The coronavirus disease 2019 (COVID-19) pandemic has had a disproportionate impact on nonacute care facilities. Some of the highest rates of infection and mortality have occurred among residents and healthcare personnel (HCP) at these sites. Reference McMichael, Clark and Pogosjans1–Reference Kluytmans-van den Bergh, Buiting and Pas3 Staff in nonacute care facilities may also work at multiple facilities, which can amplify the spread of respiratory viruses across these settings. Reference Van Houtven, DePasquale and Coe4 Implementing infection control measures in long-term care and nonacute care facilities can also be challenging. For example, memory care facilities may face challenges with isolation practices and restricting patient movement. Reference Velayudhan, Aarsland and Ballard5 In addition, acute care facilities generally have access to healthcare personnel trained in infection prevention, which may not be the case in nonacute care settings. Reference Hori, Fukuchi, Sanui, Moriya and Sugawara6
HCP in nonacute care settings can also be vulnerable to changes in availability of PPE, and they may have limited training on appropriate PPE use. Reference Abbasi7 Rapid changes in the availability of COVID-19 diagnostics, transmission and quarantine protocols, treatment considerations and vaccine availability create additional challenges for HCP. Reference Ness, Saylor, Di Fusco and Evans8,Reference Razu, Yasmin and Arif9 Considering these challenges, there is a high concern that the ongoing pandemic will affect the physical and mental well-being of HCP in nonacute care settings. Reference Chew, Lee and Tan10,Reference Felice, Di Tanna, Zanus and Grossi11
Recent literature shows increased psychological stressors, anxiety, sleep disturbances, increased workload and burnout among HCP in acute care settings during the COVID-19 pandemic. Reference Felice, Di Tanna, Zanus and Grossi11–Reference Liu, Yang and Zhang14 Surveys of HCP at acute care facilities during the pandemic have also shown significant heterogeneity in the knowledge and attitudes toward COVID-19 transmission, infection prevention, and COVID-19 vaccination. Reference Maude, Jongdeepaisal and Skuntaniyom15–Reference Nguyen, Irvine and Chung17 Prior studies of respiratory virus transmission in a single LTCF have revealed knowledge gaps regarding recommended infection prevention practices. Reference O’Neil, Kim and Prill18 However, limited information is available on the experiences, attitudes, and infection prevention practices related to COVID-19, as well as the impact of the pandemic on HCP working in nonacute care facilities. Therefore, we assessed the experience, knowledge, beliefs, and perceptions of risk related to COVID-19, infection prevention practices, and COVID-19 vaccination among HCP employed in 3 nonacute care facilities.
Methods
In April and May 2021, an anonymous survey was distributed to HCP at 3 nonacute care facilities in the St. Louis, Missouri, metropolitan area. To include a range of nonacute care settings, 1 skilled nursing facility, 1 memory care facility, and 1 postacute rehabilitation facility were selected as the sites for this survey; these facilities had inpatient capacities of 56, 125, and 96 beds, respectively. The total number of staff employed at the nonacute care facilities at the time of survey completion was estimated to be 620. The survey included 83 total questions about demographics (age, sex, race, ethnicity), experience working in healthcare, job role, frequency of contact with patients with COVID-19, and COVID-19 history and exposures. Respondents were also asked to respond to a series of statements about COVID-19 beliefs and knowledge, SARS-CoV-2 vaccination, COVID-19 policies and practices at their facility, behaviors at work and outside work, fears related to COVID-19 and their job, and the impact of COVID-19 on the respondent. The survey was based on a prior study on respiratory infections in long-term care facilities. Reference O’Neil, Kim and Prill18
A secure link to complete the survey electronically was distributed to all facility employees via email. Paper copies of the survey were also placed in staff work areas at each facility and could be placed in sealed envelopes in a deposit box. Respondents reviewed a consent information sheet prior to completing the survey. Completion of the survey was considered consent for study participation. Respondents were allowed to skip any questions that they preferred not to answer.
Survey data were collected and managed using REDCap electronic data capture tools hosted at Washington University in St. Louis. Reference Harris, Taylor, Thielke, Payne, Gonzalez and Conde19,Reference Harris, Taylor and Minor20 The analysis was completed using SPSS Statistics version 27 software (IBM, Armonk, NY). Responses to each survey question were summarized and then stratified by facility and extent of HCP contact with patients with COVID-19. Using Mann-Whitney U tests, descriptive statistics were calculated for group comparisons of survey responses from HCP who had more versus less contact with COVID-19 patients.
The study protocol was approved by the Washington University Human Research Protection Office (IRB no. 202102194) with a waiver of consent for recruitment and a waiver of documentation of consent.
Results
Attitudes, beliefs, and practices related to COVID-19 infection prevention and PPE use
In total, 156 HCP responded to the survey, with most surveys completed on paper (n = 104, 66.7%). Respondents were evenly divided among the 3 facilities, and one-third of HCP reported healthcare experience of 15 or more years. The demographics and workplace roles for the survey respondents are noted in Table 1. The overall survey participation rate was 25.2%: 42.5% at the skilled nursing facility, 23.5% at the memory care facility, and 19.0% at the postacute rehabilitation facility. Furthermore, 87.8% of HCP reported having been tested for COVID-19 at some time in the past, and 20.5% reported having previously tested positive for COVID-19. Nearly one-quarter of respondents (23.1%) reported having someone in their household who tested positive for COVID-19; 46.8% reported knowing someone outside work who had been hospitalized for COVID-19; and 41.7% reported knowing someone outside work who had died of COVID-19.
