The COVID-19 pandemic has posed significant challenges for care homes across the nation. Care homes can be residential, nursing or dual registered. With a combination of often confusing advice and insufficient recognition of the needs of care providers, care home workers and residents have experienced many of the devastating effects caused by the coronavirus. At the time when the project described in this article was started, in April 2020, 28.3% of all COVID-19 deaths in the UK were among care home residents (Office for National Statistics (ONS), 2020a). This was largely due to the complications of the virus affecting those who are older, who often have multiple comorbidities. Other factors included the typical nature of care home environments, with many residents walking about freely and meeting in social areas. Barnett and Grabowski (2020) highlighted increased COVID-19 risks to people requiring a substantial amount of direct care, for example, those in nursing homes, due to their increased clinical need. This makes care homes a high-risk site for transmission, as seen with other viruses, such as influenza and norovirus (Green et al, 2020). Evidence from Tulloch et al (2020) showed additional risk factors for care homes, including the use of agency staff, who may not be as well versed in the infection control protocols of the care home. Further research also found that care home staff moving between care homes, which may be required due to varying demand across sites, posed a potential increased risk (Bonanad et al, 2020). However, in February 2020, Public Health England (PHE) (2020a) stated in their now withdrawn guidance that: ‘there is no need to do anything differently in any care setting at present’. This was contradictory to a statement made in the same month by the Government's Scientific Advisory Group for Emergencies (SAGE) (2020), that it was possible that there was already sustained transmission in the UK and that it would soon become established.
Care homes were initially considered at a low transmission risk, according to Government guidance produced in February and March 2020, with PHE (2020a) stating in the now withdrawn document that: ‘It is therefore very unlikely that anyone receiving care in a care home or the community will become infected’. They also supported the transfer of untested patients to care home settings from NHS hospital beds. Only later in April 2020 did the guidance change, advising all discharged patients would be tested prior to leaving secondary care. At this point, over 28 000 older patients had been discharged from hospitals to care homes, although no statistical evidence was available to account for how many potential cases of COVID-19 were contracted as a result (Butcher, 2020). In mid-April 2020, 5700 care home residents had died due to COVID-19 since the start of the pandemic, with a total of 20 000 associated deaths by July 2020. In the Vivaldi study (ONS, 2020b), it was estimated that 55.6% of care homes had at least one case of COVID-19, with just under 20% of care home residents testing positive in homes with at least one confirmed case.
In March 2020, the Government launched the National Supply Disruption Response (NSDR), which was aimed at creating a centralised line for health and care providers to raise concerns regarding personal protective equipment (PPE) shortage. PPE includes hand hygiene materials, gowns and/or aprons, masks, goggles and/or face shields and gloves (Agalar and Ozturk, 2020). On 10 April 2020, a PPE action plan (Department of Health and Social Care (DHSC), 2020) was formed, which looked at ensuring appropriate distribution to care homes through local authorities. However, it was not until May 2020 that care homes had their own bespoke supply routes and specific guidance. For many, this was already too late and not representative of Health Secretary Matt Hancock's view in May's Downing Street briefing that the government had thrown a ‘protective ring round care homes at the start of the pandemic’ (Rajan et al, 2020).
Staff working within district nursing teams had identified some issues with PPE usage within many care homes, which were being raised internally and communicated to home managers. Some of the issues raised included care staff not wearing aprons when providing personal care and re-use of equipment, such as thermometers, between patients. An abundance of guidance was made available by different bodies, including the National Institute for Health and Care Excellence (NICE) and PHE, and incorporation of this vital education into frontline practice was fast becoming a priority.
The project
Due to the concerns raised in care homes regarding appropriate PPE attainment, the author was authorised to lead a team to provide direct education and support to all residential and nursing care homes under its remit within the clinical commissioning group (CCG). At the time of the project starting, there was no formal training plan in place to support care home staff that involved direct support and education relevant to COVID-19 and PPE. In the author's locality, there are 46 care homes providing social/nursing care to residents. The project plan was to contact all 46 care homes and offer face-to-face direct training and support. This project was considered a priority from senior management in order to reduce potential spread and protect vulnerable patient groups.
The team was led by the author and included a fellow specialist practice teacher (SPT) from the district nursing team and a nurse practitioner (NP) from the Specialist Care Home Support Team (SCHST). Both SPTs and NP also continued in their regular roles throughout, with the NP recently joining from an infection control team in the region. Many staff members had changed roles and had been redeployed elsewhere within the trust; some were allocated to district nursing due to the increased demand for these professionals on the frontline. Although remotely working in its office base, the SCHST provided telephone consultations to the care homes in the region to monitor and offer any support that was needed. At any given time, the PPE support team included four to five members of nursing staff. The dynamic of this team changed throughout the project, as redeployed staff who would form part of the team were called back to their usual roles, often after a period of weeks. In total, there were seven different members of the team throughout the project lifespan, totalling 3 months.
