Nursing Home Leaders Research Articles

Nursing home leader response during COVID-19: a qualitative descriptive study about use of external resources during the pandemic

BackgroundUS nursing homes were ground zero for COVID-19 and nursing home leaders faced multiple challenges to keep residents and staff safe. Understanding the leader’s role and their use of external resources to rapidly respond to the pandemic is important to better prepare for the next infectious disease outbreak emergency. The purpose of this study is to describe Missouri nursing home leaders’ use of external resources to manage challenges encountered during the pandemic.MethodsThis qualitative descriptive study uses data from semi-structured interviews conducted with leaders from 24 Midwestern nursing homes between March 2022 and March 2023. Interviews were transcribed verbatim and analyzed using Dedoose software. Directed content analysis, guided by Donabedian’s Structure, Process, Outcome framework, was used for analysis. Interviews were conducted as part of a larger mixed-methods study focused on developing knowledge and recommendations to improve US nursing homes’ capacity to respond to infectious disease outbreaks.ResultsForty-three interviews were conducted across the 24 homes. Participants included administrators (n = 24), nurse leaders (n = 19), and infection preventionists (n = 16). Six sub-categories of external resources/support were used by leaders to manage challenges during the pandemic:1) corporate support and communications, 2) statewide resources, 3) community-based resources, 4) health care coalitions focused on emergency response planning, 5) existing affiliations with local organizations i.e., hospitals, and 6) community members and families. Corporate support was a primary resource; however, it was limited to chain-based homes. Leaders from standalone homes seemed most reliant on statewide agencies, existing affiliations, and other community-based resources due to their lack of corporate connections. Health care coalitions were few, but when available, helped nursing homes prepare for the pandemic onset. Family and community members were vital despite being off-site from nursing homes at the pandemic onset.ConclusionLeaders played a pivotal role in accessing and using external resources to manage challenges during the pandemic. Statewide and community-based agencies and existing affiliations were particularly critical for standalone homes who otherwise had little to no means of support. Federal, state and local agencies must consider opportunities to build multi-agency regional collaborations, local health care coalitions and community-based partnerships that include nursing homes as member. Finally, community members and family were important in providing support, thus closing visitation is a double-edged sword that needs careful, future consideration.

Efforts to Support the Mental Health and Well-being of Nursing Home Staff: Insights From Leaders

ObjectivesThe sustained stress and trauma experienced by frontline nursing home (NH) staff throughout the COVID-19 pandemic has been described in health care literature and popular press. Yet, limited attention has been given to attempts to support NH staff. The objective of this study was to examine efforts to support the mental health and well-being of NH staff during the COVID-19 pandemic. DesignQualitative, multiple-case-study design that purposively sampled NHs from 3 groups based on the Centers for Medicare & Medicaid Services NH 5-star quality performance ratings [ie, high (4-5-star), medium (3-star), and low (1-2-star)]. Settings and ParticipantsNinety-four US NH leaders participated in semistructured interviews via phone, between January 2021 and December 2022. MethodsA 3-step rapid qualitative analysis process was used to conduct a thematic analysis. ResultsFive themes emerged as NH leaders described strategies used to address the mental health and well-being of their staff, including (1) efforts to address stressors in staff’s personal lives (eg, risk of COVID-19 transmission to families, finances), (2) providing mental health services (eg, counseling, Employee Assistance Program) and resources (eg, staff self-care, mindfulness), (3) appreciation initiatives to combat negative media portrayals of NHs, (4) fostering an environment that supports mental health and well-being (eg, leadership initiatives to prioritize mental health, embedding training on burnout into standing meetings), and (4) modifying staff benefits (eg, expanding mental health coverage within staff insurance plan, paid time off). ConclusionsIn light of concerns about NH staffing levels and the recently proposed minimum staffing levels, there is a need to design and evaluate initiatives to recruit and retain qualified NH staff. Insights into efforts implemented by NH leaders to improve mental health and well-being can inform the design of future efforts to improve staff retention.