Table 1. Demographics and Job Roles of Surveyed Healthcare Personnel
Note. NP, nurse practitioner; PA, physician assistant; PT, physical therapist; OT, occupational therapist; ST, speech therapist; RT, respiratory therapist.
Overall, 78.7% of survey respondents agreed that COVID-19 was a serious problem in the community, and 29.7% agreed that COVID-19 was a serious problem at their facility. Also, 97.5% of respondents knew that asymptomatic COVID-19 infection could occur, and 81.9% stated that wearing a face mask could help protect them from COVID-19. However, 58.7% agreed that wearing a mask made it more difficult to communicate with others. Furthermore, 81.3% of respondents reported having received adequate training on how to put on and remove PPE. Although 90.3% of HCP stated that PPE was readily available at their facility at the time of the survey, 27.7% stated that they had had to reuse PPE in the past due to supply shortages. Also, 31.0% stated that it was difficult to keep up with changing rules and recommendations regarding PPE use during the pandemic.
Differences in COVID-19–related practices by degree of contact with patients known or suspected to have COVID-19
In total, 145 HCP provided information about how frequently they had contact with patients who were known or suspected to have COVID-19 while at work, 58 (40.0%) reported contact at least a few days per week. Survey responses were stratified by the extent of HCP contact with known or suspected patients with COVID-19 and are detailed in Table 2. Notably, a higher proportion of respondents with less contact with patients with COVID-19 agreed that they had inadequate PPE due to supply shortages, with the P value approaching significance (4.6% vs 10.3%; P = .06).
Table 2. Respondent COVID-19 Beliefs, Knowledge, PPE Use, Social Distancing Practices, Fears, and Impact, Stratified by Extent of Contact with Patients with COVID-19
Impact of COVID-19 on HCP at nonacute care facilities
Only 56.1% of respondents reported that their facility made it easy for them to stay home when they were sick, and only 25.2% stated that adequate mental health support had been provided to staff during the pandemic. Many HCP (56.1%) reported having taken on extra responsibilities at work due to staff shortages related to COVID-19, and 52.9% stated that their job had become more stressful because of COVID-19. Half of respondents (50.3%) stated that they felt they were at higher risk for getting COVID-19 because they worked at a healthcare facility, and 18.1% stated that they had been afraid to go to work because of COVID-19. Perhaps because of these factors, 13.5% of survey respondents stated that they had contemplated quitting their job because of COVID-19. HCP with more contact with patients with COVID-19 were more likely to agree with the statement that they had taken on additional responsibilities at work due to staff shortages (63.8% vs 49.4%; P = .027).
Attitudes and beliefs regarding COVID-19 vaccination
When asked about COVID-19 vaccination, 78.1% of respondents reported having received at least 1 dose of COVID-19 vaccine, and 71.6% reported having completed a primary vaccine series. Among vaccinated HCP, the most common reasons given for having decided to be vaccinated were to protect family and friends (84.3%), to help stop the spread of COVID-19 (81.8%), to protect themselves (78.5%), and to protect their patients (73.6%). Among the 34 HCP who reported not having received a COVID-19 vaccine, 9.7% stated that they did not intend to be vaccinated. Among unvaccinated HCP who stated that they did not intend to be vaccinated, the most common reasons given for this decision were concern about vaccine side effects (52.9%), concern that the vaccine had not been tested well enough (50.0%), and concern about how quickly the vaccine was developed (47.1%).
Discussion
Optimal infection prevention in nonacute care facilities has been a unique public health challenge during the COVID-19 pandemic. Disproportionately high rates of COVID-19 spread among patients and/or residents and HCP in nonacute care facilities have been reported. Reference McMichael, Clark and Pogosjans1–Reference Kluytmans-van den Bergh, Buiting and Pas3 Nevertheless, studies evaluating the impact of the pandemic on HCP have primarily focused on acute care facilities. Reference Chew, Lee and Tan10–Reference Wu, Wang and Luo13 In this study, we addressed this knowledge gap by focusing on practices, knowledge, and attitudes regarding COVID-19 among HCP working in 3 types of nonacute care facilities.
