A Framework for Providing Nursing Care to Seniors with COVID-19 in Nursing Homes – Gray-Miceli – 2021 – Public Health Nursing


The characteristics of the LTC system include: (a) the delivery of nursing care in the practice setting, (b) the nursing staffing and skill mix, (c) the characteristics of the health workforce, (d) the building structure and living conditions, and (e) infection prevention and control education. NJ has 375 NH accredited facilities (74% for-profit and 23% not-for-profit owned) with an average bed size of 145 beds, 82% occupancy, and an average of 119 residents treated daily (Manatt Analysis Report , 2020). NHs in NJ are similar to NHs in the United States in terms of occupancy, property type, and average number of beds (CDC, 2020).

1.3.1 Provision of Nursing Care in the Practice Setting

The provision of safe and quality health care is a standard of practice and a goal of professional nursing in any nursing practice environment (Flynn et al., 2010). Nurses are concerned with providing what is necessary for “the protection, promotion and optimization of health and capacity, prevention of disease and injury, facilitation of healing, alleviation of suffering through diagnosis and treatment of human response, and advocacy care. individuals, families, groups, communities and populations ”(ANA, 2015). Among other elements of the practice environment, the delivery of nursing care is influenced by the workplace culture for patient safety, teamwork, nursing leadership, autonomy and nursing staffing (ANA, 2015).

1.3.2 Nursing staffing and skill mix

In New Jersey, NHs were unprepared for the threat of widespread infection and lacked resources due to long-standing staff shortages or low staff ratios (Manatt Analysis Report, 2020). According to the ANA, staffing is defined as a match between the expertise of registered nurses (RNs) and the needs of the recipient of nursing services in the context of the practice setting and the situation (ANA, 2012). Staffing issues have long plagued long-term care facilities in the United States, especially healthcare facilities, as found in the seminal work of Dr Harrington who compared the nursing workforce state to federal staffing requirements, noting the need for higher minimum staffing standards to provide care to residents (Harrington, 2010). In addition, the provision of appropriate nursing staff is necessary to achieve safe and quality outcomes and is achieved through multi-faceted decision-making processes that must take into account a wide range of variables (ANA, 2012). Additionally, research has shown that rescues failure, cardiac arrests, and hospital-related mortality are all lower when professional nurses are higher (Kane et al., 2007), in particular, when the staffing included a higher proportion of nurses with a bachelor’s degree or above (Aiken et al., 2003; Clarke & Donaldson, 2008). The Coalition of Geriatric Nursing Organizations (CGNO), representing more than 28,700 nurses who provide geriatric care in a variety of clinical settings, including NHs, postulates the need to provide safe, high-quality, necessary and cost-effective care. This requires avoiding and removing barriers that are imposed by an insufficient number of RNs or restrictions on the total number of hours of nursing care provided. Accordingly, the CGNO proposes minimum endowment levels to be adopted, funded, implemented and made public for NHs (see Table 1). In 2016, approximately 1,460,400 FTEs of nurses – including RNs, LPNs or LVNs and assistants – and approximately 35,000 FTEs of social workers worked in the LTC sector (Harris-Kojetin et al., 2019). Of these nursing and social work employees, 63.3% (945,700 FTEs) worked in NHs.

With respect to the skill mix, defined as the ratio of RN hours to CNA hours, NH care is largely delivered by registered nurse practitioners (LPNs) and nursing staff. direct (certified nurse assistants [CNAs]) and less by AI. Average hours of work per resident per day and type of staff in the United States in 2016 included: RNs providing 0.54 hours, LPNs providing 0.85 hours, and NACs providing 2.41 hours (Harris-Kojetin et al., 2019). Thus, CNA’s make up the largest proportion of staff in most states across the country, and in New Jersey, the minimum CNA staffing standard for skilled nursing facilities or NHs is 2.5 hours per day. resident (Harrington, 2010). In fact, CNAs provide most of the care in NHs with 90% of direct care, including bathing, lifting, grooming, and helping with daily activities for residents (Manatt Analysis Report, 2020). Before COVID-19 in NJ, NJs cared for an average of eight residents during the day, 10 residents at night, and 17 residents at night (de Cordova, P., author tabulation from this NJ data Health Care Quality Assessment, Nursing to Patient, 2020). When comparing the LPN staffing ratio, the LPN cares for an average of 26 residents during the day, 32 residents at night, and 45 residents per LPN during night shifts (de Cordova, P., author tabulation based on these data from the NJ Health Quality of Care Assessment, Nurses to Patient, 2020).

