Gerry Kupferschmidt put on a tuxedo and, as usual these days, a face mask to see his wife Laura at her Mississauga, Ont., nursing home. It was Oct. 8, the Kupferschmidts’ 54th wedding anniversary, and even amid a second wave of COVID-19, the couple was celebrating it in style .
The staff members of Ms. Kupferschmidt’s long-term care home Sheridan Villa, owned and managed by the Ontario region of Peel, were determined of that. Knowing that, before she fell ill with dementia, she adored attending formal events, they styled her hair, ordered in a pasta dinner for two, served up a wedding cake, and arranged a table in a balloon-filled private room.
“I walk in there and Laura was dressed to the nines. She had makeup on. She looked fabulous,” said Mr. Kupferschmidt, who had undertaken all the mandatory infection control measures before entering the home, including a routine COVID-19 test, daily temperature check, and hand-sanitizing.
“She smiled big time. She was engaging,” he said, noting that the thoughtfulness the staff demonstrated on this special occasion exemplified the kind of care his wife has received during the pandemic. “It was a lovely, lovely day.”
As long-term care residents across the country face the devastating dual threats of COVID-19 and isolation, the Kupferschmidts’ experience suggests that protecting residents from one threat does not necessarily mean leaving them vulnerable to the other.
While experts emphasize the critical need to increase staffing and allow loved ones into nursing homes as essential caregivers, they are also advocating for practical, low-cost strategies to ensure residents have a good quality of life, in spite of COVID-19 restrictions. These strategies range from the routine, such as managing residents’ physical pain and providing clear communication about changes and disruptions to their schedules, to the creative, such as tailoring the use of digital technology to suit residents’ interests and abilities and finding ways they can safely celebrate holidays and special occasions.
At the heart of these solutions is the need to provide compassionate and personalized care. And for residents like Barry Hickling, who lives in a long-term care home in Windsor, Ont., they cannot come soon enough.
During the first wave of the pandemic, more than 80 per cent of COVID-19 deaths in the country occurred in long-term care homes and retirement homes, according to the Canadian Institute for Health Information. And with outbreaks in these facilities surging again, so too are fears about staffing shortages and further isolation.
The loneliness, confusion and mental anguish his peers have experienced over the past eight months “should never, ever have happened,” Mr. Hickling said. In his role as a member of the board of directors for the Ontario Association of Residents’ Councils, which represents long-term care residents throughout the province, he has heard from residents who were moved from their own private rooms to unfamiliar surroundings and forced to share accommodations with strangers, as homes tried to contain outbreaks. Residents languished in their rooms over the sweltering summer without air conditioning, and individuals were left wondering whether their families had abandoned them.
“That hurts the heart," he said, his voice breaking. "That pains me.”
Andrea Iaboni, a geriatric psychiatrist with University Health Network’s Toronto Rehabilitation Institute, has been asked to see an increasing number of residents who are depressed, withdrawn and experiencing delusions. Some have lost their sense of day and night, and have become deconditioned and weak from spending long hours in their rooms. Others are expressing their distress through anger and aggression.
While there has been considerable variation in terms of how individual homes have responded to the pandemic, some homes have implemented provincially-mandated infection control guidelines and restrictions very rigidly, at the cost of residents’ mental and emotional wellbeing, Dr. Iaboni said.
In advocating a more flexible approach, Dr. Iaboni and her team have developed a toolkit to help long-term care administrators and staff determine what the right thing to do is when having to make countless decisions under these novel and stressful circumstances. The toolkit provides guiding principles, including the need to minimize harm and the need for reciprocity – in other words, when homes must take away certain freedoms or pleasures, they have a responsibility to offer others in return. And, it states, homes need to ensure any actions they take are proportionate to the risk.
For instance, if a resident has stopped eating and is dying because a family member has been restricted from entering the home to feed them, then the harm of this restriction is greater than the risk of infection, Dr. Iaboni said. So, the home needs to find a way to bring that family member back in.
Her downloadable toolkit also includes instructional signs that homes can put up to remind residents of COVID-19 protocols and worksheets that staff can use to create what are called person-centred care plans. These involve considering residents’ individualized needs, preferences and interests to come up with strategies to support them when isolation is necessary.
At one home, this approach led staff to discover why a resident with COVID-19 kept leaving her room, at the risk of spreading the disease to others: she was searching for a phone to call her son, Dr. Iaboni said. Once they understood her motivations and provided her with a phone, she stopped leaving her room. “It was just really trying to understand the individual,” she said.
