key: cord-0818493-vzv6qni5
authors: Mo, Shenjiang; Shi, Junqi
title: The Psychological Consequences of the COVID-19 on Residents and Staff in Nursing Homes
date: 2020-10-08
journal: Work Aging Retire
DOI: 10.1093/workar/waaa021
sha: 927a7af25fbbe24bd4323dee59b06b723674fe27
doc_id: 818493
cord_uid: vzv6qni5

In this commentary, we overview the existing research on psychological consequences caused by COVID-19 for both residents and staff in the nursing homes. We identify loneliness and emotional anxiety as main psychological consequences for nursing home residents, whereas uncertainty, hopelessness, work overload, and role conflicts are the most salient psychological challenges for the staff in the nursing homes during the pandemic. We then summarize the existing strategies and interventions responsive to the above challenges. We suggest that this overview may help nursing home managers understand what are the key psychological challenges and how to deal with them during a crisis period. Finally, we also encourage future research to pay more attention to exploring interventions specifically designed for vulnerable older people, understanding the role of the nursing home leader team in managing emotional and ethical challenges in organizations, and developing community-wide collaboration with multiple external stakeholders.

During the past several months, the coronavirus disease 2019 (COVID-19) pandemic has caused great challenges for the world. COVID-19 exhibited a clear predilection for and danger to nursing homes. On the one hand, older people residing in nursing homes are the most demonstrably vulnerable group to COVID-19 because they are typically with high levels of chronic illness and functional and cognitive impairment (Fallon, Dukelow, Kennelly, & O'Neill, 2020) . Recent studies reported that residents in nursing homes and other assisted living facilities accounted for 45% of all COVID-19 deaths in the United States (Girvan & Roy, 2020; Shmerling, 2020) . Another analysis from the London School of Economics also showed that nearly half of all COVID-19 deaths, ranging from 42% to 57%, appeared to be happening in nursing homes in European countries such as Italy and Spain (Fallon et al., 2020; Kemenesi et al., 2020) . On the other hand, staff such as nurses who are at the forefront in nursing homes are grappling with the effects of relatively low health literacy and competency, rapidity of change in health information, and a lack of resources to keep themselves safe ( Jackson et al., 2020) . As a result, many confirmed cases of COVID-19 affecting staff in nursing homes, particularly nurses, were found in the context of rapidly escalating COVID-19 outbreaks (McMichael et al., 2020; Ouslander & Grabowski, 2020) . Therefore, nursing homes have become an epicenter for the shifting pandemic (Barnett & Grabowski, 2020; Gurwitz, 2020; Kluge, 2020) , affecting both residents and nurses.

Despite the negative outcomes of the pandemic for nursing homes and their residents and staff, research has shown that the nursing homes have done better preparation in terms of resources (e.g., personal protective equipment), guidance (e.g., infection control), and response actions (e.g., visitor restrictions) for pandemics such as COVID-19 than before. A study on Michigan nursing homes showed that compared with a 2007 pandemic, nursing homes were able to make policy and procedure changes within 1 week in response to urgent guidance from the World Health Organization (WHO) or the Centers for Disease Control (CDC), which helped the facilities prepare for the COVID-19 pandemic . In addition, Quigley, Dick, Agarwal, and Jones (2020) survey on 56 nursing homes in the United States reported that all sampled nursing homes had guidance documents for COVID-19, plans for training staff to address COVID-19, and processes to limit/restrict visitors and outside vendors/consultants. These restrictions and practices are deemed necessary for nursing homes to effectively respond to the pandemic. However, limited efforts have been made to investigate the psychological consequences for residents and staff in the nursing homes with these restrictions, as well as effective interventions that can help deal with the psychological challenges during a pandemic like COVID-19 (O'Neill, 2018) . This is problematic because policies and guidance will not be well followed and implemented if residents and staff in nursing homes have symptoms of poor mental and physical well-being.

Hence, in this commentary, we first overview the existing research on the main psychological challenges caused by COVID-19 for residents and staff in the nursing homes. We then summarize the existing strategies and interventions responsive to those challenges. Last, we end our commentary with suggestions for future research.

