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The Role Of Nurses In Nursing Homes During COVID-19

Jul 8, 2020
Sarah Jividen, RN, BSN, SCRN

Nurses working in nursing homes in the U.S. have been facing a unique challenge during the coronavirus pandemic. The elderly patient population they serve is the one most adversely affected by the COVID-19 virus.

In fact, out of the 114,000+ deaths caused by COVID-19 in the United States as of early June, over 40% have been nursing home residents.   

There is a mountain of evidence that COVID-19 affects the elderly and those with co-morbidities. However, there is less focus on the nurses who are actually fighting to care for them and keep them safe.

Whether you are a nursing new grad who has a soft spot for working with the elderly, or you are an experienced nurse who wants a change of pace from the hospital setting, there is opportunity to make a positive difference to our elderly in the nursing home setting.  

This article will go more into detail about working as a nurse in a nursing home as well as the unique challenges that COVID-19 had brought into this more vulnerable area of patients.  

elderly man looking out of window in nursing home


The Types and Roles of Nurses Who Work in Nursing Homes

All types of nursing roles in the nursing home setting aim to provide compassionate healthcare while maintaining dignity and safety.

Certified Nursing Assistant (CNA)

A CNA’s work in a nursing home is very similar to the work that they do in the hospital setting. It includes bathing, toileting, changing, ambulating, dressing, turning, and repositioning patients.   It is a primary care role and is extremely important in helping elderly patients with normal activities of daily living that they are unable to complete without assistance.  

Licensed Vocational Nurse (LVN)/Licensed Practical Nurse (LPN)

An LVN and LPN are the same roles—the title they have depends on the state in which they live. In California, they are called LVNs, and in the rest of the US, they are referred to as LPNs.  This role works under the supervision of a registered nurse or doctor. The scope of practice of an LVN/LPN depends on the laws of the state they work in, as the criteria vary from state to state. In general, the role includes taking vital signs, giving oral medications, checking a patient’s blood glucose levels, charting in a patient’s medical records, as well as other daily patient care activities. 

Registered Nurse (RN)

Registered nurses usually oversee the work of the CNA and LVN/LPN, but all the positions work together to best manage individual care for each patient. RNs in a nursing home perform many of the same duties as they do in the hospital setting, including taking vital signs, giving medications, performing assessments, and overseeing patient treatment plans. There is usually a higher nurse to patient staffing ratio in a nursing home as compared to in a hospital, so it is extremely important that every caretaker works together to ensure that patients get the medical and hygienic care they need to stay safe.

Nurse Practitioner (NP)

Nursing homes don’t always have an NP on staff, however some do. They play an important role in assessing physical and neurological changes and overseeing care for a large number of residents. Nurse practitioners are also able to prescribe and change medications and order treatments for patients. (The scope of practice for an NP depends on state law and varies around the country; in some cases, an NP must work under the license of a physician on staff.)

How Is Working in a Nursing Home Different Than Working in a Hospital Setting?

Nursing homes are unique from the hospital setting for many reasons. First of all, elderly people who usually move into a nursing home do so to receive permanent care for the remainder of their lives. Oftentimes, in addition to their older age, they have longer medical histories that have resulted in the inability to take care of themselves. A nursing home provides both medical care and safety that they are no longer able to maintain while living at home. Nursing homes also offer a community where residents can be social and take part in daily activities with one another. 

elderly woman sitting on bed and smiling into camera


How Nursing Home Nurses Are Adapting to Patient Care During COVID-19

Residents in a nursing facility wholly depend on their nursing care. Many residents are often memory impaired and are unable to perform the normal activities of daily living that they once were. Some are struggling with depression and anxiety, which has been compounded by the effects of the coronavirus pandemic.  