How Nursing Home Leadership Strengthens the Workforce Pipeline Through the Teaching Nursing Home Collaborative

How Nursing Home Leadership Strengthens the Workforce Pipeline Through the Teaching Nursing Home Collaborative

Implementation of an Advance Care Planning Intervention in Nursing Homes: An International Multiple Case Study.

The inability of individuals in the advanced stage of dementia to communicate about preferences in care at the end-of-life poses a challenge for healthcare professionals and family carers. The proven effective Family Carer Decision Support intervention has been designed to inform family carers about end-of-life care options available to a person living with advanced dementia. The objectives of the mySupport study were to adapt the application of the intervention for use in different countries, assess impact on family satisfaction and decision-making, and identify costs and supportive conditions for the implementation of the intervention. A multiple-case study design was chosen where the nursing home was the case. Nursing homes were enrolled from six countries: Canada, Czech Republic, Italy, Netherlands, Republic of Ireland, and United Kingdom. Seventeen cases (nursing homes) participated, with a total of 296 interviews completed including family carers, nursing home staff, and health providers. Five themes relevant to the implementation of the intervention were identified: supportive relationships; committed staff; perceived value of the intervention; the influence of external factors on the nursing home; and resource impact of delivery. There is a commonality of facilitators and barriers across countries when introducing practice innovation. A key learning point was the importance of implementation being accompanied by committed and supported nursing home leadership. The nursing home context is dynamic and multiple factors influence implementation at different points of time.

CARE FOR OLDER ADULTS: WHAT SKILLS DO HEALTH CARE EMPLOYERS VALUE IN COMMUNITY COLLEGE STUDENTS?

Abstract Community colleges (CCs) play an important role in educating healthcare workers engaged in caring for aging populations with greater healthcare and long-term care needs. Healthcare employers and nursing home leaders are obligated to ensure that care provided by their employees meets quality standards, is patient-centered and free from psychological and physical harm. To increase the employability of CC students and understand the skills valued by employers in improving care for older adults, we explored the role literacy, numeracy, and problem-solving skills play in CC student success in the workplace. Using a qualitative descriptive design, we conducted semi-structured interviews with CC administrators (n=9), faculty (n=6), and employers (n=10) who hire healthcare workers (certified nursing assistants, licensed practical nurses (LPNs), and registered nurses (RNs)) educated at CCs. Our findings show that communication skills are highly valued, especially the ability to communicate on the level of the nursing home resident or hospital patient, along with their family members. Numeracy skills, such as measuring medication dosages, critical thinking skills, and problem-solving skills, including conflict resolution, emotional intelligence, and compassionate care are valued by employers. Employers reported that LPNs and RNs have limited leadership and supervisory skills and there is a need to use innovative mechanisms (e.g., case studies, online courses) to improve those skills. Serving on CC advisory councils, clinical rotations and employers’ input into program development were reported as beneficial strategies. Findings from this project will inform both CC administrators and employers regarding skills that are valued in caring for older adults.

IMPLEMENTING SMART AMBIENT BRIGHT LIGHT (SABL) IN NURSING HOME RESIDENTS WITH DEMENTIA: CHALLENGES AND STRATEGIES

Abstract Effective non-pharmacological interventions are critically needed to reduce agitation for nursing home residents with dementia. Lighting interventions (LIs) improve agitation among persons with dementia. However, LIs have not been widely implemented in “real-world” care settings, and a feasible implementation approach to ambient LIs has not been established. This study describes challenges and strategies in implementing the smart ambient bright light (SABL) to provide auto-controlled, consistent indoor lighting that incorporates natural daylight. This SABL includes tunable LED lights, photosensors, and controllers and has a pre-programmed 24-hour control schedule for illuminance. The SABL will be installed in participants’ bedrooms, dining areas, and activity rooms for four weeks. Key challenges include nursing home leadership team’s concerns about compliance with regulations and increased staff workload. Our implementation strategies include 1) engaging the nursing home stakeholders early on to address their concerns, 2) setting up an advisory board at each facility to involve the administrator, director of maintenance, and frontline healthcare workers to ensure the implementation protocol is congruent with their regulations, policy, and staffing, 3) tailoring lighting schedule based on the care routine and resident schedules, and 4) monitoring the SABL operation on-site and remotely. Moreover, the study incorporates a mixed methods design to interview staff/administrators and evaluate the intervention’s acceptability, feasibility, and appropriateness from their perspectives. This is the first study that addresses the implementation strategies of LIs. Findings will establish evidence-based implementation strategies and the best design for SABL to reduce agitation for nursing home residents with dementia.

