MSF Supports Nursing Homes in Houston, Texas, During COVID-19
MSF's IPC nurse manager Kira Smith and MSF nurse Jonathan Garcia provide infection prevention and control guidance for an environmental services worker at Misty Willow Healthcare and Rehabilitation Center, a long-term care facility in Houston, Texas. MSF conducted infection prevention and control (IPC) training and mental health and wellness training with medical and non-medical staff, including EVS workers, at nursing homes in Houston during the summer and fall of 2020.
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IPC & Wellness Tool Kit video series

LTC facilities throughout the country often lack proper IPC knowledge and resources. Students in schools of nursing, public health, and social work are uniquely positioned to implement training programs for these facilities in their own communities. In this video, Dr. Buffy Lloyd-Krejci guides students on how to identify and connect with facilities that need training and support to implement the IPC practices they are required to follow. 

Resources in video

• Resource 1A: Standard operating procedure (SOP) for facility IPC assessment
Resource 1B: Intro email template
Resource 1C: Nursing home infection preventionist training course
Resource 1D: Training agenda for IPC nurse
Resource 1E: How to protect yourself while working in LTC facilities
Resource 1F: CDC demonstration of donning PPE
Resource 1G: CDC demonstration of doffing PPE
Resource 1H: PPE handouts for facilities

Additional resources

• Resource 1I: CMS nursing home reopening recommendations
• Resource 1J: COVID-19 FAQs
• Resource 1K: IPC nurse job description

Click here to view the transcript

Hi, I'm Dr. Buffy Lloyd-Krejci. I'm an epidemiologist board certified in Infection Control. I worked as an infection prevention and control—or IPC—manager with Doctors Without Borders as part of the organization's emergency response to the COVID-19 global pandemic in the United States. Doctors Without Borders is an international medical humanitarian organization that brings free health care to underserved, underrepresented communities around the world. For nearly 50 years, we've worked to prevent and treat outbreaks of infectious and communicable diseases. 

In 2020, the COVID-19 pandemic has devastated nursing homes and other long-term care facilities. Elderly residents are among those most vulnerable to the disease, as are the staff working closely with them. In response, Doctors Without Borders brought its IPC expertise to these facilities in parts of Europe and the Americas. Here in the US, in Michigan and Texas, we helped more than 80 facilities better implement IPC practices through in-person training while also attending to the mental health of these staff by offering wellness support. 

Our short-term intervention has concluded, but there is still a lot of work to be done inside long-term care facilities—otherwise known as LTCs. These facilities need on-going support and nursing schools are in a unique position to provide it. That's why we've made our IPC and wellness tool kit freely available to nursing schools across the country to incorporate into their curricula. LTCs can benefit tremendously from having access to trained nurses that are skilled in IPC. And students can use the experience to conduct capstone or thesis projects in this often overlooked but extremely important area of health care. 

So, let's get started. Our tool kit includes a set of videos and resources to help you prepare for, conduct, and follow up on IPC and wellness training sessions. In this video series, I will walk you through the process, provide recommendations, and offer learnings from my own experience. This tool kit should not be used as a strict guide, but rather something you can adapt too, to help meet the needs that you identify in the LTC. 

LTCs and other congregate care facilities throughout the country often lack IPC knowledge and resources. This was true even before COVID-19. Studies from 2018 show that an estimated 380,000 people per year—or more than 1,000 people per day—were dying of preventable infections in LTCs. The novel coronavirus has further exacerbated this existing issue. 

It is important to understand why LTCs have been lacking in this area. It begins with the ineffective and complex regulatory system in the US. Under the umbrella of LTCs you have nursing homes, skilled nursing facilities, and assisted living facilities. These facilities are governed by federal, state, and local legislation. There are often different guidelines and regulations regarding the exact same issues. Stakeholders involved in the regulation of the industry include different levels of government, as well as for-profit and nonprofit organizations. These bodies often have competing priorities and are in a constant tug of war over funding. 

The majority of LTCs operate in the private sector and they are either financed through private insurance, Medicare, or Medicaid. Facilities that participate in Medicare or Medicaid are regulated by the Centers for Medicare and Medicaid Services, or CMS. 

Infection prevention and control has not traditionally been a priority for CMS—the agency only began regulating IPC in these facilities in 2017. One challenge with the implementation of the new federal rule requiring all CMS-licensed LTCs to have an infection prevention and control program is that they were given very little resources and support to effectively implement the new guidelines and regulations. This has been harmful to the LTCs, as they have faced punitive actions when they have been unable to meet the IPC requirements at a 100% compliance. 

The LTC sector, as a whole, has been chronically underfunded, which translates to outdated, under-resourced facilities and an underpaid workforce. Consequently, this drives high turnover rates, leaving many facilities with an undertrained workforce. 

Beginning in November of 2019, LTCs were required to have an infection preventionist—or IP—on site at least part-time. Given the timing of this new mandate, you will find that the IP at many facilities have typically only received online, remote training through the CDC, the Association for Professionals in Infection Control and Epidemiology—APIC—or the American Healthcare Association. And there are very few national programs that offer one-on-one, on-site support that enables IPs in training to implement evidence-based IPC practices that are tailored to their environment. 

