A New Age of Health Promotion: The Use of Digital Infographics in Nursing Education.

ABSTRACT: The COVID-19 pandemic has shifted how nursing education and information are delivered, with many classes being moved to an online platform. This opened opportunities to find creative ways to engage students. As a result, an entirely online infographic assignment for final-year baccalaureate nursing students was created. The focus of this assignment was to engage students to identify important health issues, consider multilevel solutions, and communicate information to relevant stakeholders using visual storytelling for maximum impact.

"We've All Lost So Much": The Long-Term Care Home Experiences of Essential Family Caregivers During COVID-19.

BACKGROUND: During the coronavirus (COVID-19) pandemic, long-term care homes (LTCHs) imposed visitor restrictions that prevented essential family caregivers (EFCs) from entering the homes. Under these policies, EFCs had to engage in virtual, window, and outdoor visits, prior to the re-initiation of indoor visits. OBJECTIVE: To understand EFCs' visitation experiences with LTCH residents during COVID-19. METHODS: Seven virtual focus groups with EFCs were conducted and analysed using a thematic approach. FINDINGS: Six themes were identified: (a) inconsistent and poor communication; (b) lack of staffing and resources; (c) increasing discord between EFCs and staff during COVID-19; (d) shock related to reunification; (e) lack of a person-centred or family-centred approach; and, (f) EFC and resident relationships as collateral damage. DISCUSSION: Our findings reflect how EFCs' visitation experiences were affected by factors at the individual, LTCH, and health-system levels. Future sectoral responses and visitation guidelines should recognize EFCs as an integral part of the care team.

Explainable Machine Learning Model to Predict COVID-19 Severity Among Older Adults in the Province of Quebec.

Context: Patients over the age of 65 years are more likely to experience higher severity and mortality rates than other populations from COVID-19. Clinicians need assistance in supporting their decisions regarding the management of these patients. Artificial Intelligence (AI) can help with this regard. However, the lack of explainability-defined as "the ability to understand and evaluate the internal mechanism of the algorithm/computational process in human terms"-of AI is one of the major challenges to its application in health care. We know little about application of explainable AI (XAI) in health care. Objective: In this study, we aimed to evaluate the feasibility of the development of explainable machine learning models to predict COVID-19 severity among older adults. Design: Quantitative machine learning methods. Setting: Long-term care facilities within the province of Quebec. Participants: Patients 65 years and older presented to the hospitals who had a positive polymerase chain reaction test for COVID-19. Intervention: We used XAI-specific methods (e.g., EBM), machine learning methods (i.e., random forest, deep forest, and XGBoost), as well as explainable approaches such as LIME, SHAP, PIMP, and anchor with the mentioned machine learning methods. Outcome measures: Classification accuracy and area under the receiver operating characteristic curve (AUC). Results: The age distribution of the patients (n=986, 54.6% male) was 84.5□19.5 years. The best-performing models (and their performance) were as follows. Deep forest using XAI agnostic methods LIME (97.36% AUC, 91.65 ACC), Anchor (97.36% AUC, 91.65 ACC), and PIMP (96.93% AUC, 91.65 ACC). We found alignment with the identified reasoning of our models' predictions and clinical studies' findings-about the correlation of different variables such as diabetes and dementia, and the severity of COVID-19 in this population. Conclusions: The use of explainable machine learning models, to predict the severity of COVID-19 among older adults is feasible. We obtained a high-performance level as well as explainability in the prediction of COVID-19 severity in this population. Further studies are required to integrate these models into a decision support system to facilitate the management of diseases such as COVID-19 for (primary) health care providers and evaluate their usability among them.

"It's the worst thing I've ever been put through in my life": the trauma experienced by essential family caregivers of loved ones in long-term care during the COVID-19 pandemic in Canada.

BACKGROUND: Essential family caregivers (EFCs) of relatives living in long-term care homes (LTCHs) experienced restricted access to their relatives due to COVID-19 visitation policies. Residents' experiences of separation have been widely documented; yet, few have focused on EFCs' traumatic experiences during the pandemic. Objective: This study aims to explore the EFCs' trauma of being locked out of LTCHs and unable to visit their loved ones in-person during COVID-19. METHODS: Seven online focus groups with a total of 30 EFCs from Ontario and British Columbia, Canada were conducted as part of a larger mixed-method study. We used an inductive approach to thematic analysis to understand the lived experiences of trauma. RESULTS: Four trauma-related themes emerged: 1) trauma from prolonged separation from loved ones; 2) trauma from uncompassionate interactions with the LTCH's staff and administrators; 3) trauma from the inability to provide care to loved ones, and 4) trauma from experiencing prolonged powerlessness and helplessness. DISCUSSION: The EFCs experienced a collective trauma that deeply impacted their relationships with their relatives as well as their perception of the LTC system. Experiences endured by EFCs highlighted policy and practice changes, including the need for trauma-centred approaches to repair relational damage and post-pandemic decision-making that collaborates with EFCs.