Live teaching and education delivery have been compromised significantly during the pandemic. The benefits of face-to-face teaching delivery are well documented, particularly with practical tasks (McCutcheon et al, 2015), allowing for the benefits of visual observation of correct procedure supported with evidence-based recommendations. The delivery of these training sessions also allowed the team the opportunity to work in alliance with local care providers. Care homes are an integral part of the adult social care team and work closely in conjunction with a range of NHS teams and specialists. It has been highlighted that people working within the adult social care sector have felt undervalued throughout the pandemic, almost ‘second class to a world-class NHS’ (Rajan et al, 2020).
It has been well documented in the media that care homes have faced considerable difficulty during the pandemic, even facing criticism from the Prime Minister, who stated that ‘too many care homes didn't really follow the procedures in the way that they could have’ (Butcher, 2020). This caused significant resentment, with these comments being described as ‘neither accurate nor welcome’ by senior representatives (Rayner, 2020). This project offered an opportunity to further develop links between the NHS and social care providers, offering not just face-to-face education directly in care homes but also support to those working with a demographically highly vulnerable group of people.
Implementation
The training sessions were planned for 30 minutes, allowing for a realistic amount of time to allow care workers to leave their duties. The sessions targeted all care home staff, including care assistants, cleaners and chefs, as well as others. Sessions were also offered consecutively, so at one visit, as many staff as possible could be trained. Many care homes arranged for their off-duty staff to come in and attend, which was a testament to how important care home managers and their staff viewed face-to-face training. All care home managers were contacted by telephone and email, informing them of the PPE Training Team project and what was on offer to the home and its staff. Prior to any session, a risk assessment was undertaken by the session trainer to ensure safe social distancing and appropriate PPE usage to protect other attendees, in line with Government guidance. All these details were recorded in an MS Excel sheet to help track and record information supplied by the care homes, including the number of active cases, staff numbers and available dates for the training team to attend.
The author created a teaching session plan, which incorporated the following:
- Introduction to COVID-19: this module informed attendees what the training would include and the context of the impact that COVID-19 was having, both nationally and in care homes
- Prevalence, signs and symptoms: number of cases (updated frequently) and how to spot suspected COVID-19
- Live donning and doffing demonstration: visual exercise showing best practice
- Myth-busting discussion: focused on dispelling common myths, such as the effect of antibiotics and other medications not scientifically proven to be of benefit
- Wellbeing of care home staff: how care home staff can protect themselves and their colleagues and maintain good health
- Q&A opportunity.
The author consulted the most recent guidance available from PHE (2020b), specifically regarding the process for donning and doffing. The introductory information was from the ONS guidance and updated continuously throughout. Information about signs and symptoms as well as the information relevant to myth-busting was taken from NHS UK (2020). Guidance on how care home staff can protect themselves was taken from the PHE (2020b) guidance ‘COVID-19 How to work safe in care homes’. As per local trust recommendations, it was advised that hand decontamination using alcohol gel should take place during every stage of doffing, although this was not stated in the PHE guidance. This reduces the risk of spreading any contamination through touching clothing and hair.
Many myths have circulated throughout the pandemic, often spread via social media and general gossip. The teaching session aimed to dispel any contemporary myths, such as the suggested benefits of hydroxychloroquine, which has been found to have no effect on mortality rates (Jorge, 2020). This part of the session offered the opportunity for care staff to share any myths or stories they may be aware of, with the session provider aiming to address any ambiguities.
The focus on the wellbeing of care staff was a highly pertinent part of the session. District nursing teams are often involved with care homes and form good working relationships with staff and patients alike. Supporting care staff is essential, and fostering closer working relationships will only further aid team working and the quality of care being provided to patients. The author has had the benefit of such positive working relationships and is highly motivated to both support and advocate for care workers. Implications of the pandemic for care workers are also of great concern. As mentioned on Good Morning Britain (2020), care home workers are three times more likely to be on zero-hour contracts than public sector workers, which could affect benefits, such as sick and holiday pay, with some workers feeling pressured to attend work even when unwell (Rajan et al, 2020). Care workers are also statistically more likely to have a higher risk of death from COVID-19, being twice as likely compared with the rest of the population (Daly, 2020). Schuklenk (2020) elaborated further on this matter, warning that many frontline workers would unfortunately die due to exposure to the coronavirus. In order to protect the most vulnerable, those caring for them must be adequately protected.