In addition, most IPs are already employed in other roles—for example, they may be the director of nursing. So, patience is key. This individual will be incredibly busy, wearing multiple hats and their sole focus will not be IPC. This is why your support is so critical. Just being on site, sharing knowledge and expertise in person, will help the IP tremendously. 

Navigating the LTC sector is challenging and unique. It's not like any other health care setting you may have worked in. To help you navigate this environment, we have created a Standard Operating Procedures, or SOP document, Resource 1A in our tool kit. You can use it as a reference throughout this video series and beyond. The SOP is a step-by-step guide that will help you navigate this process. 

As MSF is an international organization working in emergency responses all over the world, we are often seen as outsiders when we come to provide assistance in a community. We work hard to listen, build relationships, and gain people's trust. But it is always a challenge. Nursing schools are already known in the community and some already have connections with LTCs, so it will likely be easier for you to establish working relationships with these facilities. You will also be a step ahead when it comes to being able to identify the LTCs that are most in need in your community. 

The nursing school faculty should be the ones to identify facilities, make initial contact, and build the relationships for their students. This relationship with the facilities can be formalized, where needed, with a written agreement called a memorandum of understanding—or MOU—between the school and the facility before students begin their clinical practice. Your school may already have MOUs in place with facilities in your community where students can start implementing an IPC support plan right away. If your school does not have any existing relationships with facilities, then the nursing faculty can identify LTCs by calling around to facilities in your area. Or, our email template at Resource 1B is a tool that faculty can use to reach out to facilities. Faculty can also identify LTCs by talking with state or local Departments of Health. It's a good idea to communicate with the Department of Health anyway in order to ensure coordination and to avoid the overlap of activities. 

Before you begin working in a facility, it is important to thoroughly understand the written IPC policies for that facility. The LTC is held to these policies by their state and federal surveyors and you must adhere to them too. For example, a facility might require a recent COVID-19 test from you before you can enter the building. Also, make sure to review all of your local, state, and county IPC regulations. 

When working in an LTC, it is important to be culturally sensitive to this environment. This healthcare setting is accustomed to regulatory bodies coming in, making assessments, giving them a long list of citations, and fining them with hefty fines for these citations. One of the facilities Doctors Without Borders visited told us that at the start of the COVID-19 outbreak they were left with 53 pages of citations, but no help or resources to improve the findings they were cited for. 

So right from the start, it is important to make clear that you are there to support them and develop a working relationship where your goal is to assist them in improving their IPC practices and this will help decrease the risk of harm and death to their vulnerable resident population. These folks are overworked, understaffed, and overloaded with a lot of new regulations in a global pandemic. Let them know that you are there, free of charge, and independent of the regulatory process, to provide actionable steps for how to implement the evidence-based IPC practices they're required to follow. 

Before you start working in a facility, you need to be up to date on the most recent IPC regulations. There is a helpful online CDC course with 23 modules—the link is available at Resource 1C. Keep in mind that this is often the only training a facility's IP has ever received. We have created a list of the modules that we suggest you complete, available at Resource 1D. You will need to create an account to access the CDC courses, but anyone can sign up and it's free. It's important to note that some nursing schools have had these modules in their syllabus for certain courses and some offer credits, including continuing education credits for faculty. So, you could potentially receive credits while preparing to work in these facilities. 

Before going on-site into an LTC, you will need to be prepared for what special personal protective equipment—or PPE—is required. Check with the facility first and ask them what their current policy is. In the tool kit, we've described some items that you may need such as a surgical mask, fit-tested N-95 mask, and eye protection such as goggles or a face shield. There is also a description of items that you will need when you leave a facility such as disinfectant spray, a paper bag, and spare clothes. You can find the complete list at Resource 1E in the tool kit. However, keep in mind that these are items that worked for our process and you should tailor them to your specific workflow and the requirements of the LTCs you work with. 

Once you have completed the suggested modules in the CDC training course and have gathered all of the materials you'll need, you must become very familiar with how to properly don—put on—and doff—take off—PPE. We suggest that you practice this before entering the LTC facility. Some short videos from the CDC can help you prepare and be confident in your donning and doffing ability before entering the facility—refer to Resources 1F and 1G. Remember, you will be training and educating the staff on these practices, so you must be proficient in this protocol. If you find during your initial assessment that the facility needs support in the proper use of PPE, there are handouts at Resource 1H that you can bring to the facility and use as a training tool. 

In the next video, we'll prepare to make your facility assessment.

An effective IPC program requires a thorough assessment to help identify what a specific LTC facility is doing well and how it can make improvements. The CDC Infection Control Assessment and Response (ICAR) tool is a standardized framework used to help facilities prepare and manage COVID-19. In this video, Dr. Buffy Lloyd-Krejci  goes over how to conduct the assessment, prepare a report, and how to share the findings with the administration to establish next steps.