FROM CRISIS TO CONTROL THROUGH COVID-19: NURSING HOME LEADERSHIP PERSPECTIVES ON DELIVERING QUALITY CARE

Abstract A year after the US Government announced that the COVID-19 pandemic has transitioned to an endemic phase, nursing home (NH) leaders are still challenged to deliver quality care. This study aimed to describe NH leadership perspectives on preparing and maintaining quality care during times of diminishing resources as experienced through the COVID-19 pandemic to gain a perspective on how best to support NHs moving forward. We used convergent mixed methods to explore experiences of NH leaders (N=15) participating in the Project ECHO (Extension for Community Health Outcomes) study. Data were collected through publicly reported survey data and individual interviews conducted at 12-month follow-up. Quantitative data were analyzed using descriptive statistics. Qualitative data were analyzed using verbatim transcripts and inductive thematic coding subsequently organized by a guiding framework. Convergent analysis indicates that participating NHs (N=136) align with national trends in infection rates of residents, staff, access to resources such as personal protective equipment and testing supplies. Leadership from a sub-sample of these homes (N=14; 43% rural; 71% not-for-profit) perceived their NH to be in varied states of operations needed so support quality infection control at the transition to endemic COVID-19 phase. Leadership reported continued challenges in addressing resident & staff vaccinations, securing testing supplies, obtaining financial resources to maintain acceptable levels of personal protective equipment, and isolation practices. Leadership valued providing person-centered care even in times of crisis. These results indicate socio-cultural reasons behind why NHs continue to struggle delivering quality care post-pandemic and offers areas to focus support efforts.

U.S. nursing home leadership experiences with COVID-19 and its impact on residents and staff: A qualitative analysis.

To explore experiences of U.S. (United States) nursing home leadership during the COVID-19 pandemic in their efforts to address resident loneliness and social isolation and to elicit stories about personal and professional impacts on themselves and staff. Qualitative inquiry via three optional open-ended questions appended to a national self-administered survey of American nursing home leaders was employed. Textual data was analyzed using an iterative reflexive thematic approach. A stratified sample frame defined by facility size (beds: 30-99, 100+) and quality ratings (1, 2-4, 5) was employed. Web survey links and paper surveys were sent to 1,676 nursing home directors of nursing between February and May 2022. Open text responses were collected from 271 nursing homes. Broad themes included: 1) Addressing needs of residents & families; 2) Challenges; and 3) Personal experiences of nursing home leadership/staff. Respondents described trauma to residents, staff, and leadership. Resident loneliness was addressed using existing and newer technologies and innovative indoor and outdoor activities. Residents experienced fear, illness, loss, and sometimes death. Isolation from family and lack of touch were particularly difficult. Regulations were seen as punitive while ignoring emotional needs of residents. Staffing challenges and pressures to do more with less created additional stress. Leadership and staff made significant sacrifices resulting in physical, social, and emotional consequences. Beneficial outcomes included staff bonding, professional growth, and permanent implementation of new interventions. New and creative interventions were successfully implemented to address social isolation and loneliness. Improved Wi-Fi and other nursing home infrastructure upgrades are needed to maintain them. Reimagining often conflicting overlapping federal, state, and local regulations, grounding them in good clinical judgement, and incentivizing performance improvement should be considered. Trauma experienced by staff needs to be addressed to deal with current and future workforce needs.

Barriers and facilitators for leading nursing homes through the COVID-19 pandemic: A focus group study in Norway.

