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Doctors Without Borders/Médecins Sans Frontières (MSF), the medical humanitarian care organization that has worked for 50 years in conflict zones and on infectious disease outbreaks throughout the world, for the first time in its history has stepped into more than 750 long-term care facilities during the COVID-19 pandemic — including dozens of nursing homes in Michigan and Texas.
MSF has provided on-site support to improve infection prevention and control (IPC) as well as mental health and wellness for caregivers. And in keeping with the communication aspects of its mission, the organization has briefed state and federal officials in the United States about the need for increased wellness support for staff, a more collaborative oversight process, and more on-site support for implementing effective IPC during the COVID-19 pandemic and beyond.
“Our job is to look for society’s most vulnerable and disproportionately affected, and [in the COVID-19 crisis], we found it in these nursing homes, both in the staff and in the residents,” said Heather Pagano, an operational analyst with MSF based in Belgium and the organization’s emergency coordinator in Michigan.
MSF’s involvement in nursing homes began in northern Italy last spring and spread to Belgium, France, and several northern European countries. As the pandemic’s epicenter shifted to the United States, MSF applied an additional lens to selecting its work sites, looking for areas of “structural exclusion and disparities,” Ms. Pagano told Caring.
The organization settled on Michigan — where, according to the Michigan Department of Health and Human Services, African Americans make up 14% of the state’s population but have represented one-third of positive cases and 40% of deaths. In particular, they have focused on the Detroit metropolitan and tri-county area. The facilities were chosen based on the number of COVID-19 cases and deaths, and after consultations with county health departments and with the state, including Michigan’s Quality Improvement Organization (QIO).
Collaboration with MSF was voluntary on the part of facilities, said Ms. Pagano, and “it took some negotiating” — as it often does in conflict zones — to secure access. The facilities had received some help with testing, but the administrators, directors of nursing (DONs), and other leaders were “skeptical of an offer of on-site support without strings attached,” she said in the interview.
Once on the ground, MSF nurses and other team members — most of whom were American due to border closures — initially found widespread “suspicion of outsiders” or disbelief that nonpunitive assistance was being offered, she said. “Once initial fears were quelled, [however,] nursing home staff were super receptive to having help.” One nurse who was the designated infection preventionist for her facility “told us that she had 50 pages of citations and that ‘nobody comes here to help me,’” Ms. Pagano said. “She was on the verge of tears ... It was jarring to see that.”
From the end of May through the end of July, MSF teams assisted 31 skilled nursing facilities in Michigan, conducting site assessments using the Infection Control Assessment and Response (ICAR) tool of the Centers for Disease Control and Prevention and then holding IPC trainings separately for clinical and nonclinical staff — just as they had in Europe. The nonclinical staff generally feel more comfortable asking questions when they’re not among their medical peers, Ms. Pagano said.
In July, MSF decided to duplicate its nursing home work in Houston; it supported 24 nursing homes there from mid-August until early October. In both areas, MSF added a component to the approach it had taken in Europe: For facilities that needed extra support, MSF embedded infection preventionists or nurses for at least several hours a week to provide one-on-one coaching and more hands-on capacity building.
Embedding occurred most often in facilities needing additional help with isolation and cohorting of suspected and confirmed COVID-19 cases and/or with environmental services (EVS), particularly, with safe cleaning practices and proper hygiene management. “What we found — and this wasn’t unique to the U.S. — was that the environmental services staff were often the ones who had the least amount of training in IPC,” Ms. Pagano said. “They’re fundamental for good infection control but are overlooked.”
In a postintervention briefing paper presented to Michigan’s QOI — one of two briefing papers about nursing homes in the United States — MSF wrote that EVS staff expressed relief at being supported and equipped with knowledge about how to protect themselves and the residents.
Hand hygiene and proper use of personal protective equipment (PPE) were covered in both arms of MSF’s training module (clinical and nonclinical), and these techniques were less likely to require extra coaching. In general, staff members had a lot of questions about extended use of PPE, especially gowns, Ms. Pagano noted.