Resources in video

• Resource 2A-2AA: Infection Prevention and Control Assessment Response tool (ICAR)
Resource 2B: IPC report template 
Resource 2C: Assessment and report how-to video
Resource 2D: Assessment follow up email template
Resource 2E: Dashboard template

Click here to view the transcript

Once you have been approved for your on-site visit at the LTC, you will schedule a date and time to meet with the IP to conduct an initial assessment. If you have a social worker, mental health officer, or wellness support officer on your team, it is advisable that they join this meeting so they can get to know the facility and identify gaps in their respective roles. We will discuss mental health and wellness training in a later video. 

The CDC developed the Infection Control Assessment and Response tool—called the ICAR. It is a standardized framework used to help LTCs prepare and manage COVID-19. When you conduct an assessment at an LTC, this is the tool you will use. The ICAR tool is available on the CDC website, see Resource 2A in our tool kit. 

Before you visit the facility, you should familiarize yourself with the ICAR. It is best if you have more of a conversation with the facility staff versus an "interview", as this will help set you apart from a traditional state or federal surveyor, and assist you in obtaining key information that you can use for the assessment and future training. Becoming familiar with the ICAR beforehand enables you to have this conversation without having to look down at a clipboard like a surveyor. However, be sure to take notes during the conversation. You will also need to go on a tour of the facility as part of your assessment, and be sure to take notes and some photos as well. It's helpful to reassure the staff that the notes and photos are to be used in the assessment to help identify what the facility is doing well and how it can make improvements in the next phase—not for regulatory purposes. As a courtesy, ask for permission before taking notes and pictures. This demonstrates your respect for them and supports building a relationship of trust. Remember, surveyors come in and do whatever they want without permission. Our goal is for them to have a different experience with us. 

After the assessment visit, you should have a short debriefing with your team members to discuss what the overall findings were and develop a plan for the next steps in supporting the LTC. Then you will write up the assessment. The ICAR tool itself is pretty simple to use. The Notes section is important in terms of providing valuable feedback to the facility. You want to provide them with constructive and objective feedback about your observations. For example, we want to provide them with insight on what they are doing right, like appropriate COVID-19 screening, and what IPC gaps are identified, such as the lack of hand sanitizer dispensers and housekeeping protocols. Once you have completed the assessment, email the PDF version of the ICAR back to the facility. You should send it to the facility administrator first, then to the IP. It's important to know that the IP is not typically a decision maker and does not have the sole authority to make changes in the facility. 

In addition to the ICAR, you will complete a pre-populated IPC report template that is located in our toolkit at Resource 2B. We have a video at Resource 2C that walks you step-by-step through completing both the ICAR and the report template. 

The IPC report is where you describe unique observations about the specific facility. It is important to identify strengths and weaknesses, and to identify how the weaknesses or IPC gaps can be improved. The template is a 12-page editable document—you will remove sections that are not applicable and expand upon areas that are. It is advisable to add photos, taken during the site visit, to illustrate some of your findings—for example, excellent signage describing the quarantine process, or a hallway that has no hand sanitizer dispensers. Your observations need to be concrete, objective, and provide positive feedback as well as highlighting IPC gaps. Many sections of the report template include helpful links where facilities can get CDC signage, guidelines, and online training sessions. 

There is a Recommendation section for each IPC domain. If the facility is doing a great job in that section, you can comment on that great work already being done without having to include any new recommendations. It is important to remember that this report is for the facility and we want to optimize it to add value to them. 

Once you've completed both the ICAR and the IPC report, you will email them together to the facility administrator and your IP contact at the facility. We suggest completing an assessment and emailing it within 48 hours of your assessment visit. There is an email template you can use in the toolkit at Resource 2D. We've found that it's appreciated when you include a short summary of a few of the top recommendations in the body of the email so that they have a little checklist of things they can quickly respond to. 

About 24 hours after you send the email, call the facility to set up a time with your contact to go over the findings. We've found that it's most effective to go through the assessment and IPC report in person. 

During the post-assessment meeting, describe the interventions that you can provide. Whether you are offering to do a clinical or nonclinical staff training, or proposing to embed with specific staff—which we will talk about in another video—you'll need to reach an agreement with the facility. And you'll need to schedule the date to begin those interventions. 

Once all of the interventions have been completed, schedule a post-assessment on-site visit. You will fill out the ICAR again, however this time it will only be focused on the domains where interventions were completed. For example, if you spent a lot of time with the EVS staff, then target the EVS section of the ICAR and the elements that applied to your intervention. Nursing schools can also follow up with re-assessments after the training is completed. There could be an opportunity for further evidence-based training and assessments. 

Once everything has been completed, schedule an exit phone call with the facility. During this call, identify if there are any final questions regarding how to continue implementing evidence-based IPC and wellness practices. Some facilities may require further visits and longer term, hands-on support, and nursing schools are uniquely positioned to do this. So even after the exit phone call, a school can continue their relationship with the facility and provide the sustainable support they need to continue improving over time. 