Work, Aging and Retirement, 2020, Vol. 6, No. 4, pp. 254-259 doi:10 .1093/workar/waaa021 Advance Access publication 8 October 2020 Commentary

Nursing home residents are mainly older people with long-term physical, medical, or mental conditions requiring 24-hour care, or patients recently discharged from a hospital who need such care temporarily (Fallon et al., 2020) . For these vulnerable older people, we suggest that loneliness and emotional anxiety are two main psychological challenges they face during the pandemic.

To respond to the COVID-19, nursing homes in many countries are using varying levels of social distancing or social isolation, defined as the objective state of having few social relationships or infrequent social contact with others (Simard & Volicer, 2020) . It is an important infection control step to stop allowing families and friends with residents to do in-person visits (Konish, 2020) because the constant movement of visitors, staff, and residents may establish a complex transmission route with the outside community (Kemenesi et al., 2020) . Moreover, residents are required to remain indoors as much as possible to decrease contact with others. Accordingly, nonessential activities such as leisure activities and communal dining and services are being restricted, which is deemed necessary to reduce the risk of contracting the virus. However, researchers noticed that these practices also imposed a significant social and emotional cost on residents (Barnett & Grabowski, 2020) , particularly for individuals with cognitive impairment and dementia (Edelman et al., 2020) . Because of the no-visitor and social distancing policies, residents have not been able to spend time with their families and friends in the same facilities (Barnett & Grabowski, 2020) , which put them at the high risk of loneliness (Simard & Volicer, 2020) . Such feeling of loneliness may further lead to many deleterious consequences, such as high blood pressure, depression, suicidal thoughts, and anxiety (Gerst-Emerson & Jayawardhana, 2015; Simard & Volicer, 2020) , which are all detrimental to the functioning of the immune system (Hall et al., 1998; Reiche, Nunes, & Morimoto, 2004) . Therefore, preventing loneliness is at least as important as providing them sufficient help for personal hygiene.

The research by Haj, Altintas, Chapelet, Kapogiannis, and Gallouj (2020) showed that nursing home residents reported significantly higher anxiety and depression during than before the COVID-19 pandemic. This can be explained by three reasons. First, residents in the nursing homes, especially those individuals with a history of trauma, benefit from feeling safe and secure in their everyday lives (Abramson, 2020; Morrow-Howell, Galucia, & Swinford, 2020). However, their normal routines have been abruptly changed by the measures to counter COVID-19, such as social distancing policy and activity restrictions. For example, residents are typically not allowed to have physical contact with their families, friends, and other residents in the same facilities, even during sickness, which can result in increased anxiety, stress, and depression (Simard & Volicer, 2020) . Second, most residents are very aware of their own vulnerability and that nursing homes are dangerous during the pandemic. Older people are known to be at greater risk of calamitous outcomes associated with COVID-19, especially when there is not enough life-saving equipment to meet demand ( Jackson et al., 2020) . Moreover, in a congregate living setting like nursing homes, residents cannot obtain sufficient safe accommodation and keep social distance from others who are potentially infected by COVID-19. Thus, it is extremely difficult for these vulnerable older people to decrease contact with others and reduce the risk of contracting the virus ( Jackson et al., 2020) . Third, residents may also perceive higher emotional anxiety because of reduced physical contact with nurses and clinicians who have been dealing with an increased workload during the pandemic (Chen et al., 2020) . Since emotional anxiety can put residents in nursing homes at risk of exacerbation of existing health and social issues ( Jackson et al., 2020) , and cause severe damage of the immune and endocrine systems (Leonard & Song, 1996; Moons & Shields, 2015) , it is important that we look out for them and provide necessary psychological support, assistance and safe social interaction.

