In Their Own Words: The Challenges Experienced by Certified Nursing Assistants and Administrators During the COVID-19 Pandemic.

This qualitative study aimed to provide an in-depth understanding of the challenges experienced by certified nursing assistants and administrators during the unprecedented COVID-19 crisis. We conducted 6 administrator interviews and 10 remote focus groups with day and evening CNAs at 5 nursing homes (N = 56) in downstate New York. Content analysis was conducted, and emerging themes were identified across sites and roles. Results showed numerous challenges for both CNAs and administrators including many that were personal. These personal challenges included feeling helpless, anxious, or fearful; experience of COVID illness; and balancing high concurrent demands of work and family. There were also many operational challenges such as a lack of COVID testing capacity, information, and consistent guidance and support, staffing and equipment. Understanding these challenges can facilitate goals to promote future safety, skill refinement, and enhanced resilience in the workforce.

Perspectives of certified nursing assistants and administrators on staffing the nursing home frontline during the COVID-19 pandemic.

OBJECTIVE: To identify best practices to support and grow the frontline nursing home workforce based on the lived experience of certified nursing assistants (CNAs) and administrators during COVID-19. STUDY SETTING: Primary data collection with CNAs and administrators in six New York metro area nursing homes during fall 2020. STUDY DESIGN: Semi-structured interviews and focus groups exploring staffing challenges during COVID-19, strategies used to address them, and recommendations moving forward. DATA COLLECTION: We conducted interviews with 6 administrators and held 10 focus groups with day and evening shift CNAs (n = 56) at 6 nursing homes. Data were recorded and transcribed verbatim and analyzed through directed content analysis using a combined inductive and deductive approach to compare perceptions across sites and roles. PRINCIPAL FINDINGS: CNAs and administrators identified chronic staffing shortages that affected resident care and staff burnout as a primary concern moving forward. CNAs who felt most supported and confident in their continued ability to manage their work and the pandemic described leadership efforts to support workers' emotional health and work-life balance, teamwork across staff and management, and accessible and responsive leadership. However, not all CNAs felt these strategies were in place. CONCLUSIONS: Based on priorities identified by CNAs and administrators, we recommend several organizational/industry and policy-level practices to support retention for this workforce. Practices to stabilize the workforce should include 1) teamwork and person-centered operational practices including transparent communication; 2) increasing permanent staff to avoid shortages; and 3) evaluating and building on successful COVID-related innovations (self-managed teams and flexible benefits). Policy and regulatory changes to promote these efforts are necessary to developing industry-wide structural practices that target CNA recruitment and retention.

It Was Trial by Fire: Recommendations for Building a Stronger Nursing Home Workforce After COVID-19

The COVID-19 crisis showed the urgent need for a unified, well-supported nursing home workforce. The objective of this qualitative study was to examine the lived experience of certified nursing assistants (CNAs) and administrators during COVID-19 to identify best practices moving forward. Six administrator interviews and 10 remote focus groups with CNAs at 5 nursing homes (N=56) were examined through directed content analysis. Based on priorities identified by CNAs and administrators, the following practices may be most impactful: 1) ongoing and responsive staff training;2) transparent, direct, and two-way communication channels;3) prioritizing hiring permanent staff to avoid shortages and reliance on agency staff;4) building collaborative staff-management relationships;5) providing flexible job benefits;6) providing staff-centered emotional support resources;and 7) appraising COVID-19 innovations. Our results suggest that rather than returning to “business as usual,” nursing homes can draw on these lessons to build a more sustainable workforce and industry.

DNR Linked to Reduced Depressive Symptoms in Nursing Home Residents During COVID-19 Illness

Prior work shows that older adults who establish future care plans have a lower risk of depression. Residents in long-term care may benefit from establishing a do-not-resuscitate (DNR) order when cardiopulmonary resuscitation is unlikely to provide medical benefit. The current study examines whether having a DNR order in place prior to COVID-19 diagnosis was associated with fewer depressive symptoms during the illness course. Residents at a NYC skilled nursing facility with a positive COVID-19 PCR test between 3/1/2020 – 6/1/2020 were included (N=338). The Minimum Data Set (3.0) was used to examine residents’ Patient Health Questionnaire-9 (PHQ-9) scores 1-30 days after diagnosis, functional status, cognition, age, and sex. A retrospective chart review was conducted to determine whether participants had an established DNR, DNI, and/or DNH order before developing COVID-19. Forty-eight percent, 46%, and 12% of participants had a DNR, DNI, or DNH order prior to COVID-19 illness, respectively. Average PHQ-9 score was 1.65 (SD=2.37). A hierarchical regression showed that after controlling for age (β=-.13, p=.06), sex (β=-.08, p=.28), cognition (β=.14, p=.04), and functional status (β=.23, p=.001;R2=.10, p=.001), having a DNR (β=-.22, p=.006) order in place prior to COVID illness was associated with lower endorsement of depressive symptoms during illness (ΔR2=.04, p=.01). Results suggest that establishing a DNR in long-term care residents when appropriate may potentially buffer depressive symptoms during illness in nursing home residents regardless of their age, sex, cognitive abilities, and functional status. Future examination of the underlying mechanism is warranted.

Variables Impacting Nursing Home Goals of Care Discussions and Order Implementation During COVID-19

Nursing home (NH) residents are especially vulnerable to COVID-19, disproportionately suffering from severe illness and death. As such, resident Goals of Care (GOC) often had to be quickly established to ensure treatment preferences were known and respected. This study examined variables related to the occurrence of GOC discussions and added orders (Do Not Resuscitate, Do Not Intubate, and Do Not Hospitalize), including demographic, physical functioning, cognitive impairment, depression, number of diagnoses, and Optum participation (Optum provided added specialized care by nurse practitioners who routinely address GOC preferences). Subjects were 286 COVID positive residents from a large NYC NH. All data were obtained from the NH’s electronic medical records. Patient median age was 81 n (interquartile range 71-88), 59% were female, 61% were long stay (stay >100 days) and 39% were short stay. Using bivariate correlations we found that older short stay residents were more likely to have GOC conversations. Additionally, older, cognitively impaired, Optum participants were more likely to have orders added. When all independent variables were entered into binary logistic regressions, only older age and being a primary English speaker were significantly related to the occurrence of GOC conversations (□2= 21.76**;N=278;Nagelkerke R2 = .10), while older age and being an Optum participant were related to added orders (□2=32.18**;N=164;Nagelkerke R2 = .24). Results have implications for (1) ensuring the GOC wishes of diverse populations are known and abided by and (2) improving the quality of clinician – resident GOC discussions.