During the COVID-19 pandemic, nursing home leaders implemented infection control to protect residents and staff. To understand the barriers and facilitators for leading nursing homes through the COVID-19 pandemic. We invited 34 nursing homes to participate, and 20 leaders (59%) attended focus group interviews. The COM-B model and the theoretical domains framework were used in design and analysis of the study. The barriers for infection control were organisational unpreparedness, high volumes of information, lack of clinical skills, protective equipment, and testing capacity, the nursing home's architectural design, health authorities' low priority of nursing homes, staff's fear, and mental pressure on the leaders over time. The facilitators were having a customised corona plan, change of routines, certification of new skills, access to the municipal quality system, the ability for crisis leadership, loyalty to the nursing home, and support from the environment. The number of part-time positions and the opportunity to outsource parts of the services were also important determinants for infection control. The results identify several barriers and facilitators for nursing home leaders' behaviour for infection control. The results confirm the importance of supporting the leaders' resilience and crisis leadership while working in the pressurised environment of a pandemic. The study provides important insights into barriers and facilitators for leading nursing homes through the COVID-19 pandemic, which could help to inform future strategies for infection control. No patient or public contribution.

Can Better Leadership Reduce Nursing Home Staff Turnover?

ObjectivesTo assess whether a measure of leadership support for worker safety, health, and well-being predicts staff turnover in nursing homes after controlling for other factors. DesignThis paper uses administrative payroll data to measure facility-level turnover and uses a survey measure of nursing home leadership commitment to workers. In addition, we use data from Medicare to measure various nursing home characteristics. Setting and ParticipantsNursing homes with at least 30 beds serving adults in California, Ohio, and Massachusetts were invited to participate in the survey. The analysis sample included 495 nursing homes. MethodsWe used a multivariable ordinary least squares model with turnover rate as the dependent variable. We used an indicator for nursing homes who scored above the median on the measure of leadership that supports worker safety, health, and well-being. Control variables include bed count (deciles), ownership (corporate/noncorporate × for-profit/not-for-profit), percent of residents on Medicaid, state, being in a nonmetropolitan county, and total nurse staffing per patient day in the 2 quarters before the survey. ResultsThe unadjusted turnover rate was lower for those nursing homes that scored higher on leadership commitment to worker safety, health, and well-being. After controlling for additional variables, greater leadership commitment was still associated with lower turnover but with some attenuation. Conclusions and ImplicationsWe find that nursing homes with leadership that communicated and demonstrated commitment to worker safety, health, and well-being had relatively fewer nurses leave during the study period, with turnover rates approximately 10% lower than homes without. These findings suggest that leadership may be a valuable tool for reducing staff turnover.

Exploring the impact of nursing home managers' leadership on staff job satisfaction, health and intention to leave in nursing homes.

To explore the impact of nursing home leadership and staffing characteristics on staff job satisfaction, health and intention to leave. The number of older people has outpaced growth in the nursing home workforce worldwide. Identifying predictors with the potential to positively impact staff job satisfaction, health and intentions to leave are important. Leadership of the nursing home manager can be one such predictor. Cross-sectional design. A sample of 2985 direct care staff in 190 nursing homes in 43 randomly selected municipalities in Sweden completed surveys on leadership, job satisfaction, self-rated health and intention to leave (response rate 52%). Descriptive statistics and Generalised Estimating Equations were conducted. The STROBE reporting checklist was applied. Nursing home managers' leadership was positively related to job satisfaction, self-rated health and low intention to leave. Lower staff educational levels were related to poorer health and lower job satisfaction. Nursing home leadership plays a significant role in the job satisfaction, self-reported health and intention to leave of direct care staff. Low education levels among staff seem to negatively influence staff health and job satisfaction, suggesting that educational initiatives for less-educated staff could be beneficial for improving staff health and job satisfaction. Managers seeking to improve staff job satisfaction can consider how they support, coach and provide feedback. Recognising staff achievement at work can contribute to high job satisfaction. One important implication for managers is to offer continuing education to staff with lower or no education, given the large amount of uneducated direct care workers in aged care and the impact this may have on staff job satisfaction and health. No patient or public contribution was required to outcome measures in this study. Direct care staff and managers contributed with data.