Previous research has classified interventions for loneliness and anxiety among older people into six categories, including social facilitation interventions, psychological therapies, health and social care provision, animal interventions, befriending interventions, and leisure/skill development interventions (Gardiner, Geldenhuys, & Gott, 2018) . Among them, social facilitation, leisure/skill development, and psychological therapies are proved to be most effective (Quan, Lohman, Resciniti, & Friedman, 2019) . In a pandemic situation of forced isolation, the research by Liotta, Marazzi, Orlando, and Palombi (2020) indicated that increased social connectiveness represents a powerful tool for residents in the nursing homes, to decrease loneliness and emotional anxiety. In most nursing homes, the nursing capacity to provide sufficient psychological care is stretched by the increased workload and by the shortage of nurses ( Jackson et al., 2020) . Thus, it is important for nursing homes to find creative ways to help residents increase social connectivity with others. Online-connection technologies such as video chat with families or friends may significantly mitigate the negative impacts of social distancing for residents in the nursing homes (Chen et al., 2020; Morrow-Howell et al., 2020; Ouslander & Grabowski, 2020; Simard & Volicer, 2020) . Besides, nursing homes may also provide residents leisure and skill development activities that can be conducted in their rooms or hallways or at staggered times, such as indoor gardening programs (Brown, Allen, Dwozan, Mercer, & Warren, 2004) . These leisure activities may help residents spend time constructively, thereby decreasing loneliness and anxiety while maintaining social distancing. In addition, trained therapists or health professionals may also use recognized therapeutic approaches, which are usually facilitated group-based activities, to reduce residents' feelings of loneliness (Gardiner et al., 2018) . However, during the pandemic period, nongroup or solitary interventions, such as laughter therapy, horticultural therapy, and reminiscence therapy, can be more effective in reducing residents' feelings of loneliness (Quan et al., 2019) .

Despite being actively engaged in the fight against COVID-19 and appearing calm and professional like everyone else, staff in the nursing homes, particularly nurses, are experiencing many psychological challenges such as uncertainty, hopelessness, work overload, and role conflicts.

Nursing homes have suffered through the rapid spread of the COVID-19 virus, multiple infection cases, and related deaths. For many nursing homes with residents with symptoms susceptible to COVID-19, it is usually not possible to create quarantine areas (Ouslander & Grabowski, 2020) . Thus, nurses are basically asked to work under conditions that pose substantial and inadequately understood risks to their health and well-being (Morley, Grady, McCarthy, & Ulrich, 2020) , and they are always required to wear full personal protective equipment and tested before every shift to keep safe (Konish, 2020) . Despite this, there is still a possibility that they may be infected when they provide care for the residents, and they have heard and seen many COVID-19 infection cases in the nursing homes ( Jackson et al., 2020) , which result in uncertainty, anxiety, and concerns. In addition, rapid change of health information and potentially modified work guidance, content, and environment may also contribute to uncertainty perception (c.f., Hyer, Brown, Christensen, & Thomas, 2020) . Thus, the continued risks and rapid changes of COVID-19 exacerbate nursing home staff 's fear of the unknown and concerned for what lies ahead for themselves, residents, and others (Unroe & Vest, 2020) .

Most nurses become nurses because they have a strong desire to provide care for people and help them maintain optimal health ( Jackson et al., 2020) . For this reason, nurses may experience a variety of consuming emotions and stress when caring for older people diagnosed with COVID-19 (Chen et al., 2020; Ouslander & Grabowski, 2020; Stenbock-Hult & Sarvimaki, 2011) . Particularly, nurses may be in a very vulnerable and helpless position when there are very few options to help those residents who are seriously ill because of COVID-19 ( Jackson et al., 2020) . During the last several months, some nursing homes have suffered through the rapid spread of the virus, multiple COVID-19 cases found in both the residents and the staff team, and related deaths like a wildfire throughout the facility (Ouslander & Grabowski, 2020) . Nurses have watched residents they have known for years die. They cannot do much to help those older people, and they do not know how to deal with the residents' families. Besides residents, nurses have also seen many losses of their colleagues, friends, and family members working in the nursing homes due to COVID-19 viral infection ( Jackson et al., 2020) . Such feelings of hopelessness can be devastating. Not only does the emotion compromise a nurse's sense of well-being and stability, it may also rob a person of the motivation required to utilize available resources or take further actions (Hanna et al., 2011) .