There's one more tool to discuss in this section. It's called the dashboard. The dashboard is a formatted Excel spreadsheet that can be used to keep track of the ICAR data from all the facilities your school has assessed. It allows schools and students to compare data across facilities and identify where the IPC and wellness gaps are. Some schools have found it helpful to collaborate on this project and share one's dashboard. In some instances, graduate students have access to the dashboard and can input their own data. Students can use the information for meaningful, data-driven projects that can lead to real, long-term improvements. You can find the dashboard tool in the IPC toolkit at Resource 2E. 

In the next video, we'll discuss how to follow up with the facility, and conduct training sessions.

Implementing an IPC initiative in a specific LTC requires careful consideration of that facility’s unique needs. A comprehensive IPC training and support initiative targets the gaps in knowledge for both clinical and non-clinical staff. In this video, Dr. Buffy Lloyd-Krejci explains how to customize these sessions to train all staff effectively.

Resources in video

• Resource 3A: Clinical staff IPC training
Resource 3B: IPC training for non-clinical staff
Resource 3C: IPC binder contents
Resource 3D: Infosheet Isolation and cohorting LTC facilities
Resource 3E: Environmental cleaning

Additional resources

• Resource 3F: Door caddy recommendation list 

Click here to view the transcript

When you have completed the ICAR assessment and the IPC and wellness report, it is now time to sit down with the facility's IP and propose the interventions that will be most helpful for this facility. 

Two possible interventions to consider are an IPC training session with clinical staff, and an IPC training session with non-clinical staff. We found that having two separate training sessions is helpful given the different levels of knowledge and education. For example, a member of the housekeeping staff might feel uncomfortable asking a medical question in front of a nurse. They might think it could sound like a silly question to someone with medical training. But if they are in a group of other non-medical staff, they might be more likely to ask their question. Keep in mind that it is not always possible to offer the different training sessions. Be flexible and accommodating to the facility's needs. 

We've included clinical and non-clinical training modules in our tool kit, available at Resource 3A and 3B, but it's important to tailor the training sessions to the specific needs of the facility. We want to make sure they are getting targeted education to improve IPC practices right away. So, draw on what you observed in your assessment to make these training modules as specific and helpful as possible. 

At an LTC, the clinical staff are typically licensed nurses, physical and occupational therapists, and CNAs—or certified nursing assistants. CNAs spend a lot of time with the residents, bathing, feeding, and changing them. 

For the clinical staff, it is important to cover information related to transmission-based precautions for the quarantine and COVID-19 positive units. They will also often have more questions related to how masks actually work and the difference between a surgical mask and an N-95 mask. 

Non-clinical staff in an LTC facility can include the administrative, who oversee operations; and secretary staff; housekeepers, who make sure the environment is clean and sanitary; food service workers who cook, prepare, and deliver the meals; and social workers, who are helping with all the social needs. There may be other non-clinical staff as well, such as receptionists and volunteers. 

Non-clinical staff are often forgotten about when it comes to IPC training and support and this is a terrible oversight. In particular, the environmental services or EVS staff are crucial to decreasing the transmission of infections. Unfortunately, they rarely receive any training, or worse, they receive inaccurate training for IPC. So, this is a crucial opportunity to fill the knowledge gap. 

Again, you'll want to really tailor the training session based on the IPC gaps that you've observed. Something that is really important to training non-clinical staff is hand hygiene. They should know that alcohol-based hand rub, or ABHR, is the preferred method for hand hygiene. If you have a session with mostly EVS staff, make sure that you cover the appropriate order for cleaning a resident's room: high to low, clockwise or counterclockwise, and the cleanest to dirtiest. I'll go into more detail about cleaning guidelines in the next video. 

It's also important to go over face coverings during this training, as you may have found that many staff wear their mask below their nose and chin, or worse, not at all. We want to describe how wearing a mask can prevent the spread of COVID-19 within the facility. 

After each training session is complete, we recommend leaving an IPC resource binder with the facility that contains printouts of the most useful documents, guidelines, and signage. Our tool kit includes a wide array of these resources. If the facility needs signage, be sure to include printouts of the CDC signage available at Resource 3C. There are also helpful clinical guidelines, for example, on how to isolate or cohort residents, available at Resource 3D. You will also find non-clinical resources, such as a list of disinfectants and how to use them so they're effective against COVID-19, available and much, much more at Resource 3E. You can select and insert the most helpful printouts into a three-ring binder and leave with the IP. This will ensure that they have these resources on hand, as sometimes the IP does not have access to a computer. 

In the next video, we will go over how to embed at a facility.

The practice of embedding allows trainers to offer additional mentorship to staff that require extra support in improving their IPC measures. In this video, Dr. Buffy Lloyd-Krejci goes over how to determine the timeline and scale of embedding initiatives. She also reviews the importance of evidence-based training, post-ICAR assessments, and why continuing to develop IPC practices has other long-term benefits beyond confronting the challenges of COVID-19.