Who's in the House? Staffing in Long-Term Care Homes Before and During COVID-19 Pandemic.

Critical gaps exist in our knowledge on how best to provide quality person-centered care to long-term care (LTC) home residents which is closely tied to not knowing what the ideal staff is complement in the home. A survey was created on staffing in LTC homes before and during the COVID-19 pandemic to determine how the staff complement changed. Perspectives were garnered from researchers, clinicians, and policy experts in eight countries and the data provides a first approximation of staffing before and during the pandemic. Five broad categories of staff working in LTC homes were as follows: (1) those responsible for personal and support care, (2) nursing care, (3) medical care, (4) rehabilitation and recreational care, and (5) others. There is limited availability of data related to measuring staff complement in the home and those with similar roles had different titles making it difficult to compare between countries. Nevertheless, the survey results highlight that some categories of staff were either absent or deemed non-essential during the pandemic. We require standardized high-quality workforce data to design better decision-making tools for staffing and planning, which are in line with the complex care needs of the residents and prevent precarious work conditions for staff.

Poor and Lost Connections: Essential Family Caregivers' Experiences Using Technology with Family Living in Long-Term Care Homes during COVID-19.

Background: Long-term care homes (LTCHs) restricted essential family caregivers' (EFCs) visitations during COVID-19, and virtual visits using technology were used. Objective: To understand EFCs' virtual visitations experiences during COVID-19 in two Canadian provinces. Methods: Seven focus groups were conducted with EFCs. Thematic analysis was used to identify themes at micro, meso, and macro levels. Results: Four themes were found: 1) a lack of technology and infrastructure; 2) barriers to scheduling visitations; 3) unsuitable technology implementation; and 4) inability of technology to adapt to residents' needs. Discussion: Virtual visitations showcased a confluence of micro, meso, and macro factors that, in some cases, negatively impacted the EFCs, residents, and the relationship between EFCs and residents. Structural and home inequities within and beyond the LTCH impacted the quality of technology-based visitations, underscoring the need to support technology infrastructure and training to ensure residents are able to maintain relationships during visitation bans. Conclusion: EFCs' experiences of technology-based visitations were impacted by structural vulnerabilities of the LTCH sector.

Development and dissemination of an ethical guidance and person-centred isolation care planning tool to support the care of people with dementia during the COVID-19 pandemic.

BACKGROUND: Long-term care (LTC) residents have been disproportionately impacted by the COVID-19 pandemic, both from the virus itself and the restrictions in effect for infection prevention and control. Many barriers exist in LTC to prevent the effective isolation of suspect or confirmed COVID-19 cases. Furthermore, these measures have a severe impact on the well-being of LTC residents. Our aim was to develop a guide for long-term care to address the ethical challenges associated with isolating dementia patients during the pandemic. The Dementia Isolation Toolkit (DIT) was developed by members of the research team in partnership with LTC stakeholders to address: 1) the practical challenges of isolating or quarantining people with dementia in a compassionate, safe, and effective manner; and 2) the need for ethical guidance to support decision-making regarding isolation and infection control in LTC, to prevent indecision and moral distress. To develop the DIT the team reviewed and synthesized the literature on pandemic ethics in a plain-language document, which was then reviewed by our partners and stakeholders. The final ethical guidance tool includes a discussion of the ethics around infection control measures in a pandemic, an ethical decision-making tool, and a person-centred isolation care planning tool. The ethical guidance tool has been downloaded more than 6500 times since it was published (bit.ly/dementiatoolkit), and has been disseminated internationally. The worksheets are being used during outbreaks to support care and decision-making, as well as proactively, to prepare for outbreaks by developing isolation care plans. There is a need for support for ethical decision-making in the context of a pandemic, particularly in settings such as LTC. Future studies will evaluate the implementation of the tool and its impact in addressing moral distress in health care providers in long-term care.

