 1 wife, 1 sister, 3 nieces, 2 granddaughters, 2 daughter-in-law). Two residents completed the survey. Five of the family members/residents were from a Health Service Executive (HSE) facility, 20 of them were from a privately owned facility and the remainder said other facilities (such as supported housing, and voluntary facilities). Just over half of the sample was Dublin based (55.5%) with respondents also from the following Counties - Clare, Cork, Donegal, Kildare, Kilkenny, Limerick, Offaly, Westmeath and Wexford. Eight of the respondents had lived at their facility for over 2 years, 11 of them had lived there between 13–24 months, and the other had lived there for between 6–12 months. 56% of the respondents said that COVID-19 had infected residents at their facility.
Qualitative interviews
Eleven one-to-one semi-structured interviews with family members were conducted remotely during December 2020. 8 females and 2 males consented to be interviewed regarding their experience of their family members care in residential facilities during the first wave of the pandemic. One participant was interviewed twice by two different researchers regarding her experience of care at both her mothers and her aunts residential care facilities. There was a mix of HSE and private run residential care facilities reported across the 11 interviews in Dublin and in other parts of the country. Two of the participants identified that their family members had died during the pandemic, one of which was due to COVID-19. No residents took part in the interviews.
Main findings
The main findings emerging from the study were integrated and are presented below.
Being prepared
Being adequately prepared to contend with the effects of the pandemic was regarded as essential by the majority of research participants. This meant good infection prevention and control protocols, sufficient and timely preparation and training, good management and governance structures, isolation and infection control resources, adequate staffing and access to medical expertise and support. One participant said
“I have a few nurses as friends and their friends are in charge of nursing homes – small ones that never got COVID. The only reason it never got COVID was that it was managed well. The same in anything. If something is managed well from the top, it will pass down through every level and the people they employ. They employ people that actually care.” (Participant 3)
The percentages of staff who perceived their service as well prepared or ill prepared were roughly equal. Among those who identified a lack of preparedness, many staff and family respondents attributed the lack of COVID − 19 preparation to poor management and leadership, for example not having a pandemic plan/protocols, slow implementation of infection control measures/government guidelines e.g. visitor/staff movement restrictions and Personal Protective Equipment (PPE) training/provision. Fundamental governance issues were raised, for example; lack of communication with staff, lack of teamwork, low staff/patient ratios, high staff turnover, high levels of junior/ inexperienced/agency staff. The main reasons cited by staff as to why their facility was adequately prepared/not adequately prepared for the pandemic are captured in Figs. 1 and 2 below.
Disease spread, mortality and morbidity
Staff identified a higher level of spread and number of clusters occurring in state funded facilities. Some respondents felt that years of under-investment in state facilities had led to residents sharing bedrooms, poorly ventilated common areas which has both facilitated viral spread. Other felt that the transfer of infected patients from the acute hospital sector and movement of staff across different sites had resulted in increased virus spread. A high proportion of staff and family carers believed that the rate of infection could have been reduced by more effective/diligent infection control measures. Family members felt strongly that the residential care homes had not provided clear guidance regarding COVID-19 infection prevention and control protocols to their staff and that staff were not clear on how to use PPE;
“They still hadn’t spoken to the staff about a uniform approach to handling people in a close situation, like mask wearing. They were doing it only for people with COVID, but it was the same staff dealing with non-COVID. It was very confusing. I think there were a lot of things that as director and head of nursing both of them should have taken a better hand. I think they were just coping with the fact that they didn’t have enough staff and they were trying not to put a lot of pressure on the staff they had remaining.” (Participant 7)
Advanced age and poor physical and mental health was cited as increased risk factors for higher morbidity/mortality among residents. Family members believed that residents who did not have family members to advocate for them were at higher risk during the pandemic.
Gaps in the service that are normally managed by visiting family members/ friends were highlighted. For example, my mother, who has limited mobility, spent several weeks in her room in isolation. Requests to be taken out to the gardens were often not met as staff were busy with family Skype calls
Inadequate access to medical support and expertise were also cited as reasons contributing to the spread of the virus at the facility. A third of staff surveyed reported that more could have been done to reduce the number of deaths that occurred. Some respondents felt that low paid healthcare staff living together in their shared accommodation resulted in limited/no opportunity to self-isolate.
Figure 3 below illustrates the main factors cited by staff as contributing to virus spread at their facility.