180 Enhancing Engagement of Nursing Home Staff and Leaders in Intervention Development

OBJECTIVES/GOALS: Recruiting under-resourced, rural nursing home (NH) staff to clinical research has proven especially difficult during COVID-19. The goal for this study was to leverage an existing group of NH providers to seek their opinions on the development of a novel person-centered risk management intervention for residents with dementia. METHODS/STUDY POPULATION: This study used community engagement studios (CES) to connect and engage with community experts (NH staff and leaders) attending, or in close vicinity to, a NH provider conference in Denver, Colorado July 25-30, 2022. Led by an experienced moderator and an assistant moderator using a semi-structured discussion guide, two CES were completed with 14 community experts. Community experts took part in a 90-minute facilitated and recorded discussion to gain their perspectives on the DIGNITY (Decision-making in aging and dementia for autonomy) study procedures and instruments along with recommendations for how to improve the acceptability, feasibility, and likelihood of intervention success. The local IRB determined this study to not be human research. RESULTS/ANTICIPATED RESULTS: Community experts most often identified as white/Caucasian (64%) females (93%) holding jobs in NHs as direct-care nurse/nursing aide (n=5), nurse supervisor/director (n=4), other NH leadership (n=3), nursing aide union organizers (n=2), and state surveyor (n=1). The primary outcomes of the CES were suggestions that could be used to adapt the elements of the study design. Following CESs, transcripts were reviewed and summarized on a rapid feedback table. The study team made changes to five of the six intervention elements based on expert feedback. Most experts (79%) agreed that the DIGNITY intervention was acceptable, appropriate, and feasible to implement in the NH community. DISCUSSION/SIGNIFICANCE: This study highlighted the voices of NH staff and leaders that is often underrepresented in research development and provides critical information for how to adapt a novel intervention for future testing in rural NH communities. Results also support the usefulness of CES as a method to develop practical interventions in NH communities.

Unfinished nursing care in nursing homes

This study aimed to describe unfinished nursing care activities in nursing homes. The study was conducted as a cross-sectional survey and employed the BERNCA-NH-instrument and one open-ended question. The participants were care workers (n=486) in nursing homes. The results showed that an average of 7.3 nursing care activities out of 20 were unfinished. A large share of the unfinished activities were related to residents’ social care and the documentation of care. Female gender, age, and the amount of professional experience were found to increase the likelihood of unfinished nursing care. The unfinished care was the result of insufficient resources, residents’ characteristics, unexpected situations, non-nursing activities, and challenges in organizing and leading care. The results indicate that all of the necessary care activities are not performed in nursing homes. Unfinished nursing activities might affect residents’ quality of life and diminish the visibility of nursing care. Nursing home leaders have a significant role to play in decreasing unfinished care. Future research should address how to reduce and prevent unfinished nursing care.

Factors Differentiating Nursing Homes With Strong Resident Safety Climate: A Qualitative Study of Leadership and Staff Perspectives.

The current qualitative study assessed leadership and staff perceptions related to resident safety at Department of Veterans Affairs (VA) nursing homes with a range of safety climates. We recruited a purposive sample of six VA nursing homes from geographically diverse regions of the United States and with diverse overall safety climate ratings. We conducted semi-structured phone interviews with 43 senior and middle level nursing home leaders and frontline providers (medical and nursing). We performed a thematic analysis of interview data to assess participant perceptions of factors that influence resident safety at higher and lower safety climate sites. Analyses identified two factors that differentiated VA nursing homes with high safety climate ratings from those with medium or low ratings: (1) communication about resident safety, particularly the important role of accessibility of physicians and managers; and (2) leadership support for and responsiveness to resident safety issues raised by frontline staff. Findings from high safety climate nursing homes underscore the importance of leadership accessibility, communication, support, and follow through regarding resident safety concerns. These results may provide a basis for designing safety climate interventions, such as those designed to improve communication, teamwork, and quality improvement structures and processes. [Journal of Gerontological Nursing, 49(2), 13-17.].