Here are a few ways that nurses in nursing homes are protecting their residents:

  1. Finding and using their own personal protective equipment (PPE), as many nursing homes have not allocated enough PPE to supply for staff, which has contributed to the spread of the virus
  2. Segregating sick patients
  3. Taking in recovered COVID-19 patients after discharge from hospitals
  4. Taking staff temperature daily
  5. Temporarily preventing family and friend visits to the nursing home (many are visiting their family members through their windows)
  6. Making temporary cutbacks on hospice visits

Unique Struggles for Nursing Home Nurses During the COVID-19 Pandemic

Staffing Ratios

One of the issues that many nurses are saying is making COVID-19 more challenging is that nursing homes generally have much higher CNA, LVN/LPN, and RN-to-patient ratios. It is generally thought that since the residents in a nursing home are not being cared for at a medical center, that the time needed to provide care for them is much less. However, it is important to note that working with an elderly community often takes more time than with a younger patient in a hospital, partly because they have different daily needs.

Many elderly patients are unable to perform normal activities of daily living due to their older age, and they need help with everything from standing, walking, turning, eating, bathing, and taking medications. They often move more slowly, and the care they require takes more time and compassion. Swamping nurses and caregivers with too many patients at time makes it very difficult to know if there has been a physical or neurological deviation from a patient’s baseline. 

You can look here to find the nurse to resident ratios in the nursing homes near you.

COVID-19 Is More Lethal in the Elderly

There are many unique caretaking challenges for elderly patients in nursing homes, and COVID-19 has stretched those challenges to the limit.  

According to the CDC, 8 out of 10 deaths from COVID-19 in the US have been adults ages 65 and older.  

For adults aged 65-84 who are positive for COVID-19, the hospitalization rate is 31-59%, the admission to intensive care rate is 11%-31%, and the death rate is 4-11%.

For adults aged 85 and older those numbers rise substantially, with hospitalization rates of 31-70%, rate of admission to intensive care is 6-29%, and death rate 10-27%.

To make matters even more complex, many doctors say that seniors with COVID-19 show “unusual symptoms.”  

Normally, in COVID-19-positive patients, doctors expect to see shortness of breath, fever, and a relentless cough.  

Elderly patients may have none of these symptoms. Doctors say that older patients with COVID-19 show atypical symptoms including seeming “off,” sleeping more than usual, or being confused.

It is well known that the elderly don’t have as strong an immune response as the younger population. But without the typical COVID-19 symptoms, efforts to make sure these patients get urgent treatment for the virus can be delayed.  

So in a nutshell, not only do the elderly have a higher COVID-19 mortality rate, but it also may take longer to recognize a medical change that would make a nurse suspect COVID-19. 

Patients With Dementia May Have a Harder Time Remembering to Follow Directions (Like Hand Washing)

One of the ways we have found that actually helps prevent the spread of the coronavirus is through aggressive hand washing and social distancing. But memory-impaired patients need frequent reminding. Yet another reason why we need lower nurse to patient staffing ratios in nursing homes, especially now during the COVID-19 pandemic.  

Nursing Homes Have the Same Personal Protective Equipment (PPE) Shortages That Other Us Hospitals Have

Not only may it take longer to realize that an elderly patient has COVID-19 due to delayed inflammatory response, but many nurses are working without proper PPE to protect themselves and their patients from contracting the virus.  

This is one reason that many nurses helping COVID-19 patients are contracting the disease (over 600 medical professionals who cared for COVID-19 patients have died of the virus in the US). Without the proper PPE, nurses can also inadvertently spread the virus.  

We Need to Honor the Heroic Efforts of Our Nursing Home Nurses

Many nurses have said that they don’t like to be referred to as “heroes.” But there really is no better term to explain the selfless actions and compassionate care that nurses are giving in nursing facilities around the county. They do not receive nearly the credit they deserve for their compassion to the nursing home community.  

Nursing home nurses are heroes in action for their work to help care for and heal our vulnerable elderly patient population. We can only hope that this pandemic influences radical changes in how we manage health care within the nursing home setting. Our elderly patients deserve better. Until then, we must focus gratitude on the nurses who are working harder than ever before to keep this vulnerable community safe while providing the compassionate care they need.

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