​Learnings From Inside and Outside the Nursing Home Sector During COVID-19

In his inaugural speech at the start of his second term in office, our President Michael D Higgins spoke of ‘a life lived together, one where there is a commitment to equality, to strong sustainable communities, to the sharing of history and to shaping of the future together; recognising our vulnerabilities, drawing on and enhancing our individual and collective capacities.’  These powerful words capture the importance of collaborative effort for the good of all.  COVID-19 has changed the world we work and live in.  It has given us all pause for thought.  Read in the context of the Michael D Higgins quote COVID-19 provides us with real opportunity. 

One of the many areas this pandemic will change is the focus it brings on our Nursing Home Sector. At the outset, I would like to acknowledge the trojan, skilled and compassionate work of the front line staff in the nursing home sector over the years and in recent times.   Many have shown enormous dedication in what were very challenging and difficult circumstances.  They have also had to rapidly adapt to changing evidence and new support structures.  We all owe them a sincere debt of gratitude, and our support as they advocate for change, improvements and progress for the people they care for and support.

We have a lot to learn and reflect on.  COVID 19 is teaching us all lessons as it evolves.  Some of these learnings can be applied to and in the Nursing home sector.

Mitigating a second wave of COVID-19 in nursing homes

The Owners, Directors of Nursing, General Practitioners and Medical Officers of Nursing homes, both private and public, accept the responsibility for providing care to many of our most vulnerable citizens.  In turn, they must have access to the necessary advice and supports from other allied stakeholders to meet these responsibilities.  There needs to be independent oversight and measurement of this care. Similarly, all involved must now quickly reflect on measures they can take to ensure we are as prepared as possible to mitigate a second wave in nursing homes should it arise.

The recently announced COVID-19 Nursing Home Expert Panel, due to report directly to the Minister of Health by the end of June, is welcome.  Surprisingly there is no general practitioner representative.  I hope the committee liaises with the Irish College of General Practitioners and owners of private nursing homes in addition to other groups whose views they should consider before finalizing their report. 

Originally as COVID-19 swept around the world we were told to be on the watch out for people experiencing Fever, Cough or Breathlessness.  These were signs of the “Visible COVID-19 Pandemic”.  As time went on we learnt of the “Silent Pandemic”.  Many are now aware of the nonspecific symptoms in older people such as an altered sense of taste or smell, deterioration in oral intake, deterioration in mobility and function or diarrhoea.  These symptoms turned out to be very important markers for COVID-19 in the frail, older and at-risk groups of patients.  While they are vague, they are symptoms we are very familiar with in the older person.  When the mass testing exercise occurred we discovered there were many others with no symptoms evident at all. Dr Ruth Martin, Consultant Geriatrician, in her personal reflection highlights how this challenged us all in the early stages of this pandemic.  Once warned…..!!!

Involving gerontologically trained specialists essential

As health care professionals involved in the delivery of care and academic matters related to older people, we must continue to grow our own knowledge and understanding of COVID-19 as a condition and the particular challenges it causes for older and at-risk people.  The Irish Gerontological Society (IGS), as an All-Ireland interdisciplinary society, must also continue to advocate for all aspects of supports for older people in our communities.  With specific reference to the COVID-19 Pandemic and the Nursing Home sector, we will continue to advocate that the regulatory body for nursing homes, HIQA,  ensures adequate input from senior gerontological nursing, geriatric medicine and old age psychiatry in any review they conduct.  Furthermore, we will continue the advocacy work we have been doing with other organizations to ensure that our new government brings about effective and long term support on policy and funding to support ageing well and ageing in place, as outlined in the recent joint call from the IGS and ALONE.     

Dr Ruth Martin’s observations and reflections will strike a chord with many of you who read it.  They highlight some of the significant challenges, inputs and supports that nursing homes, their owners and staff have faced.  Some of these are new and some relate to previous unmet needs. For a lasting positive legacy from this pandemic their origins must be recorded and collated for future reflection on what needs to be provided for the nursing home sector.

Exploring new models of congregated living

Indeed we need a system rethink about how congregated living and the nursing home sector meet the needs of complex and at-risk people.  The continued practice of institutional care or congregated living is no longer deemed acceptable for children, people with disabilities, or mental health disorders.  Now is the time to explore other models of supported community living for older people with complex care needs, when they, their families or community are unable to meet the need.  We need to explore other options including skilled nursing facilities and hospitals within homes.

The voice of the resident of these institutions and homes must also be sought out and listened to, they have been isolated, uncertain about the future and lost out by not being able to be visited by family and friends.  What do they think and what do they want?

We also need to value and support the people who work providing the care and support in the nursing home sector.  It should go without saying that appropriate staffing levels, skill mix, and ongoing education are crucial in maintaining standards of care.

The consequences of ignoring COVID-19 lessons are unthinkable

Out of the drive to improve care delivered in the nursing home must grow robust care standards in line with evolving national, international knowledge and developments in the care of older people in nursing homes.  These lessons learnt should be applied across the community. This information should include evidence of planning and preparations for epidemics/pandemics, protocols for infection control, occupational health support (so that for example, the quarantining and staff health is appropriately managed), adequacy of medical cover, the extent of staff leaving employment during the pandemic, integrity of linkages with secondary care, appropriate equipment from PPE to syringe drivers for palliative care.  Learning the lessons from this pandemic must result in concrete actions and progress for this sector, the consequences of not doing so, are unthinkable. 

There is a discourse evolving that General Practitioners, Geriatricians and Advanced Nurse Practitioners, among others should have a larger role to play in the Nursing Home sector.  Some are already very involved.  The recognition that there should be increased involvement from Geriatricians and Advanced Nurse Practitioners to support the General Practitioners and Directors of Nursing is not without challenge.  Liaison services including Palliative Care, Psychiatry and Geriatric Medicine offer advice on people referred to the Directors of Nursing and General Practitioners who currently have direct clinical governance.  If more input is required to the nursing home sector this will require a significant increase in the number of Advanced Nurse Practitioners and Geriatricians.  It will also require a focus on training and continuous educational updates.    

I sincerely hope the report the COVID-19 Nursing Home Expert Panel feeds back to the Minister of Health and new government results in meaningful improvements, progress and change. 

Having read Dr Ruth Martin’s reflection I hope you will consider writing a personal reflection on your own experiences during these extraordinary times.  The IGS is now archiving them.  We will publish some of them over the coming months and include others in our upcoming ejournal.  Please submit them to IGS Secretary, Elaine O Connor, secretary@irishgerontology.com 

I will return to the words of our President, Michael D Higgins.  In his inaugural speech at the start of his second term in office he spoke of ‘a life lived together, one where there is a commitment to equality, to strong sustainable communities, to the sharing of history and to shaping of the future together; recognising our vulnerabilities, drawing on and enhancing our individual and collective capacities.’ Never has this been truer, more challenged and more needed. 

Dr. Diarmuid O'Shea, President of the Irish Gerontological Society