Carrie McAiney, an associate professor in the school of public health and health systems at the University of Waterloo, suggests there are two different categories of low-cost strategies that homes can use during the pandemic to support the wellbeing of residents, a majority of whom have dementia or other kind of cognitive impairment.
The first she describes as strategies that best position residents to benefit from social connections. These include simply making sure residents have their eye glasses and hearing aids, and that their pain is managed, she said.
The second category involves activities, such as music, crafts and exercise, as well as attending to spiritual needs and cultural practices, and using technology in a thoughtful way, including for virtual museum visits, audiobooks and tutorials, said Dr. McAiney, who holds the Schlegel research chair in dementia.
In Ms. Kupferschmidt’s unit within Sheridan Villa, which operates under a person-centred care model known as a Butterfly Home, staff arranged in the early stage of the pandemic to have meaningful items, as well as DVD players and music, in each resident’s room to occupy them and keep them engaged while they were isolated. For one resident, who was a retired accountant, they set up a desk with office materials, including accounting books, papers and a calculator, with which he could busy himself. For Ms. Kupferschmidt, who loves music and reading, a staff member in personal protective equipment reads and sings to her, her husband said.
During the initial lockdown, staff recognized residents needed human touch, so they gave them hand and head massages, albeit with gloves on, said Mary Connell, dementia advisor for the region of Peel.
In spite of these efforts, they did see worsening depression among their residents, she said. So once they were safely able, they took further steps, such as bringing residents out of their rooms to enjoy the sunshine and ordering in special food. One resident, who had stopped eating, quickly regained his appetite when they brought in one of his favourites, kielbasa, Ms. Connell said.
At Villa Cathay, a non-profit long-term care home in Vancouver that serves Chinese residents, executive director Szuchi Lee said staff have strived to make residents’ lives as normal as possible. They introduced activities such as ping pong, which could be played at a physical distance, virtual mah-jong, and drawing with personal art supplies. She notes one of the main reasons her home has been able to keep residents both comfortable and safe from COVID-19 is each has his or her own private room and washroom, and the newly built facility has enough space in its indoor common areas to allow people to interact while maintaining physical distance.
But Villa Cathay’s creative use of digital tablets has also helped residents stay connected with their families remotely. Even before the pandemic, the home had been using a type of intervention studied by Lillian Hung, an assistant professor of nursing in the school of nursing at the University of British Columbia and clinical nurse specialist at Vancouver Coastal Health.
The intervention involves having family members pre-record short video clips of themselves speaking directly to their loved ones in hospital or long-term care. Whenever the patient or resident feels stressed, lonely or agitated, staff members can replay these videos to them on an iPad.
Dr. Hung has found these videos, which deliver a familiar face and voice, help comfort individuals. And particularly for those with advanced dementia, pre-recorded clips are preferable to live video chats because they are consistent, do not require an immediate response, and can be replayed multiple times around the clock. The type of device makes a difference too, she said; iPads are ideal since the smaller screens of smartphones can be difficult for many to see and follow.
The intervention, which has been adopted at Vancouver General Hospital and Richmond Hospital, not only calms individuals, it makes the staff’s job safer and more efficient, Dr. Hung has found. Showing a video clip, which takes less than a minute, can make bathing, changing and administering medications go a lot more smoothly, she said. “It actually helps nurses to [provide] care.”
Other measures that make residents happier and more comfortable can benefit staff too. For example, when residents are regularly assessed for pain, their pain is better managed and the use of certain psychotropic medications, which can cause drowsiness and falls, declines, said Thomas Hadjistavropoulos, a professor of psychology and research chair in aging and health at the University of Regina. His research has also found that, over time, staff who regularly assess residents for pain experience a reduction in stress and job burnout.
The fact that staff at many long-term care homes are already overworked trying to provide a basic level of care is not lost on those seeking measures to help residents enjoy their lives.
Dr. McAiney said this is where family members and other essential caregivers can play a role.
And to further help mitigate the dire shortage of nurses and personal support workers, Mr. Hickling and others at the Ontario Association of Residents’ Councils are proposing that homes create a new staff position, called a “resident experience ambassador,” devoted to residents’ psychosocial and emotional needs. Those in this job, which would not require special certification, would arrange in-person and virtual visits with loved ones, facilitate residents’ council meetings, and help deliver “the simple pleasures in a day,” explained Dee Lender, executive director of the association.
“Yes, we need more PSWs [personal support workers]. Yes, we need more nursing team members. Yes, we need more recreational team members,” she said. “But by bringing in this level of resident emotional support, it will ease the burden across the board.”
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