Care homes, their communities, and resilience in the face of the COVID-19 pandemic: interim findings from a qualitative study

Abstract

Background From late February 2020, English care homes rapidly adapted their practices in response to the COVID-19 pandemic. In addition to accommodating new guidelines and policies, staff had to adjust to rapid reconfiguration of services external to the home that they would normally depend upon for support. This study examined the complex interdependencies of support as staff responded to COVID-19. The aim was to inform more effective responses to the ongoing pandemic, and to improve understanding of how to work with care home staff and organisations after the pandemic has passed. Methods Ten managers of registered care homes in the East Midlands of England were interviewed by videoconference or phone about their experiences of the crisis from a structured organisational perspective. Analysis used an adapted organisational framework analysis approach with a focus on social ties and interdependencies between organisations and individuals. Results Three key groups of interdependencies were identified: care processes and practice; resources; and governance. Care home staff had to deliver care in innovative ways, making high stakes decisions in circumstances defined by: fluid ties to organisations outside the care home; multiple, sometimes conflicting, sources of expertise and information; and a sense of deprioritisation by authorities. Organisational responses to the pandemic by central government resulted in resource constraints and additional work, and sometimes impaired the ability of staff and managers to make decisions. Local communities, including businesses, third-sector organisations and individuals, were key in helping care homes overcome challenges. Care homes, rather than competing, were found to work together to provide mutual support. Resilience in the system was a consequence of dedicated and resourceful staff using existing local networks, or forging new ones, to overcome barriers to care. Conclusions This study identified how interdependency between care home organisations, the surrounding community, and key statutory and non-statutory organisations beyond their locality, shaped decision making and care delivery during the pandemic. Recognising these interdependencies, and the expertise shown by care home managers and staff as they navigate them, is key to providing effective healthcare in care homes as the pandemic progresses, and as the sector recovers afterwards.

Impact of the COVID-19 pandemic on end of life care delivery in care homes: A mixed method systematic review

“…24 In the UK, a lack of prioritisation of care home services by the government was noted which led to changing rules and regulations not being effectively communicated to care home staff. 25 Similar findings emerged from a study in Pakistan where changes to end of life practice, such as amendments to social distancing were not effectively communicated to care home staff. 27 One study indicated that these increased responsibilities and expectations led to some staff becoming more tenacious and creative in their roles, especially to facilitate 'good' deaths.…”

“…14 Other studies suggest that it may be because of decreased clinical routines and visits from external service staff such as General Practitioners and specialist palliative care teams. 25,30 Lastly, particularly towards the beginning of the pandemic, care home staff's fear of being infected or infecting residents with COVID-19 may have prevented regular care planning discussions. 26,27 Reductions in advance care planning discussions seem to have most significantly impacted residents living with dementia, who are often reliant on relatives and surrogate decision makers.…”

“…A common theme running through the studies regardless of country was the increased responsibilities and expectations of care home staff delivering end of life care during the pandemic. 15,[24][25][26]30 Care home staff were found to be taking on care responsibilities usually delivered by trained clinicians within primary care, 25 and specialist palliative care teams. 30 For example, it was found some managers in the UK were asked to verify residents' deaths without appropriate training or support.…”

“…Furthermore, in the UK during the first lockdown some managers were making decisions as to whether to admit residents with COVID-19 to the care home. 25 Moreover, more untrained care home staff were relied on to administer drugs during residents end of life care. 15 It was evident that many of these increased responsibilities and expectations were due to poor communication, demand and access restrictions impacting on external services usually involved in supporting residents' end of life care in care homes.…”

“…15 It was evident that many of these increased responsibilities and expectations were due to poor communication, demand and access restrictions impacting on external services usually involved in supporting residents' end of life care in care homes. 24,25,30 For example, Martinsson et al 30 found that as a result of the restrictions in Sweden, fewer residents were examined by a physician during the last days of their life, and pain management as well as oral health were assessed less frequently, and consultations with specialist palliative care teams reduced. Similarly, a study which collected data from four countries in Europe and Latin America also highlighted instances where care home staff expressed feelings of abandonment by external services and government organisations.…”