“It’s like fighting a war with rocks”: Nursing home healthcare workers’ experiences during the COVID-19 pandemic

Sandhya Seshadri PhD, MA, MS1 , Cathleen ConcannonMPH2, Jane A. WoodsMPH3, KathrynM. McCullough RN, CCRN3 and Ghinwa K. Dumyati MD34 1School of Nursing, University of Rochester, Rochester, New York, 2Department of Neurology, University of Rochester, Rochester, New York, 3Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, New York and 4Infectious Diseases Division, University of Rochester Medical Center, Rochester, New York


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School of Nursing, University of Rochester, Rochester, New York, 2 Department of Neurology, University of Rochester, Rochester, New York, 3 Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, New York and 4 Infectious Diseases Division, University of Rochester Medical Center, Rochester, New York To the Editor-The coronavirus disease 2019  pandemic has resulted in unprecedented stress and has revealed significant vulnerabilities in nursing homes. They lack resources such as adequate staffing, 1,2 financial reserves to address unexpected expenses, and physical spaces to contain the spread of the highly contagious novel coronavirus. These shortages have impacted the care of vulnerable older adults and the physical and emotional well-being of healthcare workers (HCWs). As part of a larger study on HCW COVID-19-related risks and exposures, we interviewed 161 nursing home staff from 28 nursing homes who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The study underwent research ethics review and approval. Herein, we report on nursing home HCW experiences, and we recommend measures to better support them.
The pandemic worsened the critical problem of chronic understaffing in nursing homes 3 due to absenteeism and infected staff who were quarantined. Historically, nursing homes hired temporary nurses from agencies to manage staffing needs, but during the pandemic, some "agency nurses just bolted." Available HCWs were taxed to the limit ( Table 1, Q1 and Q2). As one physical therapist noted, "I do everything : : : I clean residents, feed them, take blood pressure-you name it." With the lack of readily available space to cohort infected residents, containing the infection has been difficult. Residents sometimes live in a facility for years, and moving them to units dedicated to the care of those infected is challenging because it entails moving all their belongings, too. Nursing homes attempted to cohort staff by color coding units as green, yellow, and red, with "green units" being free of COVID-19 residents. Due to staffing shortages, nurses "floated" from one unit to another, putting other residents at risk (Table 1, Q3 and Q4).
The acute shortage of personal protective equipment (PPE) has been disproportionately challenging for nursing homes compared to hospitals. The rise in hospitalized patients initially led to PPE guidelines being more "hospital-centric," 3 with nursing homes adapting those guidelines. For example, prior to the pandemic, most frontline nursing home HCWs did not routinely use respirators such as N95 masks. During the pandemic, nursing homes were unable to rapidly fit test their HCWs for these masks. As one certified nursing assistant (CNA) trainee said, "It [N-95 mask] was cutting into my skin and was the wrong size. But they said they only had 1 size and I had to wear it." With limited PPE supplies, HCWs were given 1 surgical mask per week, which felt "like fighting a war with rocks while the other guys [coronavirus] have guns." HCWs shared gowns, used raincoats as gowns, or wore ill-fitting gowns ( Table 1,  Q5). Additionally, the messaging around PPE use was chaotic, and protocols changed frequently (Table 1, Q6 and Q7). HCWs had limited access to PPE and needed to follow cumbersome rules for procurement, leading some HCWs to purchase masks from "beauty salons" and "grabbing 2 masks instead of 1 when no one is there." Physically stressed and emotionally vulnerable, our participants were scared to "have to go back there." During the severe acute respiratory syndrome epidemic in 2002, HCWs experienced distress due to perceived stigma and fear of contagion. 4 Lack of support and stigma contribute to distress, and those at higher risk for exposures experience greater post-traumatic stress disorder. 5 Although the foremost fear is fear of developing COVID-19 and transmitting SARS-CoV-2, 6 our participants were also afraid of not knowing how they got infected, of reinfection, and of transmitting the virus to their families (Table 1, Q8, Q9, and Q10). They felt their workplaces had failed them, and they were angered that, despite the risks, they were not protected (Table 1, Q11). They perceived disparities related to PPE when they saw nursing home administrators had N95 masks while "those in the front line [were] not protected" ( Table 1, Q12).
Although their counterparts in hospitals were regaled as heroes, nursing home HCWs felt ignored, overwhelmed, stigmatized, and underprepared to cope physically and emotionally. An LPN said, "It messes with me mentally. I am just scared that I don't know anything. I've been a nurse for 28 years and I thought I was so careful." Some were burdened by the guilt of having unknowingly transmitted the infection to their residents. With restrictions on visitors and limited staff, several HCWs experienced acute grief watching the residents they had loved die (Table 1, Q13).
Despite physical exhaustion, anxiety, anger, guilt, and grief, these HCWs were the unsung heroes who continued to serve vulnerable older adults. 3 It has been recommended that healthcare facilities prepare for pandemics by building individual and organizational resilience and by providing training and support to staff. 4 Although COVID-19 is described as an "occupational disease" for which HCWs need social and psychological support, 7 our participants felt unsupported and feared returning to work.
Nursing homes need more resources, and COVID-19 may not be the last challenge of this magnitude that we will face. Therefore, it is imperative that nursing home HCWs are supported through measures such as (1) education and training on pandemics and disaster preparedness, (2) easy access and clear communication on infection control and appropriate use of PPE, (3) systems to cope physically under such circumstances such as rest breaks, and (4) systems to cope emotionally such as training on caring for the dying, and grief counseling to cope with death. With the continuous rise in the number of vulnerable older adults needing longterm care and the decrease in staff willing and needed to care for them, these measures may no longer be optional.