PROMOTING RESIDENT SAFETY THROUGH TRAINING FOR CERTIFIED NURSE AIDES, RESIDENTS, FAMILIES, AND OMBUDSMEN

Abstract Preventing COVID-19 infections and ensuring resident safety in the nursing home (NH) setting requires collaboration among NH leadership, staff, residents, and their advocates including families, caregivers, and nursing home ombudsmen. To address this multi-collaborative need, the University of North Texas Health Science Center Geriatric Workforce Enhancement Program developed training in two focus areas. The first focused on resilience training for Certified Nurse Aides (CNAs) with the United Way that addresses factors influencing well-being, economic stability, mental health, and other social determinants. The second focused on training residents, families, ombudsmen, and other resident advocates to become active partners with NH leadership and staff in the prevention and control of healthcare acquired infections. To ensure training reflects the needs and preferences of key NH stakeholders, we developed a Nursing Home Advisory Council in partnership with state Ombudsman Programs in Texas, Louisiana, and New Mexico.

A NURSING HOME–BASED COVID-19-ONLY REHAB PROGRAM: VARIABLES RELATED TO SUCCESSFUL COMMUNITY DISCHARGE

Abstract Many COVID-19 patients continue to test positive for COVID-19 beyond the typical quarantine period. Persistent positive testing complicated hospital discharges to nursing home (NH) based rehabilitation facilities when (in May 2020) New York State (NYS) required a negative COVID result prior to NH admissions. To meet the needs of medically stable persistent positive patients, NYS approved 19 NHs as COVID-only facilities (COF). These facilities provided rehabilitation services and allowed hospitals to regain critical space for incoming acute care patients. In the present study we describe the (1) establishment of a 100 bed COF, (2) patients admitted to the COF and care provided, and (3) predictors of successful discharge to the community.Information on the establishment of the COF was obtained from interviews with NH leadership and clinical staff. Patient, treatment, and outcome data were obtained from the NH’s electronic health record. Of 319 COF admissions over four months, 54% were female and the mean age was 80 years (SD=10.56). 51% had cognitive impairment and the mean number of comorbidities was 6.75 (SD=2.47). All patients received physical and occupational therapy while 37% received speech therapy. Medical treatment included: anticoagulants (52%), oxygen (37%), antibiotics (35%), inhaler/nebulizers (31%), and oral steroids (15%). 59% of COF stays resulted in successful community discharges. This outcome was more likely for patients who had fewer comorbidities, less speech therapy, and did not require antibiotics. Implications for COVID care as well as leveraging NH potential during crisis will be discussed.

ORGANIZATIONAL SUPPORTS ASSOCIATED WITH NURSING ASSISTANTS’ JOB SATISFACTION DURING COVID-19

Abstract The COVID-19 pandemic has disproportionately affected nursing home residents and staff, including the nursing assistants who provide critical supports for older adults and people with disabilities. The pandemic has added significant strain to an already vulnerable nursing home workforce, which has historically experienced high levels of turnover, chronic staffing shortages, and high burnout. At the same time, it has generated awareness of the value of the direct care workforce to provide care in places for those most at risk from the disease. Job satisfaction of nursing assistants is as major driver of turnover and intent to leave the job. Research has demonstrated organizational supports and job stresses that are associated with job satisfaction and turnover. However, limited research has investigated the factors associated with job satisfaction in nursing homes during the COVID-19 pandemic. Using data from an employee engagement and management system, we examined organizational supports (e.g., supervision, appreciation, safety) and work-related stresses associated with job satisfaction among nursing assistants in nursing homes (n=402). Higher quality of supervision, feeling appreciated for the job, and feeling safe and comfortable at work were associated with higher levels of job satisfaction. Work-related job stressors –increased workload demands and understaffing – were associated with lower job satisfaction. Our findings provide insights into the importance of employer supports and reducing work-related stressors in nursing assistants’ job satisfaction and practical implications for nursing home leadership regarding how to support workers

Longitudinal changes in nursing home leadership, direct care staff job strain and social support in Swedish nursing homes-findings from the U-AGE SWENIS study.