Resources in video

• Resource 4A: Standard operating procedure (SOP) for embedding
Resource 4B: CDC best practice for environmental cleaning
Resource 4C: Best cleaning practices (Oregon Patient Safety Commission)
Resource 4D: EPA list of disinfectants to use against COVID-19 (N-list)

Additional resources

• Resource 4E: Daily surveillance sheet

Click here to view the transcript

It will become clear—either early on during the ICAR process, or after you've conducted the training sessions—that a facility could use additional support in order to improve targeted IPC practices. This might require a few short follow-up visits, or longer-term support that entails working closely with specific staff to address certain IPC issues. We call this on-site, targeted support "embedding" or "mentoring". In either case, your school should work with the facility on how to best facilitate this level of support. 

We've created a Standard Operating Procedures, or SOP document at Resource 4A in our tool kit. You can use it as a reference during this video and while you are preparing your embedding activities. 

One question that we get a lot is, "How do you determine what the timeframe of an embedding initiative should be?" As I mentioned in an earlier video, nursing schools have the advantage of being in the same communities as LTC facilities and may be able to offer some insight into how much support is needed. In addition, the ICAR assessment and IPC report should really guide you in this process. For example, if the environmental services—or EVS—staff don't have the supplies they need, are cleaning the rooms in a way that can cross-contaminate the environment, or if they are not in the habit of conducting hand hygiene, then you may be looking at multiple sessions working solely with the EVS staff. 

Extended, in-person embedding can also potentially provide the opportunity for a doctorate of nursing practice student to conduct a thesis or capstone project. The idea is that the student would identify where a system or process needs improving and then implement the evidence-based practice. For example, if a facility is optimizing PPE as a result of the COVID-19 pandemic, the student could assess the current protocols and tools being used, for example, the CDC's PPE calculator. If gaps are identified within the existing process, then the student could implement a proposed intervention to mitigate the IPC gap. 

A key term to keep in mind is "evidence-based training". For example, if you conduct an ICAR assessment of a facility and provide targeted training and support, the following semester you may be able to reassess the facility and compare the outcomes. You would have the potential to identify, based on other research studies, if the facility was following evidence-based protocols. This could lend itself to future research and support. Keep in mind that if you are going to collect data and utilize it for a research study, you need to discuss with your academic institution what processes you must undertake prior to collecting baseline data. This could include an IRB approval process. 

Embedding sessions over the long-term can provide insight into what other areas need improvement. For example, a nursing school in Detroit that conducted an IPC training at one facility is now proposing to research the mental health of its residents. So, one project can segue into areas for additional research. 

As I mentioned in a previous video, according to the CDC, even before COVID-19, it was estimated that more than 1,000 people died every day from infections in LTCs. The IPC knowledge and support has simply not been there. And when COVID-19 is under control, IPC problems won't simply go away. LTCs across the US have significant issues with multidrug-resistant organisms, such as C. diff and CRE, Candida auris and MRSA. These infections continue to run rampant in our LTCs, resulting in significant harms and deaths to our vulnerable residents. 

The CDC, CMS, and other local, state, and national public health organizations are working very hard to mitigate the lack of IPC education and support for LTCs. However, there is a lot of work to be done, and it will require stakeholders and staff to come together and work jointly on this burden. Key to this is the nursing home leadership taking an active role in empowering and equipping staff to perform their duties while implementing safe and effective IPC practices. 

So how can we also support this process? Providing impactful education and training during an embedding or a long-term initiative requires the right approach. 

One of the most significant concepts that I want to convey about working in LTCs is that you must be flexible, patient, and empathetic. The staff working at LTCs are truly in the trenches. They often have multiple roles and are pulled in many different directions. Your coming in to help is probably the last thing on their minds and, at first, you might actually be an added stressor. During Doctors Without Borders' intervention, many of the LTC staff initially thought we were from the state regulatory office and were nervous. Others simply wanted to get their jobs done and leave for the day. Try to put yourself in their shoes and realize that this is a super challenging health care setting and staff are working with a very vulnerable population, including disabled and elderly people. Their residents are immunocompromised and often have memory disorders such as dementia and Alzheimer's. 

When we come in with compassion and empathy, this can go a long way in building trust with the staff. Remember, you are an ally. You're there to support them and to impart the knowledge and training that is needed. Even if you are shocked by certain IPC practices, remain neutral and respond in a positive way, never with a judgemental or harsh response. One way to demonstrate empathy is to work side by side with the staff that you are mentoring. For example, if I'm supporting housekeeping to implement better infection control practices, I usually ask them to show me how they clean. And then I'll provide feedback, but I'll also ask them, "Can I work alongside you?" When they see that I'm a partner and not just somebody behind a clipboard taking notes about what they're doing wrong, that bond of trust can be strengthened. 

Working alongside the staff also makes them feel appreciated and valued. I have had many housekeeper staff tear up when I remind them that they are critical to the safety of the residents, that infection control starts with them. Scrubbing floors and toilets is critically important but it can be a thankless job. A bond of trust develops when you are willing to scrub the toilet with them. We must convey to them how valuable they are, that they are on the front lines every day, and that they are essential workers. 

