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Massachusetts Trainings Facilitated Nursing Home Staff Resilience, Peer Support During COVID-19

Key findings

  • The National Nursing Home COVID Action Network comprises 99 training centers that provided free small-group, interactive, instructional meetings and mentorship to nursing homes earlier in the COVID-19 pandemic
  • Through videoconferences, the Massachusetts training center led 16-week educational programs for 295 nursing homes, grouped into nine cohorts
  • The network was conceived as a way to disseminate evidence-based guidance about infection control, but one of the greatest benefits of the trainings were that they fostered peer-to-peer solution-building and sharing of emotions by nursing home staff
  • The Massachusetts training center fostered a learning culture and adaptive leadership by encouraging nursing home leaders to submit their own best practices and share successful interventions

The COVID-19 pandemic has placed unprecedented strain on nursing home residents, their families and nursing home staff: staggering infection and mortality rates; constantly changing, sometimes discordant federal, state and local regulatory guidelines; and fears about personal safety.

To help nursing homes implement evidence-based infection prevention and safety practices, the Agency for Healthcare Research and Quality (AHRQ), the University of New Mexico's ECHO Institute and the Institute for Healthcare Improvement created the National Nursing Home COVID Action Network. Academic medical centers and other health care organizations provided free small-group training and mentorship to 9,017 nursing homes in all 50 states, the District of Columbia and Puerto Rico.

The training experience in Massachusetts was recently described in the Journal of the American Geriatrics Society by Amy Baughman, MD, MPH, physician in the Department of Medicine at Massachusetts General Hospital, Sharon Levine, MD, section head of Geriatric Medicine at Mass General's Division of Palliative Care and Geriatric MedicineVicki A. Jackson, MD, MPH, chief of the Division of Palliative Care and Geriatric Medicine, Charles Pu, MD, FACP, CMD, attending physician at the Division of Palliative Care & Geriatric Medicine and a medical director at Mass General Brigham's Center of Population Health, and colleagues.

The Network

The network adapted the "hub-and-spoke" knowledge-sharing approach of Project ECHO (Extension for Community Healthcare Outcomes), in which expert teams lead virtual clinics. For weekly videoconferences, each of 99 training centers recruited nursing homes, refined the curriculum and scheduled co-facilitators and expert speakers.

The Program in Massachusetts

The Massachusetts training center was a partnership between the Massachusetts Senior Care Association and Hebrew SeniorLife. It served 295 nursing homes, grouped into nine cohorts of 30–33 nursing homes. The 16-week educational program coincided with the second COVID-19 surge in Massachusetts.

Each of the 16 sessions was 90 minutes and covered a topic such as COVID-19 prevention, outbreak management and return-to-work policies. A 20-minute didactic component was followed by a 20-minute case presentation, then a 20-minute section on quality improvement. The final 30 minutes was for questions and discussion.

The curriculum was modified in real-time by the training center team and co-facilitators to address issues as they arose, such as vaccine clinic implementation, changes in COVID-19 treatment options and staff burnout.

Lessons Learned

The Network provided participants many benefits beyond infection control advice:

Peer collaboration and connection—The sessions were highly structured, but they were designed to be interactive. Leveraging the Zoom software, the facilitators used breakout groups, open discussion and the chat function to encourage support and mentoring. Nursing home staff could share challenges and receive feedback and suggestions from peers. The meetings thus fostered collaboration and a feeling of esprit de corps.

A learning community—During the interactive lectures and case presentations, trainers encouraged participants to share successful experiences and ongoing "pain points." In the beginning, only one or two participants spoke, but as participants became more familiar with each other trust strengthened and there was more discussion.

Conversations often included group brainstorming, such as about processes for acquiring and reusing personal protective equipment, procedures for resident isolation and quarantine, reconfiguring spaces for visitors, and repurposing areas to accommodate the need for social distancing. Participants often shared checklists, protocols and photographs of their newly designed spaces.

Promotion of resilience and well-being—Some nursing home leaders described emotional and physical exhaustion, including feelings of helplessness, moral distress, isolation, overt burnout and symptoms of post-traumatic stress disorder. Some also reported feeling humiliation and personal failure because of community criticism, negative media coverage and the inability to meet fast-changing regulatory requirements despite their best efforts.

Discussions with peers were an important source of emotional and moral support to health care professionals struggling with so much uncertainty and an enormous responsibility.

Looking Ahead

The pandemic has created new vulnerabilities in nursing homes (e.g., employee shortages) and exacerbated existing vulnerabilities. It will be important to continue broadly supporting safety improvements in nursing homes and help staff maintain peer-to-peer connections. Optimally, local governments and health care systems will collaborate to sustain these efforts.

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Christine Ritchie, MD, MSPH, and Anne M. Walling, MD, PhD, of the Division of Palliative Care and Geriatric Medicine, served as advisors to a project of the U.S. Department of Veterans Affairs that aims to improve palliative and end-of-life care for cancer patients.


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