Evaluation
Of the 46 care homes in the locality, 30 homes accepted the offer of face-to-face training and support. In the first month of the project, the team delivered over 55 training sessions, some of which were consecutive in the same care home so as to target as many staff as possible during one visit. After the first month, a further 18 sessions were delivered, although they were now more sporadic, since most had been targeted within the first month. Six of the care homes had requested further training updates between 2 and 3 months of the project starting and initial training being delivered. However, only three of these sessions took place, as the care homes had to cancel them. Registers were taken during the sessions and certification supplied to each member of staff who attended, signed and completed by the session trainer. The specific number of staff who received training at each session was not recorded, but the estimation for the number of care home staff directly trained by the PPE Training Team was 250–300. Attendees were asked at the end of the session for feedback, which the session trainer would document, although formal feedback sheets were not left for staff to complete due to infection control concerns. Care home managers were invited to feed back any responses via email if desired.
The challenges to project implementation were mainly logistical. There was often negotiation for staff availability among members of the PPE team to ensure that adequate staff were available to deliver sessions at the convenience of the care home staff. Certain members of the PPE Training Team were highly flexible with their hours, visiting from 7 am until late in the evening in order to attain best attendance in line with the care home dynamics. The use of MS Excel caused some difficulties, as it was through a shared folder, requiring all staff to keep it regularly updated and as ‘live’ as realistically possible. At some points during the project, there were intervals when the system was not up to date, as staff had not had the chance to record information prior to going off work, accounting for leave.
The feedback from care home staff and managers was overwhelmingly positive. Many care home staff voiced concerns that they had ‘just been left’ throughout the pandemic. Consistent feedback also included the amount of different information from different visiting professionals, which was often contradictory and ever changing. No negative feedback was received throughout the training delivery about the sessions provided, although no online tool for feedback was used, which may have prevented attendees from feeding back any negative comments. Nonetheless, the response from care homes requesting further training was deemed to be a positive outcome. The staff involved in the PPE Training Team commented on the often positive and welcoming reception from care home workers and their engagement in the sessions.
Discussion
The project had a significant impact on frontline staff in the initial month of its initiation. As the staff members involved also had other duties, there was often negotiation around availability and the need to try meet requests from care homes. It would have been beneficial to have a full-time regular training team, where observation and feedback based on assessed performance could have taken place, like a competency-based assessment. Russell et al (2020) discussed how compliance with infection prevention and control (IPC) practices may be claimed to be higher than when being observed, potentially attributable to people's perceptions around IPC. Competency-based systems were rolled out later in 2020 through the CCG, focusing on competency-based systems, although this was mainly performed virtually.
Face-to-face teaching in the community setting allows for not just the sharing of knowledge and skills but also the opportunity to work with and build connections with care providers. District nurses and community professional teams rely significantly on colleagues in the social and private healthcare sector and need to continue finding ways to develop those networks to contribute to the integrated care agenda and meet the needs of vulnerable patient groups. Unfortunately, no data are available to prove the effect of the project relating to transmission of COVID-19 in the care homes. However, the informal information received from care homes and attendees indicated a positive response to the training delivered.
Conclusion
COVID-19 will be an ongoing issue despite the incredible achievements made with the vaccination drive. PPE and IPC awareness and competence remains high on the healthcare agenda and must be an ongoing skill, not to be viewed complacently, regardless of what tier the nation is in or transmission rates are being recorded. Safe and effective use of PPE will protect patients and care staff from a range of contagious and infectious illnesses, prolonging life and improving health. Pandemics are not, in essence, unprecedented, and history shows how devastating their impact can be. Ensuring adherence to evidence-based protocols and business continuity planning for such occurrences must be a priority for all social and health care providers.
KEY POINTS
- Competent PPE usage is vital to reduce transmission of COVID-19 and other diseases
- Care home residents are amongst the most vulnerable of patient groups
- NHS providers need to work collaboratively with external community partners to achieve best practice
- PPE competence requires ongoing supervision and support to ensure correct use
- NHS staff have a responsibility to promote best practice through education and guidance
CPD REFLECTIVE QUESTIONS
- Are you up to date with best practice guidelines for PPE in your area?
- What are the main barriers to appropriate PPE usage and how can you overcome these?
- Why is it important to provide support, guidance and education to those working outside the NHS?
- How as professionals can we maintain our competence and improve our understanding with infection control?