Comparisons between state and private provision of elder residential care during COVID-19
There was a marked variation in the perceived level of preparedness between state run and private facilities. Staff in private facilities reported higher standards of accommodation (space and single rooms), staff training, infection control practices and governance structures. However, a deficit in medical support and clinical leadership in private care facilities was a limiting factor.
Higher rates of clusters occurred in state facilities compared with privately run facilities, attributed mainly to congregated, unsegregated, poorly ventilated areas, frequent movement of staff and patients through various care units and poor uncoordinated governance in state provided facilities. A family member described the infrastructure of their family members residential setting;
“The home is a small community hospital. 14 permanent residents and 14 respite care. It is 28. Half of those roughly are standalone wards, single bedded small rooms, and the other half are two person bedrooms...They didn’t have a room per se that you could bring people in, visitors, and things like shared toilets. Structural deficits came home to roost during the COVID time and put extra challenges on the establishment. Not having en suite bathrooms, things like that. I don’t know how they would have coped in terms of isolation rooms. They maybe had one room.” (Participant 1)
However, it was evident that residents had better access to medical care, physiotherapy and occupational therapy/psychosocial supports in state run care than in private facilities.
Our findings showed that there was a perception of higher staffing levels in private facilities but analysis of the staff survey data showed no statistical differences across the numbers of registered nurses or Health Care Attendants (HCAs). Twenty-five of the facilities reported that the state had provided them with additional staff and that this was most welcome.
Impacts on residents
Mental health/social health
Staff reported that at least one third of residents were confined to their own room without company during the first wave of the pandemic. Although psychosocial services (occupational therapy, pastoral/spiritual care) were maintained in some settings, for many residents, these activities were suspended for wave one of the pandemic. Staff observed many adverse psychosocial impacts for residents and families, the most significant issue being that they were unable to see their loved ones during the pandemic. This resulted in loneliness and lack/loss of connection. Staff and family members reported that the majority of residents (98%) could connect remotely with their family members during the pandemic using mobile phones/smartphones for video calls, window visits and brief visitations in the garden or other outside areas of the facility. However, this apparent high level of remote connectedness was deemed to be of poor quality and unreliable by many family participants in the qualitative interviews. Family members placed great emphasis on the need to maintain direct contact with residents and felt that staff had prioritised the public health imperative over the psychological and emotional needs of residents and families and that their relational needs for human connection of residents were not adequately recognised or supported by staff.
“the whole situation is really worrying, it’s really unsatisfactory, the social isolation, the lack of movement, the lack of activities. I asked again when I was on with the CEO, “Can we pay more money? Can we give voluntary contributions to try and bring people in to try and get people? Can you please encourage mum to walk? Can you encourage mum to go down to the lounge?” Participant 5
The interviews with families starkly demonstrated the impact of the visiting restrictions on connectedness with family members; not having the opportunity to see loved ones for long periods of time, grandchildren not being able to hold hands, challenges to maintaining meaningful relationships/intimacy. Speaking through Perspex or glass or using technology was identified as less than ideal, especially when residents were trying to communicate their fears of contracting COVID-19 knowing that other residents had died of the virus; anxiety about loneliness and isolation and fears of dying without their loved ones near. The cognitive and expressive abilities of residents were an important determinant of the success of remote visits and hearing and vision also played a role in this regard. The weather was also a deterrent to the quality of the connectedness especially if family members had to be in outside areas of the facility with no shelter. Many staff and family participants observed a decline in residents’ mental health and attributed this directly to the visiting restrictions imposed at the time.
“They keep saying, ‘She’s alright. She’s there, she’s safe.’ I said, ‘Absolutely not.’ My mother was used to seeing us all, and there is no way, now. Even if it comes back, and we are going to be allowed, whatever it was, one half an hour once a week, I said, ‘I am not prepared to accept that.’ I will be still up at the door the rest of the week, to talk through a door at her. She needs it.” Participant 2.
Physical health
Staff and family members and families reported that the usual care of patients who did not contract COVID-19 was reduced or neglected during the period of the pandemic. It was clear from the interviews with family members that in the majority of cases overall health and wellbeing of residents deteriorated during the COVID-19 restrictions, more that they would have expected over that period in “normal times”. While there was an acknowledgement that physical decline was to be expected in residents due to their age and pre-existing morbidity, participants described a marked and acute decline in their loved one’s physical health during the COVID-restrictions which some found shocking and distressing. The prevailing description of physical decline related to weight loss, however other issues such as reducing mobility, pressure sores, dehydration, and generally the observation of an unkempt appearance were also described. This impacted on residents’ physical and mental health and was very upsetting for family members.
