From the beginning of the pandemic’s spread throughout the United States, COVID-19 has taken a particularly devastating toll on nursing homes. Elderly residents have been among those most vulnerable to the disease, as have the staff working closely with them. Essential workers in these facilities are often on duty for long hours with no time off. They see residents and colleagues fall sick, or become sick themselves. They worry about bringing COVID home to their families, or bringing the disease to the residents. In far too many of these facilities across the US, staff have not received the specific training and tools they need to protect themselves and others. According to the most recent data collected by The New York Times, more than 35 percent of coronavirus deaths in the US have been linked to nursing homes and other long-term care facilities.
Doctors Without Borders/Médecins Sans Frontières (MSF) has decades of experience in implementing infection prevention and control (IPC) measures in projects around the world. After applying this expertise to respond to COVID-19 in nursing homes in Europe, we decided to offer support to long-term care facilities in the US. MSF teams have provided training to nursing home staff in the Navajo Nation and in Michigan, and are currently working in Houston, Texas. Here, Kira Smith, an MSF nurse and midwife leading the IPC team in Houston, describes our work there.
Nursing homes have been extremely hard hit by COVID-19 all over the world, so it’s no surprise that MSF decided to focus on these facilities in the US. How did MSF come to work in Houston?
The genesis of our project in Houston came from our experience in Belgium. MSF teams worked extensively in nursing care facilities in Belgium, Italy, France, Portugal, and Spain early in the pandemic. They worked in hundreds of nursing homes, and through that experience they were able to develop an adaptable IPC training module for staff working in care facilities. When the pandemic arrived in the US and nursing homes here started seeing so much sickness and death, MSF opened a project in Detroit, Michigan. A medical team of nurses and a mental health and wellness specialist worked in 50 nursing and care facilities—and the assistance was really well received. In July, there was a spike in cases in Texas, so MSF decided to duplicate the program in Houston. We thought this was a place where we could make a real difference.
Other national and state-level agencies in the US are providing guidance for facilities like these. What is MSF offering that is different?
To begin with, what we’re doing differently is addressing IPC needs at nursing homes by working with the staff in person. First, we conduct an assessment of how the facility is operating, and we provide our recommendations to improve IPC measures. Then, we start the in-person training sessions. We work not only with the skilled health providers, but also with the staff in housekeeping, maintenance, food services, and administration. Each group has specific needs, and we customize each training to meet those needs.
We work with the facilities to see if more help is needed in certain areas—and, if so, one of our nurses will embed with the staff and help them focus on that area. One function where we’ve helped the most through embedding is safe cleaning practices, particularly in what order to clean things in a room. I can tell you the best way to clean a bathroom, but it takes practice and you need to understand the ‘why’ in order to make that change. For example, you should always clean from cleanest to dirtiest, otherwise you’ll spread germs around the room. But a lot of people want to clean the toilet first, they just want to get that part over with and that’s how they are accustomed to doing it. But if I can spend time with you to help you understand the reasons for doing it the other way, and you practice it with my help, you can make that change.
Some other key differences in MSF’s training are that we’re also providing mental health and wellness support for the staff. And we are working to make the entire training package sustainable. We are looking to partner with local nursing schools in Houston and hand over our IPC training to them. We did this in Michigan, as well, and we are reaching out to nursing schools elsewhere in the US. We hope the schools will take our IPC and wellness training materials and methods and integrate them into their curricula. It could be a really symbiotic relationship.
Why did you decide to offer wellness support for nursing home staff?
We are providing wellness support for nursing home staff because they’ve been hit really hard. They've suffered a lot of losses. I like to think of residents who live in these facilities as ... this their home. And the staff—whether it's housekeeping or the nurse’s aid or the nurse—are kind of like family members in their home. So, as staff, you're in their home every day, you see them every day, you have interactions with them. And when you see them get sick and suffer or even die, that takes a toll.
At one facility, I was helping a housekeeper clean a resident’s room and she told me that this resident was one of her favorites. She used to be a strong, vibrant woman, a leader of the Vietnamese church services they offered there, until she contracted COVID and became really sick. She recovered from COVID, but now she can’t get out of bed and she’s suffering from long-term consequences of the disease. The staff member told me it made her so sad to see this resident like that, and every time she sees her she tries her best to brighten her day a little.
Some staff have also seen their coworkers fall ill and die, and they're dealing with that stress and fear, too. Some are also dealing with anxiety from not having the proper equipment to help care for others and to protect themselves. They're all working much longer hours. They're worried about taking COVID home or bringing COVID to work.
What kind of mental health and wellness support does MSF offer?
A key activity is going in and helping them form peer-to-peer support groups where they can talk about different stressors, identify positive and negative coping skills, and decide how they can support each other. We also work with the administration on how they can support their staff.
We hear some really affecting stories from people. There was one staff member who made her own funeral arrangements because she had COVID and didn't expect to recover. She didn't want her family to have to make those arrangements for her. Here she is, believing she’s on her deathbed, still thinking of how she can keep her family from suffering. Thankfully, she recovered and was able to tell me that story. But she is a great example of the kind of person you want taking care of your elders, someone who is always thinking of other people.
There was also an environmental services manager at one facility—he and his wife had just had a new baby. He sent his wife and baby away to stay with other family members so that he could continue to work and not come home and potentially expose them to the disease. As a midwife, I immediately thought of his wife, a new mom having to navigate that alone while worrying about her husband—both of them without their support system.
Data from the Centers for Disease Control and Prevention (CDC) and other sources show that people of color, particularly Latinx and black people, are contracting and dying from the coronavirus at a much higher rate than white people. Recent reports confirm that this is also playing out inside nursing homes—have you seen this in Houston?
Anecdotally, yes, I have. And it’s not just the residents. Within the facilities where we've worked, a high percentage of the staff are people of color, predominantly black and from the Latinx community—and a lot of those staff have had COVID. We also know that people who work in health care are being more affected overall, whether that’s someone who is providing direct clinical care or environmental services like cleaners or kitchen staff. And so, when you put those two things together, being a person of color and working within the healthcare system, I have seen that they are certainly being affected disproportionately.
In Houston, what has been the biggest challenge from your perspective?
I think one of the challenges that we’ve faced going into nursing homes in Houston is gaining trust. There is a lot of fear associated with allowing an outsider to come in and do an assessment and a review. That fear comes from a very real place—a regulatory system based on punitive measures. We find a lot of places not truly understanding why they are required to implement some measures and not receiving the support they need from the system as a whole in order to carry out those measures.
I think that MSF’s approach has been from a place of support. It's from a place of, “We want to help. We don't want to criticize and penalize.” So we go in, and we'll make suggestions, and then discuss how they can do this. We meet them where they are and help them work with what they have to solve the problems.