The COVID-19 pandemic caused work overload for nurses working in the nursing homes. Specifically, due to unexpected staff shortages, high job demands and low resources during the pandemic period, many nurses must perform extra tasks and duties falling outside of their job descriptions ( Jackson et al., 2020) . Moreover, there are increased anxiety and mental health needs from the residents as well as within the nursing team on a daily basis (Burch, Dugan, & Barnes-Farrell, 2019; Jackson et al., 2020) , during the pandemic period. Hence, in order to be responsive and provide sufficient care for the residents, nurses need to input an adequate amount of time and effort in the nursing homes. This may have led to working periods that significantly exceed the conventional working hours, such as overtime, night work, and on-call scheduling (Rosa, Postic, Wiskow, & Humblet, 2018) . Some of them even come to work while symptomatic because their employers exert pressure or because they have a strong desire to provide high-quality service for the residents (Fell, 2008) . However, it is worth noting that high degree of work overload or irregular work hours is likely to cause many negative consequences on the health and safety of nurses, such as poor quality of care offered, increased sickness absenteeism, and even severe damage of the immune systems for the nurses (Burch et al., 2019; Rauhala et al., 2007) , we thus suggest that work overload is another major concern for nursing homes during the pandemic.

In the nursing homes, nurses frequently cope with unfamiliar and stressful tensions between themselves and residents and their families. Particularly during the pandemic period, they may meet many challenges of role conflicts. For example, nurses instinctively want to hug older residents who are diagnosed with COVID-19 and in pain, but they as health professionals fully notice the importance of wearing full personal protective equipment and keeping a safe distance (Ouslander & Grabowski, 2020) . Thus, nurses providing care for infected residents are likely to struggle with finding solutions that may balance compassion and safety. In addition, nurses understand that it can be emotionally traumatic for families who cannot visit their loved ones during the pandemic (Ouslander & Grabowski, 2020) . However, again they as professionals must restrict visitation in line with the social distancing policy. Such role conflicts are likely to be very high when they experience tragic even potentially dehumanizing scenarios, such as persons dying in isolation from their families. Therefore, most nurses may find it extremely difficult to make or implement an ethical decision given their own human response, and their professions' expectations and norms (Morley et al., 2020) .

Researchers emphasized that providing sufficient resources and support for safeguarding staff 's mental and physical well-being is essential for success of the nursing home care system during a crisis period (Fallon et al., 2020; Mo et al., 2020) . First, all nursing home staff, particularly those who provide care for residents with COVID-19 symptoms, should receive sufficient guidance in infection control and the use of resources to mitigate their concerns of uncertainties. Second, mentoring sessions should be provided for staff in nursing homes (American Geriatric Society, 2020). Specifically, education and skills training sessions on work stress management, clarification of work and life roles, and ethical decision making (Morley et al., 2020) are beneficial for nurses to improve psychosocial well-being as well as to quickly mobilize into new settings of care during changes like the current pandemic. These are especially valuable for those staff more than 50 with lower work ability (Cadiz, Brady, Rineer, & Truxillo, 2019) . In addition, external psychologists and mental health practitioners should be invited to build psychological intervention medical teams during a crisis time (Chen et al., 2020) . These teams may provide online courses to guide nursing home staff to deal with common psychological problems of the residents, families of the residents, colleagues, and themselves. These psychologists also can help the nursing home staff address self-care (e.g., practicing meditation and/or mindfulness) and stress management by offering materials, supplies, and best practices (Abramson, 2020).