“I could not believe what I saw. My mum had lost a lot of weight in that month; she was grey, drawn, she had weeping eyes, and her lips were all desiccated; very, very dry, dehydration. And I was really taken aback. I was thinking “God, how did she go downhill this quickly?” Participant 7
Some felt the responsibility lay directly with the staff caring for the resident. Staff cited reasons for the deterioration in care provision as resulting from staff shortages and lack of availability of medical interventions. Staff were distressed that they were unable to meet the palliative care needs of patients during the pandemic. Figure 4 below illustrates the impacts on residents as reported in the staff surveys.
Impacts on family members
Family members felt the impact of the pandemic on behalf of residents and themselves. Common emotional responses included fear, distress, anxiety, loneliness, helplessness, frustration and some participants experienced physical challenges such as being outside in all weathers trying to communicate via a window. A strong theme which emerged was the disruption to their customary caregiving role.
“we used to feed her. We would go up with the night time food. We would know what we would give her. She couldn’t feed herself that well. You would have to be very patient and stay with her till she finished it. If she was left to eat it by herself, she probably wouldn’t do it.” Participant 3
The large extent to which family members had hitherto provided direct care, and the importance of this direct care to their loved one became apparent during the pandemic. The majority of families did not perceive themselves to be visitors, but regarded themselves as continuing in their care giver role in the residential environment. Therefore, the visiting restrictions caused huge frustration to family members and their inability to be directly involved in providing care to their loved one during the period of visiting restrictions was described by many as a contributing factor for the physical decline of the resident. This anger and frustration was amplified when families observed the mental and physical deterioration of their loved ones through lack of caring resources, yet, due to public health concerns and government restrictions, they were prevented from intervening and providing this much needed care.
“I don’t hold that in any way against any of the staff there. They are doing their utmost. But I do feel, yes, she wasn’t… She can’t possibly be getting the stimulation that she would have been getting from our family going into her... every night, she had at least two members of the family with her for two or three hours. So, obviously, that all was stopped. Absolutely, she went downhill from there.” Participant 2
A family member who completed the survey added the following comments in the open text boxes which supports this theme also
“Gaps in the service that are normally managed by visiting family members/ friends were highlighted. For example, my mother, who has limited mobility, spent several weeks in her room in isolation. Requests to be taken out to the gardens were often not met as staff were busy with family Skype calls or latterly family visits. Seemingly minor issues such as having the batteries in a TV remote control replaced took weeks and several phone calls. While not critical in terms of a global pandemic, being unable to change the channel or adjust the volume of a TV is unnecessary mental hardship. Similarly, it takes several calls to ensure that the radio is not unplugged”.
Staffing levels
Multiple issues relating to staffing were highlighted, including low staff-to-patient ratios, due to staff shortages arising from self-isolating, illness, redeployment and not showing up for work. One site reported that there were only two healthcare assistant (HCA) staff to thirty residents some days during the pandemic. A family member at interview noted that
“when you don’t have enough staff, people get neglected.… What I would worry about is that they are not even registered as COVID deaths, but they are COVID related in a way because if you don’t have the staff, you can’t take care of people to the level. I can say just looking, observing mum not as mum but as a body, that was a neglected elderly person.” (Participant 7)
Other staffing issues of concern included high turnovers, too few senior staff, staff who lacked the specific skills required, as well as too many agency staff. Family members highlighted the need for a more stable staffing structure which would ensure familiarity with the facility and the resident’s individual needs and wishes. These deficits were of major concern to the majority of family members interviewed.
“There was no staff there, which meant the staff from the other floors had to go up. That is how it happened. Staff from other floors had to cover for the floor that was empty. That is how I reckon it spread. It was on every floor.” (Participant 3)
Because of the visiting restrictions, many care interventions customarily performed by families/visitors e.g. help with eating, hygiene and mobilising were now reduced or absent. This was a major source of distress to family members.