Laying Down the Groundwork for an International Measurement Infrastructure

The COVID-19 epidemic has brought to light the significant problems in the long-term care (LTC) sector, specifically the lack of an infrastructure to collect and aggregate data between LTC sectors in different countries. This talk will briefly describe goals of the WE-THRIVE initiative, and focus on exploring the development of “workforce and staffing” common data elements for LTC. We will describe how the subgroup is “laying down the groundwork” within this domain with various methodologies to develop CDEs related to workforce and staffing. The CDEs aim to measure staff retention and turnover, evaluating nursing supervisor effectiveness, and staff training in LTC. Anticipated challenges of this international work will also be highlighted. International research on LTC can valuably inform LTC policy and practice, and the proposed CDEs can facilitate data sharing and aggregation internationally, including low-, middle-, and high-income countries.

Who’s in the House: Staffing in Long-Term Care Homes During the COVID-19 Pandemic

There is an absence of high-quality workforce data that could be used globally for comparative research on workforce planning in the residential long-term care (LTC) sector. We know that older adults residing in the LTC settings have multimorbidities resulting in complex care needs, yet the workforce is insufficiently able to meet their needs. A further reduction in LTC workforce was noted during the COVID-19 pandemic which increased the risk of adverse outcomes for residents. Survey results focused on the workforce in LTC homes collected from several countries during the current pandemic, highlighted that several members of the workforce were either absent or worked virtually (e.g., physicians, social workers). A better understanding of who is/or should be in the house to meet the needs of residents during or after future pandemics requires a workforce data system that routinely collects this information to ensure best quality outcomes for residents and their carers.

“We’ve all Lost so Much”: The Experiences of Essential Family Caregivers’ Long Term Care Visitations During COVID-19

Family caregivers are integral to the care of long-term care (LTC) residents. COVID-19 public health policies initially restricted all essential caregivers from visiting LTC homes. In lieu of in-person visitations, caregivers were allowed technology-based visits then restrictive outdoor visits, followed by indoor visitations. This study aims to illuminate the experiences of essential caregivers’ as they visited their loved ones in LTC during COVID-19’s restrictive policies. We conducted seven caregiver focus groups (N=30) from Ontario and British Columbia, Canada. Thematic analysis and line-by-line coding were completed using NVivo. We found six themes that were common to all the visitation types: 1) “LTC Home disorganization” to facilitate visits and poor communication;2) “Lack of staffing and resources”;3) “Mistreatment from staff and management” as caregivers were seen as inconveniences;4) “Shock and disbelief” when family members first saw their loved ones;5) “Significant lack of person-centered or family-centered ethos” for example the residents’ needs were ignored such that their cognitive and physical impairments sometimes made visitations impossible, as well as the burden of multiple weekly COVID-19 tests;and, 6) “Collateral damage” in the form of trauma and irreparable harm to the relationships between residents and families. These results emphasized caregivers who ultimately felt betrayed and ignored by the broader healthcare system. Our findings provide an in-depth understanding of how COVID-19 public health policies have impacted the essential caregivers and the long-lasting impacts on residents and caregivers alike. Understanding caregiver’s experiences can inform future pandemic response policies and encourage more person-centered protocols.

Person-centred infection prevention and control during a pandemic: The Dementia Isolation Toolkit

Objectives:People working in long-term care homes (LTCH) face ethical dilemmas about how to minimize the risk of spread of COVID-19, while also minimizing psychological hardship and other harms of infection control measures on residents. The Dementia Isolation Toolkit (www.dementiaisolationtoolkit.com;DIT) was developed to address the gap in ethical guidance for LTCH on how to safely and effectively isolate people with dementia while supporting the personhood and well-being of residents. In this presentation, we will present the DIT and report on the results of a survey of LTCH staff in Ontario, Canada on their experiences isolating residents in LTCH and the use of the DIT in supporting person-centred isolation care.Methods:A link to an online survey was distributed to LTCH staff through provincial organizations and agencies as well as through social media and the DIT website. Inclusion criteria were LTCH staff working on-site at a LTCH since March 1, 2020, who had direct or indirect experience with the isolation/quarantine of LTCH residents. Results were summarized descriptively.Results:A broad sample of LTCH staff (n=207) participated in the survey, most of whom had experienced an outbreak in their LTCH. Dementia (96%) was the most important barrier to implementation of infection control measures in LTCH, followed by staff distress about the effects of isolation on residents (61%). Important facilitators for isolation included delivery of 1:1 activities in the resident’s room (81%) and designating essential caregivers to provide support (67%), while inadequate staffing levels were reported as a barrier (55%). 65% of respondents indicated some familiarity with the DIT, and of those who had used the toolkit, 62% found it helpful in supporting isolation care, particularly in developing care plans and making and communicating decisions. Of those who had used the DIT, 48% found it fairly or very helpful at reducing their level of distress.Conclusions:Isolation as an infection control and prevention (ICP) measure in LTCH environments can be harmful to residents and create moral distress in staff. ICP guidance and support of LTCH needs to address how to minimize these harms by providing dementia-specific guidance such as in the DIT.