Caring for the Caregivers
MSF knows well from its crisis work that the mental wellness of health care workers can impact the quality of care provided. For nursing homes, the organization sent in social workers and psychologists with its nursing teams to offer individual debriefings and group sessions on stress, grief, and coping mechanisms — whatever activities each facility preferred — and to create wellness boards with resources for counseling, grief support, and crisis hotlines.
MSF teams listened to staff talk about fear, frustration, sadness, and helplessness. “One [DON] told me that she left her badge on one day when she went to Walmart, and people said nasty things to her about how nursing homes were killing people,” Ms. Pagano said. “She was horrified — she had been working 12 hours a day for months trying to protect the residents.”
“The stigma this sector faces is really awful. Not just here, but also in Europe. We saw staff there with [post-traumatic stress disorder],” said Ms. Pagano. MSF team members shared with nursing home staff and administrators some tactics they’ve used themselves when working in difficult environments, like having a buddy system or peer-to-peer support groups so that everyone has someone to confide in, and ensuring that leaders are approachable and supportive.
In its Michigan briefing paper, MSF cites Buffy Lloyd-Kriecji, MD, who worked as an infection prevention and control manager for the organization. “More than anything,” she said, “staff need mental health support to recover from the trauma that was experienced [as they saw residents die and colleagues get sick while] operating with little to no staff, having state surveyors on their back, having little to no resources and little to no initial testing capabilities,” all while being “vilified on the news.”
Connie Flanigan, a DON in Wayne, MI, said in an excerpt in the paper that she was “educating nonstop” so that she and her colleagues could care safely for their residents. “We come here every day, we spend 12 to 14 hours a day here, because this is where we want to be.”
Creating Sustainable Support
Since its founding in 1971 by doctors and journalists, MSF has routinely spoken up about what it observes and learns while providing short-term medical aid — and, especially in well-resourced countries, it advocates for needed resources, capacity, and sustainability for the longer term.
In its two briefing papers on responding to COVID-19 in U.S. nursing homes, MSF calls for a more collaborative oversight process “with on-site training and support that is constructive and non-judgmental,” increased support for staff wellness and access to mental health resources, in-service training for nonclinical staff, funding for adequate staffing, full-time infection preventionists, and more supportive leadership. (The facilities where DONs had to simultaneously fill mandated IPC positions “fared worse in MSF’s IPC assessments,” they stated.)
These and other recommendations were shared with Michigan’s QIO — which, according to Ms. Pagano, has since deployed more on-site assistance — as well as with some federal lawmakers and others who have the “ability to make changes,” she said. MSF was planning to produce a fuller and more “public-facing” report by early 2021.
In addition, MSF has compiled the resources used in its IPC training into an IPC tool kit and is encouraging schools of nursing to integrate the materials into their curricula. “My understanding is that IPC is a neglected area of nursing education,” said Marina Novack, RN, BSN, MSN, CRNA, who has worked with MSF since 2013 and is now the long-term care project coordinator for MSF-USA.
Not only can nursing students benefit from a better foundation in IPC, but graduate-level nurses could use the tool kit to go into nursing homes and build upon MSF’s support. Students of the doctorate in nursing practice (DNP) “in particular can spend a longer amount of time, maybe over the course of a semester, to be embedded and really target IPC deficits and enact long-term changes,” Ms. Novack said.
The Wayne State University College of Nursing, which sits in midtown Detroit, was beginning to pilot such a program with a small group of DNP and public health nursing students as 2020 closed. “The overall goal is to help [nursing homes] further develop what Doctors Without Borders has done with the assessment and all the education, and to help them develop a more global IPC program beyond COVID,” said Katherine Balint, DNP, RN, APHN-BC, MSN-NA, CRRN, CHSE, FCN, an assistant professor at the college. “Ultimately a goal will be that long-term care facilities see the benefit of having a relationship with nursing schools … that we can learn from them and their residents as well,” she said. “That’s a bigger ideal for me.”
Ms. Pagano, in the meantime, feels deeply affected by her nursing home experience in Michigan. “These facilities are overstretched to a degree we found distressing, and it’s not only here in the U.S. — we see it in our European projects,” she said. “It made me and many of my colleagues question how we treat our older population. Are we really OK with this? We all became fierce advocates for a topic we never saw ourselves working on.”