As I mentioned, EVS—which includes the housekeeping, maintenance, and laundry staff—are often overlooked when it comes to IPC education and support. One issue is that housekeeping staff usually do not have the training, checklists, and IPC protocols that the clinical staff follow. They are often trained on what chemicals to use, but not on the importance of hand hygiene, appropriately donning and doffing PPE, or the proper cleaning order of a room. 

For the purpose of EVS practices, let's dive a little deeper into IPC measures that make cleaning and disinfecting more effective. For example, you always want to clean from high to low to remove any dust or dirt in higher regions. It is important to clean in circular movements- either clockwise or counterclockwise- so that all surfaces are cleaned. Finally, always, always, always, clean from the least dirty to most dirty—or from the cleanest area to the dirtiest area—in order to reduce the risk of cross-contaminating the environment. These guidelines are described in the CDC's best practices document at Resource 4B and demonstrated in these helpful videos at Resource 4C. Unfortunately, about 95% of the time I observe the opposite of these best practices, with the staff cleaning the restroom first, and even the toilet first, because it's the dirtiest and then, without changing their gloves or rag, they clean the resident's room, including the tray table where they eat their meals. 

Cleaning for IPC is not highly complex, but it does require some education and training. Sometimes during a training you see a light bulb go off and they say, "Oh my gosh, that makes so much sense." They just didn't think about it that way. They were thinking, "I have 30 rooms to clean and I have six hours to do it, so how fast can I do this?" That doesn't always equate to cleaning based on infection control practices. 

Staff should always use environmental cleaning and disinfectant products that are EPA-registered and effective against COVID-19. The IPC tool kit includes a list of disinfectants appropriate to use against COVID-19, referred to as the end list at Resource 4D. They also need to be properly equipped with supplies such as mops and towels that can be laundered at high temperatures of 160 degrees or higher to kill microorganisms. You will find that the EVS staff don't always have the proper supplies, or they lack adequate quantities of what they do have. For example, they may not have the appropriate amount of hand towels for cleaning the rooms and the restrooms. I have observed a facility that used one hand towel for every resident restroom for the entire resident unit and then another hand towel for every resident room in the unit. We're talking about 30 beds and only two hand towels. Without realizing it, the cleaning staff were contaminating the environment by using the only one hand towel they had available to them. If possible and available, it is recommended that each resident room be cleaned with four or five hand towels. 

You will also find that sometimes the EVS staff do not have access to the appropriate cleaning and disinfecting chemicals. This is a good opportunity for you to check that they are EPA-registered and effective for health care. I have seen outbreaks of infections in LTCs that could have been linked back to the fact that the staff thought they were cleaning with a disinfectant when it was actually only a fragrance. Remember to reference the N list in the IPC tool kit at Resource 4D to determine if the chemicals being used are effective against COVID-19. Many state and federal surveyors may have already verified the appropriate use of the chemicals, but it is always helpful to double check, as they may have recently started using new chemicals. What is really important for the housekeeper to know is how long the chemical takes to kill microorganisms on surfaces. Typically, the contact or kill time is anywhere from 30 seconds to 10 minutes. This matters because it may require the process of cleaning to be altered to ensure that the chemical remains on the surface for the appropriate amount of time. The contact or kill time information for each agent is also provided on the N list at Resource 4D. 

The benefits of in-person follow-up and embedding are clear. You will get a sense of what the facility's specific needs are and a more global sense of how all the different parts of the system interact and influence each other. There is no substitute for in-person observation and interaction. 

If it has been determined that the clinical staff need additional support, it is typically with the certified nursing assistants. They are the primary caregivers of the residents and spend the most time with them. They often need guidance on when to conduct hand hygiene, such as before and after donning and doffing gloves, before and after contact with a resident, and after contact with the environment. Other areas to observe are how they don and doff PPE, and how they clean shared resident equipment, such as those found on vitals cards and in a shower room. Sometimes working with CNAs are a lot more challenging, as they are incredibly busy running from room to room assisting the residents. Remember that we do not provide any clinical care with the residents as part of this IPC program. 

Finally, remember when conducting the embedded sessions that you do not want to work with any one staff member for longer than one hour in a day. Even though we are helping and supporting them, remember that we are also slowing them down. Therefore, it is better to schedule multiple visits rather than to work with one person for a long period of time. We do not want to be responsible for the staff running behind and having to leave work late or not completing their work. 

After you've finished your training and embedding sessions, conduct a post-ICAR assessment. Evaluate the specific area that you focused on and complete a new ICAR. Consider comparing the information from the baseline assessment to determine if your intervention improved IPC practices. 

It is critical to continue to develop the IPC practices of every graduating medical professional, and this can be done sustainably by carrying out long-term embedding activities in these facilities. In turn, the LTCs will benefit from on-going support and IPC reassessments. Nursing schools can maintain relationships with the facilities over time and bring students back to carry out future assessments to ensure IPC practices are maintained. 