A multicenter study of short-term changes in mental health emergency services use during lockdown in Kitchener-Waterloo, Ontario during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic and subsequent lockdown measures have led to increasing mental health concerns in the general population. We aimed to assess the short-term impact of the pandemic lockdown on mental health emergency services use in the Kitchener-Waterloo region of Ontario, Canada. METHODS: We conducted an observational study during the 6-month period between March 5 and September 5, 2020 using National Ambulatory Care Reporting System metadata from mental health visits to three regional Emergency Departments (ED); mental health and substance related police calls; and calls to a regional mental health crisis telephone line, comparing volumes during the pandemic lockdown with the same period in 2019. Quasi-Poisson regressions were used to determine significant differences between numbers of each visit or call type during the lockdown period versus the previous year. Significant changes in ED visits, mental health diagnoses, police responses, and calls to the crisis line from March 5 to September 5, 2020 were examined using changepoint analyses. RESULTS: Involuntary admissions, substance related visits, mood related visits, situational crisis visits, and self-harm related mental health visits to the EDs were significantly reduced during the lockdown period compared to the year before. Psychosis-related and alcohol-related visits were not significantly reduced. Among police calls, suicide attempts were significantly decreased during the period of lockdown, but intoxication, assault, and domestic disputes were not significantly different. Mental health crisis telephone calls were significantly decreased during the lockdown period. There was a significant increase in weekly mental health diagnoses starting in the week of July 12 - July 18. There was a significant increase in crisis calls starting in the week of May 31 - June 6, the same week that many guidelines, such as gathering restrictions, were eased. There was a significant increase in weekly police responses starting in the week of June 14 - June 20. CONCLUSIONS: Contrary to our hypothesis, the decrease in most types of mental health ED visits, mental health and substance-related police calls, and mental health crisis calls largely mirrored the overall decline in emergency services usage during the lockdown period. This finding is unexpected in the context of increased attention to acutely deteriorating mental health during the COVID-19 pandemic.

Technology Recommendations to Support Person-Centered Care in Long-Term Care Homes during the COVID-19 Pandemic and Beyond.

The COVID-19 pandemic has exposed persistent inequities in the long-term care sector and brought strict social/physical distancing distancing and public health quarantine guidelines that inadvertently put long-term care residents at risk for social isolation and loneliness. Virtual communication and technologies have come to the forefront as the primary mode for residents to maintain connections with their loved ones and the outside world; yet, many long-term care homes do not have the technological capabilities to support modern day technologies. There is an urgent need to replace antiquated technological infrastructures to enable person-centered care and prevent potentially irreversible cognitive and psychological declines by ensuring residents are able to maintain important relationships with their family and friends. To this end, we provide five technological recommendations to support the ethos of person-centered care in residential long-term care homes during the pandemic and  in a post-COVID-19 pandemic world.

The Impact of COVID-19 on Social Isolation in Long-term Care Homes: Perspectives of Policies and Strategies from Six Countries.

Preventing the spread of COVID-19 in long-term care homes is critical for the health of residents who live in these institutions. As a result, broad policies restricting visits to these facilities were put in place internationally. While well meaning, these policies have exacerbated the ongoing social isolation crisis present in long-term care homes prior to the COVID-19 pandemic. This perspective highlights the dominant COVID-19 LTC policies from six countries, and proposes five strategies to address or mitigate social isolation during the COVID-19 pandemic that can also be applied in a post-pandemic world.

Factors Influencing Nurse Assistants' Job Satisfaction in Nursing Homes in Canada and Spain: A Comparison of Two Cross-Sectional Observational Studies.

OBJECTIVES: To access associations between job satisfaction and supervisory support as moderated by stress. METHODS: For this cross-sectional study, data collected from 591 nursing assistants in 42 nursing homes in Canada and Spain were analyzed with mixed-effects regression. RESULTS: In both countries, stress related to residents' behaviors was negatively associated with job satisfaction, and, in Canada, it moderated the positive association between supervisory support and job satisfaction. Stress related to family conflict issues moderated the positive association of supervisory support and job satisfaction differently in each location: in Canada, greater stress was associated with a weaker association between supervisory support and job satisfaction; in Spain, this was also observed but only when supervisory support was sufficiently weak. DISCUSSION: Stress was associated with lower job satisfaction and moderated the association of supervisory support and job satisfaction, reinforcing the importance of supervisors supporting nursing assistants, especially during the COVID-19 pandemic.