I don’t think they should have shut off families. I don’t think the lockdown should have… I think we should have been part of the testing. If the carers can go in and be tested routinely, they could have nominated a family member to do the same. I know it would cost, and all of that, but they shouldn’t have let go of the care that the family were giving. We are part of it, instead of shutting us out of it.” (Participant 4)
The lack of medical and ancillary/ psychosocial support interventions put additional pressure on staff workloads. However, the state provision of some additional staff during this period was welcomed and staff participants reported that the redeployment of student nurses as HCAs really helped to ease the burden. Many family participants praised the work of the facility staff who they perceived as committed and working to the best of their abilities to keep residents safe in a confusing and stressful context. Staff distress, emotional and physical exhaustion was observed by residents’ family members and reported in their interviews. These reports were accompanied by a high level of concern and care for the wellbeing of staff.
“They are doing their utmost...We keep talking about mentally, and I can see it. I can see it, as plain as the nose on my face. I can see that the staff are burnt out. I would be too, if I was in there. They are doing their level best, but they are burnt out.” (Participant 2)
Numerous respondents felt that HIQA needed to be more involved and could have helped on the front line. Others felt that additional Allied Health Professional deployment of social workers, occupational therapists, physiotherapists etc to support frontline nursing staff and Health Care Attendants (HCAs) should have taken place.
Impacts on staff
The staff survey showed that staff had many concerns and challenges during the pandemic. The most frequently reported adverse impact was the level of stress and burnout experienced. This was followed by concerns about virus transmission, trauma and fear about death of residents and self. Many alluded to the personal toll it had taken on them. This ranged from information overload, to physical and mental exhaustion, to supporting their peers and covering for colleagues while off sick in addition to managing their own fears. Maintaining work life balance was very difficult for staff. It was evident that the majority of staff had put the needs, fears and concerns of residents above their own needs, fears and concerns. Many staff expressed their distress at witnessing the impact of the virus on vulnerable people who were traumatized, alone and fearful. Others were angry and distressed about the numbers of care staff who contracted the virus and felt unsupported and that their well-being and safety had not been valued or protected. Some staff felt traumatised; perceiving that it would take them years to process and recover from the direct and indirect/occupational impact of COVID-19.
I can see it, as plain as the nose on my face. I can see that the staff are burnt out. I would be too, if I was in there. They are doing their level best, but they are burnt out. Here we go with the second wave.” (Participant 2).
The impacts on staff as captured in the staff survey are illustrated in Fig. 4.
Trust and responsibility/blame
Most staff perceived that the virus itself was responsible for the morbidity and mortality rates among residents and that the age and vulnerability of residents made them more vulnerable. Some expressed anger about what they regarded was the slow governmental response in their sector. Many staff felt that government agencies did not prioritise the health and safety of residents and staff, particularly in wave one and this caused huge anger and distress. Staff placed trust in their own services in which they worked and the majority (89%) said they would trust their facility to provide safe care for residents in the event of future waves. There was no statistical difference between state and private care in the level of trust expressed.
Family members questioned the role of the relevant government agencies and the priority and pace of the response in this sector. Several family members likened the experience of the residents to being ‘prisoners’ with no rights and no freedom. One family member noted; “that there had been more public disquiet about the closing of pubs than there had been about the fatality rates in nursing homes”.
Others referred to the limited time that residents have left in their lives and that infection prevention and control measures need to be balanced with quality of life and time remaining to be spent with their loved ones. It was articulated that facilities with good leadership/management/governance prior to the pandemic fared better than with those with obvious poor performances prior to it. Nonetheless, a high percentage of family members said they would trust their facility to provide safe care for residents in the event of future waves of the COVID-19 pandemic. Figure 5 below illustrates where staff felt responsibility for the deaths at their residential centres lies.
Role of the media
While media reports were regarded as important in highlighting the issues in residential care in relation to the rapid viral spread and the need for prompt intervention, some staff and families were distressed at the level of media sensationalization and blaming. These headlines of failures and fatalities caused distress to residents and families and made some staff feel ashamed and embarrassed by where they worked. Significantly, in this context of blame and shame, a small number of participants in our study reported that attempts were made to hide the fact that the virus was in their facility and that it would have been better to have “told the truth” earlier.
Priorities for future waves
Priorities include support in securing PPE, less movement of staff and patients, earlier visiting restrictions, rapid access to testing, more local accountability and better support from government agencies. Some additional responses included the need for a higher profile of the impact of the virus on nursing homes in the media and earlier provision of appropriate accommodation for low paid care staff. In relation to visiting restrictions, and in contrast to the findings of the staff surveys, family members who were interviewed placed much greater emphasis on the need to maintain some direct contact with their loved one.