In New Jersey, nurses provided 0.83 hours per resident per day, LPNs provided 0.87 hours, and CNAs provided 2.06, and collectively, the total number of hours for all licensed personnel. was 3.76 (see Table 1; from Cordova, 2020, tabulation of public data). This trend of increasing LPN work relative to RN work is also seen nationally and dates back to a 1995 Bureau of Labor Statistics finding (Institute of Medicine (US) Committee on the Adequacy of Nurse. Staffing in Hospitals and Nursing Homes, 1996), which represents a change in the composition and skill mix of RNs (Corazzini et al., 2015). Other issues created by changes in the recommended skill mix include the quality of care provided (Institute of Medicine (US) Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes, 1996). Fewer professional nurses in NHs equals fewer opportunities for comprehensive nursing assessments and plans, initiating care plans, evaluating the effectiveness of the care plan, and delegating to nurses not approved (CGNO, 2014). The insufficient number of registered nurses in health facilities, with an average of 30-38 minutes of direct care per resident over a 24-hour period (Harrington et al., 2011), increases the risk of residents experiencing poor quality results (Castle & Engeberg, 2005; Institute of Medicine (US) Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes, 1996), which includes increased susceptibility to COVID-19. Basic research has shown that NHs perform well for residents, and they must have nursing leadership provided by professional nurses (Rantz et al., 2004). In summary, given the current number of hours provided per day to residents compared to the recommended 4.1 hours per resident, the current NHLNs appear to provide approximately 60% of the recommended number of hours per resident for care. Thus, they fall short of national recommendations and violate minimum federal nurse staffing requirements, further increasing susceptibility to COVID-19.

1.3.3 Characteristics of the health workforce

As of June 24, 2020, among the nationally available data, 729 deaths have occurred due to COVID-19 among healthcare workers in the United States (CDC, 2020). There are disparities in the working environment for skilled healthcare workers, as these jobs are disproportionately occupied by minorities, women and legal immigrants who are paid at low wages. As ‘critical responders’, CNAs work with COVID-19 positive AOs, which increases their own risk of COVID-19 and their risk of exposing their families to COVID-19 (Manatt Analysis Report, 2020). The physical and emotional toll of frontline healthcare workers dealing with AOs during the COVID-19 pandemic is considerable. Other important factors affecting the health of healthcare workers include the lack of availability of personal protective equipment (PPE), which was scarce in NJ NH (Manatt Analysis Report, 2020) because “the emphasis on hospitals has prompted a prioritization of the distribution of supplies, PPE and other resources to this sector” (Manatt Analysis Report, 2020), as well as insufficient and ineffective testing of healthcare workers in the early stages of COVID-19 (Manatt Analysis, 2020). As Ouslander and Grabowski noted (2020), another important problem causing COVID-19 viral infections in the NH establishments studied (Abrams et al., 2020; Li et al., 2020; White et al., 2020) was “the prevalence of the virus in the surrounding community” (Ouslander & Grabowski, 2020).

1.3.4 Building structure and living conditions

The Code of Federal Regulations (38 CFR 59.140) regulates NH care requirements with respect to size, location and number of residents per room, among other characteristics (American Planning Association, 2020). Overall, many of the structures of the NJ NH buildings are archaic, containing more four-bedded rooms for residents to share living and sleeping space compared to NHs in other parts of the country (Manatt Analysis Report, 2020) where the room capacity is less. Due to structural features, including the number of beds per room, the size of residents’ rooms, and shared meals in dining rooms, infections can spread more easily. The physical structure of the building leaves little opportunity for social distancing and / or the ability to maintain isolation.

1.3.5 Infection prevention and control education

NHs require mandatory annual safety and infection prevention training for all employees. Using monetary funds from civil penalties imposed on NHs due to deficiencies, funds are directed to training NH staff in infection prevention and control through a partnership with the NJ Hospital Association and the Northern Chapters and South NJ Association for Infection Control and Epidemiology Professionals (available on the Internet at: http://www.njha.com/media/550704/EDU-1915-PPT-Infection-Control-J-Arias.pdf). The Infection Control Assessment and Response Team (ICAR), which is deployed through the NJ Department of Health, is led by an infection prevention nurse who provides resources and support services to NH facilities in NJ to reduce infections.


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