This commentary raises several suggestions for future research. First, although loneliness and anxiety are identified as two most salient psychological consequences for residents in the nursing homes during the COVID-19 pandemic, and several interventions such as social connectiveness and psychological therapies are introduced to combat these challenges, little is known about the most appropriate interventions for vulnerable older people in nursing home settings (Fallon et al., 2020) . For example, online-connection technologies are widely used in the current pandemic to help residents in the nursing homes connect with their families. However we notice that these technologies are not specifically designed to meet older people's needs, and many older adults may do not feel competent using such technologies, especially when they are under stress or ill (Robinson, MacDonald, & Broadbent, 2014) . Therefore, we suggest future research conducting more qualitative studies with residents and staff to explore effective interventions that are responsive to the residents with different psychological needs (Amabile, 2019). Furthermore, older people, especially residents with COVID-19 symptoms, usually prefer to receive more physical and emotional support from the staff in the nursing homes. Thus, we encourage researchers to discuss more on the ethical issue that how to reach the balance between compassion and safety in providing care for older people in the nursing homes during the pandemic period. Given the current circumstances, researchers may also want to study the long-term consequences of physical and social distancing during the pandemic on older people' psychological well-being in the nursing homes. One way of studying this is by conducting longitudinal research.

Another area recommended for future research is exploring approaches that may help staff in nursing homes cope with increased negative psychological consequences such as uncertainty, hopelessness, work overload, and role conflicts during a crisis like the current pandemic. Besides providing nurses with more effective training tools and programs which can help them quickly mobilize into new settings of care, research suggested that nursing home leader teams (e.g., administrators, medical directors, directors of nursing) played an extremely important role in facilitating frontline nurses' psychological adaptation in the unknown circumstance (Rudolph & Zacher, 2020; Zhang et al., 2020) , and keeping up staff and residents' morale (American Geriatric Society, 2020). For instance, although early work mainly viewed emotion regulation as a within-person process that involved exerting influence over one's own feelings, recent research has emphasized the importance of interpersonal emotion regulation, which involves deliberate attempts to influence the experienced or expressed feelings of others (Gross, 2013; Niven, 2016) . Accordingly, it is valuable for future research to further explore the role of nursing home leader team in regulating nurses' emotions and actions. In addition, leaders may provide nurses opportunities to prepare for various psychological and ethical challenges during the rapidly changing pandemic through participative decision making or improvisation practices (Hanley & Fenton, 2007) . In short, research is needed to fill gaps in our knowledge about effective leadership behaviors that can significantly help nursing home staff reduce negative emotional consequences and deal with ethical challenges caused by the COVID-19.

Echoing the repeated advocacy for collaborative dialogue between nursing homes and various stakeholders which have already heavily invested in pandemic preparedness (Kim et al., 2020; Mody & Cinti, 2007) , research has emphasized the development of a high-quality nursing home care system with the input from a range of specialties, such as researchers, educators, practitioners, government bureaucrats (Behrens & Naylor, 2020; Fallon et al., 2020; Kim et al., 2020) . Hence, a final suggestion for future research is to conduct case studies to explore strategies that may facilitate effective community-wide collaboration among external stakeholders in mitigating psychological consequences of COVID-19 for residents and staff in nursing homes. A state-wide quality improvement program developed in Missouri would be a good example (Rantz et al., 2009 ). The quality improvement program of Missouri was a clinical consultation program based on quality improvement principles and driven by data from the nursing home residents upon admission, quarterly, and upon significant changes conditions in the state. This program was initiated by the nursing school in the University of Missouri, supported by the state and federal data collection agency, and evaluated by various nursing homes that received its services. In general, this program significantly improved the quality of care and resident outcomes in nursing homes through identifying nursing homes most at risk for quality concerns, and matching them with external experts who can provide services for quality improvement accordingly (Rantz et al., 2009) . We highlight that such a state-wide collaborative system is extremely helpful for nursing homes to identifying successful strategies and solutions to deal with negative consequences of crisis like the COVID-19 (Behrens & Naylor, 2020) .

The COVID-19 pandemic and subsequent restrictions have raised a host of psychological challenges and ethical issues, especially in the nursing homes. We identify that loneliness and emotional anxiety are the most salient psychological consequences for the residents, whereas uncertainty, hopelessness, work overload, and role conflicts are the challenges for the staff in the nursing homes during the pandemic period. We believe it is important for researchers and practitioners to work together to address the above challenges. We hope that our commentary may motivate people to further explore effective interventions for both residents and staff in the nursing homes during a crisis like the current pandemic.

This research was supported in part by the National Natural Science Foundation of China (grant numbers 71772158 and 71425004).

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