In the next video, we will discuss how to strengthen staff mental health and wellness at an LTC.

Developing and structuring a mental health support plan is crucial for staff in LTC facilities. In this video, Licensed Clinical Social Worker Athena Viscusi goes over the MSF psychosocial intervention model and shares insights from the sessions that MSF carried out to support the mental health and wellness of staff in various nursing homes during the COVID-19 pandemic.

Resources in video

• Resource 5A: Cumulative stress reactions
Resource 5B: Mental health support plan
Resource 5C: Elder abuse in nursing homes
Resource 5D: Staff wellness flier
Resource 5E: Psychological first aid
Resource 5F: Supporting wellness of health care staff

Additional resources

Resource 5G: Standard operating procedure (SOP) for staff wellbeing intervention
Resource 5H: Job description wellness instructor 
Resource 5I:  Technical resources 

Click here to view the transcript

During the height of the COVID-19 pandemic, we saw health care workers in hospitals receiving an outpouring of public support—which was well-deserved. At the same time, however, staff in nursing homes and other long-term care facilities who were caring for vulnerable, often ill, elderly residents were often forgotten. In some cases, they faced stigma and blame as nursing homes became hotspots for the virus, and many of the residents they had worked so closely with day after day did not survive. 

Working in a nursing home or other long-term care facility—or LTC—is a difficult job, as evidenced by the chronically high staff turnover. Certified nursing assistants, or CNAs, for example, are reported as having a turnover rate of 74% annually. As a result, nursing homes are nearly always understaffed. COVID-19 has only exacerbated this, leaving remaining staff overwhelmed, often without the PPE and other resources they need to keep themselves and the residents safe. All of these stressors have had a cumulative effect and staff had been deeply impacted. Some examples of reactions to cumulative stress include problems sleeping, feelings of alienation, difficulty concentrating, and substance abuse. You can find a comprehensive list of these reactions in our tool kit at Resource 5A. 

Workplace wellness depends upon all aspects of an employee's working life, from their physical safety to the emotional climate at their place of work. Staff are well when they're safe, healthy, and actively engaged in their work according to the International Labour Organization. Even though work at a nursing home can be very rewarding, sometimes it doesn't meet the criteria for staff wellness, especially during times of crisis like the COVID-19 pandemic. So it's very important to identify the stressors that are undermining staff wellness and examine their effects. It's crucial for the health of the individuals and also crucial for maintaining a consistent and productive staff who's then able to provide quality care for the residents. 

Doctors Without Borders is an international medical humanitarian aid organization with a long history of providing mental health care in crisis and conflict situations. As part of our response to the pandemic and the outsized impact it's had on nursing homes, our organization decided to focus on providing staff wellness training sessions, along with infection prevention and control trainings in LTCs. In the US, we sent mental health professionals with different backgrounds, including clinical social workers and psychologists—to 59 facilities in Michigan and Texas over a six-month period. Our teams conducted one-off group sessions lasting between 45 and 90 minutes each. The ultimate goals of these brief sessions were to get staff to recognize their stressors, the effects of those stressors, and their own coping mechanisms and to guide them and developing a peer support network to help them better manage their stress. 

We received such positive, enthusiastic feedback from participants—from administrators to environmental services staff—that we want to make it available to more people and to more LTCs. Because you, the students, are based in the same communities as these facilities, you have the flexibility and time to take what Doctors Without Borders did and develop it further to improve and ensure its effectiveness. You also have the opportunity to help address systemic problems. Helping staff to identify and better manage stress is essential, but it won't solve the root problems that they face. Problems like understaffing are chronic in nursing homes and they need to be addressed on the administrative level. Students in school should think about how they can use long-term placements inside these facilities as a way to better advocate for working conditions which can reduce turnover and understaffing and go a long way towards improved wellness. 

In this video, I'll go over the Doctors Without Borders psychosocial intervention model and some of the learnings from the sessions we carried out during the chronic phase of the COVID-19 pandemic. Our tool kit provides guidance on how to develop and structure a mental health support plan—at Resource 5B. So I won't go into that, but I'll talk a bit about the core parts of the program. 

An important thing to know as you start to plan an initiative, whether it's a single training session or a long-term project, is that much depends on the facility's administrator in charge. In our experience, it was key to engage administration early on while offering to support their staff. Sometimes an administrator might not be aware of the impact that stressors can have on staff or the importance of supporting staff wellness. They're focused on productivity, but they might need help making the link between wellbeing and performance. 

You can sensitize them about the values of wellness training and peer support networks. Consider how to share this information with the administrator. You could even create a presentation for them. There is data-driven information in peer-reviewed publications that you can refer to. For example, we know that stress in the context of caregiving relations is a risk factor associated with increased elder abuse. You can find that study at Resource 5C in the tool kit. We also provide a handout with tips for managers during the pandemic that recommends concrete things they can do for their staff. That's available at Resource 5D. These can all be useful tools in connecting the dots between wellness support and improved work performance. 