Promoting healthy work environment as a manager in nursing homes is important to safeguard staff health and well-being as well as care quality when facing increasing demands. The impact of leadership on staff work environment needs further exploration. To describe longitudinal changes in nursing home leadership, direct care staff characteristics, job strain and social support. This study has a repeated cross-sectional design, a five-year follow-up study. Nursing home staff in 181 corresponding units (n=1253 in 2014 and n=1176 in 2019) completed surveys about leadership, staff job strain and social support in a five-year follow-up study. Descriptive and regression analyses were conducted. A higher degree of leadership defined by coaching and providing direct feedback to care staff, handling conflicts in a constructive way and having control of the clinical work, was significantly associated with a lower degree of job strain and a higher degree of social support among staff, with stronger associations at follow-up. The proportion of enrolled nurses increased significantly at follow-up. Leadership is increasingly important for staff work environment, especially in times of increased workload and decreasing collegiality and deteriorating work atmosphere at work. Stakeholder and policy makers in nursing home care may reflect on how managers' leadership is prioritised in these environments because such leadership is associated with staff job strain and social support. Managers striving to improve the work situation of staff may consider their own role and allow flexibility in how and when the work can be performed.

This Was My Crimean War: COVID-19 Experiences of Nursing Home Leaders.

ObjectiveTo describe professional and personal experiences of nursing home care leaders during early waves of the COVID-19 pandemic.DesignQualitative interpretive description.Setting and ParticipantsEight sites across 2 Canadian provinces. Sites varied by COVID-19 status (low/medium/high), size (under or over 120 beds) and ownership model (for-profit/not-for-profit). We recruited 21 leaders as participants: 14 managers and 7 directors of care.MethodsRemote Zoom-assisted semi-structured interviews conducted from January to April 2021. Concurrent data generation and inductive content analysis occurred throughout. Sampling ceased once we reached sufficient analytic variation and richness to answer research questions.ResultsMost participants were female, over 50 years of age and born in Canada. We found 4 major themes. 1) Responsibility to protect: Extreme precautions were employed to protect residents, staff and leaders’ families. Leaders experienced profound distress when COVID-19 infiltrated their care homes. 2) Overwhelming workloads: Changing public health orders and redeployment to pandemic-related activities caused administrative chaos. Leaders worked double shifts to cope with pandemic demands and maintain their usual work. 3) Mental and emotional toll: All participants reported symptoms of anxiety, depression and insomnia, leading to ongoing exhaustion. Shifting staff focus from caring to custodial enforcement of isolation caused considerable distress, guilt and grief. 4) Moving forward: The pandemic spotlighted deficiencies in the nursing home context that lead to inadequate quality of resident care and staff burnout. Some leaders indicated their pandemic experience signaled an unanticipated end to their careers.Conclusions and ImplicationsNursing home leaders faced mental distress and inordinate workloads during the pandemic. This is an urgent call for systemic change to improve working conditions for leaders and quality of care and quality of life for residents. Nursing home leaders are at increased risk of burnout, which must be addressed to mitigate attrition in the sector.

Beyond Compliance: A More Integrated Public Health Approach To Outbreaks In Nursing Homes And Other Disasters.

Nursing home residents are vulnerable to disproportionate harm during disasters and health emergencies, as evidenced by the recent impact of COVID-19 and extreme weather events. Evaluation of these disasters shows that the nursing homes in question were often in compliance with relevant regulations around emergency planning. However, advance planning for disasters cannot anticipate every contingency, leading to the need for flexibility and quick adaptation on the part of nursing home leaders. In addition, disasters often involve larger, regional problems and situations that individual providers cannot solve. We suggest that policy makers need to prioritize development and expectations around leadership skills in nursing home management and better integrate the long-term care sector into local, state, and federal public health planning for future pandemics and other disasters.