Most HCP responding to the survey reported accurate knowledge about COVID-19 transmission and were confident in their ability to protect themselves from infection. However, 31% of HCP reported difficulty keeping up with changing PPE rules and requirements as the pandemic evolved. Implementing effective and concise communication regarding changes in PPE, both at institutional or regional levels, may help reduce potential confusion among HCP. More than half of the HCP who responded to the survey also reported that wearing a mask made communication difficult. This difficulty has been reported as a concern by both the general public and HCP in other studies, especially among hearing-impaired individuals, and strategies such as clear masks have had limited success and raise concerns about PPE effectiveness. Reference Chu, Collins and Chen21,Reference Wong, Yip and Mercer22
Half of the survey respondents felt they were at greater risk for becoming infected because they worked at a healthcare facility, and nearly 20% stated that they had been afraid to go to work. Notably, however, it remains unclear whether HCP who had more frequent contact with patients with COVID-19 were more likely to acquire infection. Studies have shown that the incidence of COVID-19 infection among HCP, regardless of the degree of contact with patients with COVID-19 at their place of work, more closely aligns with the rate of COVID-19 transmission in the general population. Reference Treibel, Manisty and Burton23,Reference Baker, Nelson and Overton24
Several studies have reported high rates of burnout and stress among HCP working at acute care facilities during the COVID-19 pandemic. Reference Lai, Ma and Wang25–Reference Salari, Khazaie and Hosseinian-Far28 Our study revealed a similar pattern among HCP working in nonacute care settings. More than half of the HCP who responded to this survey reported additional work responsibilities and stress due to the pandemic. A notable percentage of HCP (13.5%) had considered leaving their job because of COVID-19. This finding is significant and underscores the need for strategies to mitigate burnout among HCP and to improve retention at LCTFs. Notably, only 25% of the HCP who responded to our survey stated that their facility had provided adequate mental health support to staff during the pandemic, and only half stated that it was easy for them to stay home from work when they were sick. A major strength of this study was including HCP with different job roles and varying levels of contact with patients with COVID-19. This allowed us to evaluate differences in practices and attitudes between HCP who had more versus less contact with patients with COVID-19. Although most beliefs and practices were similar among the 2 cohorts, HCP with more contact with patients with COVID-19 were more likely to agree that they had taken on additional responsibilities due to staff shortages (63.8% vs 49.4%; P = .027), compounding the concern for the impact of the pandemic on HCP taking care of patients with COVID-19.
Although >75% of the HCP who responded to the survey had received at least 1 dose of COVID-19 vaccine, several had not yet been vaccinated, and some did not intend to be vaccinated. Reasons that HCP provided for their vaccine hesitancy were similar to those reported in a study evaluating HCP at acute care facilities Reference Browne, Feemster and Shen29 and included concerns about side effects, rapid vaccine deployment, and inadequate vaccine testing. Since this study was completed, COVID-19 vaccine formulations have received full approval from the Food and Drug Administration (FDA), and booster doses have been recommended by public health guidelines. Future studies could re-examine the prevalence and causes of vaccine hesitancy in this cohort following these changes. Notably, as the pandemic has evolved, studies have shown that societal attitudes toward pandemic-related rules and regulation have undergone a paradigm shift and continue to move away from compliance due to fear alone; these attitudes appear to have become increasingly nuanced. Reference Six, de Vadder, Glavina, Verhoest and Pepermans30,Reference Nivette, Ribeaud and Murray31
This study had several limitations. Guidance regarding PPE use, vaccination requirements, isolation practices have gone through multiple iterations during the COVID-19 pandemic and the availability of resources (eg, PPE, COVID-19 testing and vaccination) have also been quite variable, especially early in the pandemic. Although this survey provides insights into the attitudes and knowledge regarding COVID-19 among HCP working in nonacute care settings at the time of the survey, practices have changed since this time and are likely to further evolve. Future research might focus on re-evaluating the knowledge and beliefs of HCP in nonacute care settings as the healthcare guidelines regarding infection prevention, PPE use, and mandatory vaccination policies are updated. These data were acquired via an anonymous survey to promote honest responses without concern for replies being tracked to an individual. As such, all data were self-reported and did allow for a strategy to ensure nonduplication of responses. Additionally, given the survey participation rate of 25.2%, the HCP who chose to respond may not be representative of all staff who worked at the participating facilities. The results of this survey may also not be generalizable to other nonacute care facilities.
Despite these limitations, these findings provide important insights into the experience, knowledge, beliefs, and perceptions of risk related to COVID-19, infection prevention practices, and COVID-19 vaccination among HCP employed in nonacute care settings. To our knowledge, this is the first in-depth survey that has focused on the impact of COVID-19 on HCP in nonacute care facilities. Additional studies are also warranted to investigate differences in such perceptions and practices between various types of nonacute care facilities. Findings from this survey and future studies can be used to improve infection prevention practices, to design strategies to increase vaccine uptake, to reduce burnout among HCP and improve workforce retention, and to help design interventions to improve occupational health and safety for HCP working at nonacute care facilities at regional and national levels.
Acknowledgments
The authors thank the staff at the participating facilities for sharing their experiences.
Financial support
This work was supported by the US Centers for Disease Control and Prevention (CDC) Prevention Epicenters Program COVID-19 Supplement (grant no. 5U54CK00482). J.H.K. received grant support from the National Institute of Allergy and Infectious Diseases (grant no. 1K23 AI137321-01A1 to J.H.K.). REDCap access at Washington University is supported by Clinical and Translational Science Award (CTSA grant no. UL1 TR000448) and Siteman Comprehensive Cancer Center and NCI Cancer Center (grant no. P30 CA091842).
Conflicts of interest
All authors report no conflicts of interest relevant to this manuscript.
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