The administrator should be involved from the beginning and should continue to be involved. When you set the day and time for the training session, the administrator will be the one sending staff members to attend it, and once the peer support group has been established, the administrator is essential to the effectiveness and longevity of this group. Ideally, that person is even helping to bring in topics for discussion at theses meetings. 

One of the first things we do during the training session is to conduct a group wellness assessment, which means talking together about work stressors—what's been happening at the facility, what are some of the main issues. Some of the problems that came up during a lot of our sessions, were understaffing, being called upon to work long hours, and not having time to grieve after residents they'd cared for had passed away due to COVID-19. Through this opening exchange, you can assess what stressors people are dealing with at the facility and bring them up for discussion later on. 

After the assessment period, we begin the intervention, which has four main parts: identifying stressors, understanding the effects of these stressors, defining healthy and unhealthy coping mechanisms, and presenting peer support. 

First, we want to help people to identify the stressors in their lives and see the differences between their individual stressors and work-related stressors. Individual stressors are events occurring in one's personal life at home. They could be financial issues or problems with a family member. Work-related stressors are due to issues at work—such as long hours and having to cover other people's duties. 

You can ask people in the group for examples of individual stressors. Offer up some of your own to get the conversation going and to get people thinking about what might be causing stress in their lives. For example, you could say, "I have a teenage daughter at home and nearly every day, we have a fight because she doesn't want to do the things I ask her to do to help around the house and this makes me very upset. What stressors are you facing at home?" A common personal stressor during COVID has been the concern that one could bring the virus home, putting the health and lives of loved ones at risk. There could also be concerns about a loss of income if a partner has lost their job, or there could be anxiety about the disruption of normal routines—like child care or elder care. 

You can then guide the group to identify work-related stressors. Some work-related stressors could include concerns about changes in work hours and duties, not having enough PPE supplies, having less interaction with and support from coworkers, fear that sick coworkers might not recover, and a whole host of other issues. To help stimulate the conversation, you can ask questions like, "If someone's not able to finish their work during their shift, how does that impact the people who come on for the next shift?" 

The next step is getting people to recognize how these stressors are affecting them. Prompting them to consider this, could enable some people to think consciously for the first time about how they're really being affected by stress. They may answer that they're exhausted, not sleeping, or feeling angry and resentful, for example. 

Next, you want them to identify what coping mechanisms they're using—good and bad. By coping mechanisms, I mean a conscious or unconscious adjustment or adaptation that decreases tension and anxiety in a stressful situation. Good coping mechanisms could be going for a walk or deep breathing. Negative coping mechanisms could be withdrawal, lashing out, or stress eating. Ask them to examine their responses and become more aware what might be unhealthy behavior. You can also encourage them to recognize that in a long-term situation like a pandemic, behaviors like this are not sustainable. Checking in with oneself is part of self-care and that's an important part of managing stress. Everyone will have their own approach to it, but during a chronic situation like COVID, we need to check in with ourselves regularly and see how we can better manage our stress. Psychological first aid, a support technique for people who've recently been exposed to severe stressors, provides some tips that could be very helpful. See a list of these tips at Resource 5E. 

Sometimes what happens during these sessions where people are talking about coping mechanisms, is that someone in the group will recognize when one of their colleagues was stressed. They'll say, "Ah, so two weeks ago, when you weren't speaking to anyone, you were really stressed out," and that's the moment where they start supporting each other. 

Finally, we want to present the idea of peer support. The fact is that coworkers in long-term care facilities know better than anyone what each other are dealing with. They all have similar types of stress on the job. So they are best positioned to hear, understand, and help each other find solutions. We want people to recognize the power of working with each other and talking to each other—essentially teamwork. Sometimes there'll be someone who says they're stressed at work, but have no way to change it. We want to guide them to see that having peer support can help them come up with a way to better manage and reduce that stress. You can find a presentation on best practices for supporting emotional coping for health care staff at Resource 5F. 

Ultimately, we want to leave behind an effective support structure—a peer support group with a designated facilitator that holds regular meetings, where they discuss their stressors and how they can reduce that stress. As I mentioned before, the administration should be closely involved with the functioning of this group so that it's prioritized and continues well into the future. 

Doctors Without Borders' project was an emergency response to the COVID-19 pandemic, but as we've moved into the chronic phase of the pandemic and beyond, more sustainable support is needed. Nursing homes and other LTCs will continue to have ongoing needs for wellness support with or without COVID. Students will be able to take the time to help form long-lasting peer support groups and to observe and measure how effective the initiative has been. They'll be able to work with the administration to build stress management into the workflow and identify what needs to be done to improve it. 

Something to note is that although more and more we've been accustomed to online resources, this kind of training and the meetings that should follow are much more effective in person. There's better engagement and the facilitator can hold people's attention better when there are no distractions. These exercises call for introspection, sharing, and clear thinking, and these things are much easier to achieve when people are in the room and in the moment. Of course, during a pandemic, we need to also ensure that our activities include proper mask wearing and physical distancing. 

Thank you and good luck.