Nursing care in a long-term care facility for older people in the context of COVID-19: scoping review

Abstract

Objective

To Identify the scientific evidence on nursing care for older people in a long-term care facility in the context of the COVID-19 pandemic.

Method

This scoping review was based on the Joanna Briggs Institute Reviewers’ Manual guidelines. The question was formulated from the acronym PCC, in which “P” corresponded to “older people, “C” to “nursing care” and “C” to “COVID-19”. The search for scientific evidence was carried out on the LILACS, MEDLINE®, CINAHL® and Web of ScienceTM databases. Articles retrieved using controlled and uncontrolled descriptors, and those from gray literature, websites and repositories were analysed. Descriptive and critical analysis of statistics from the studies was performed.

Results

The final study sample consisted of 14 scientific publications. Most of the output constituted technical reports (35.7%) published in Brazil (64.28%). Nursing care was categorized under: managerial interventions; educational interventions; care interventions, especially those forts preventing and controlling the spread of SARS-CoV-2, residents with suspected or confirmed COVID-19, and handling the corpse in the event of death; interventions facilitating communication between residents and their family/friends and between this group and the nurse; in addition to emotional support interventions for professionals/caregivers and residents.

Conclusion

Amid the COVID-19 pandemic, nursing care is essential to prevent and control the spread of SARS-CoV-2.

Keywords
Older Adult; Gerontological Nursing; Nursing care; Long-Term Care Facility for Older Adults; Coronavirus infections

Resumo

Objetivo

Identificar as evidências científicas sobre os cuidados de enfermagem à pessoa idosa em instituição de longa permanência no contexto da pandemia covid-19.

Método

Trata-se de revisão de escopo baseada nas orientações do Manual para Revisões do Joanna Briggs Institute (JBI). A formulação da questão ocorreu a partir do acrônimo PCC, em que o “P” correspondeu a “pessoa idosa”, o “C” a “cuidados de enfermagem” e o “C” a “covid-19”. A busca das evidências cientificas foi realizada nas bases de dados LILACS, MEDLINE®, CINAHL® e Web of Science^TM. Foram analisados artigos recuperados ao se empregar os descritores controlados e não controlados, e aqueles provenientes da literatura cinzenta, sites e repositórios. A análise deu-se por estatística descritiva e crítica dos estudos.

Resultados

A amostra final do estudo foi composta por 14 evidências cientificas. Verificou-se que a maioria das produções pertenciam a modalidade relatório técnico (35,7%) publicadas no Brasil (64,28%). Os cuidados de enfermagem foram organizados em: intervenções gerenciais; intervenções educacionais; intervenções assistenciais em especial aquelas voltadas à prevenção e controle da disseminação do SARS-CoV-2, residentes com quadro suspeito ou confirmado de covid-19 e ao corpo em caso de óbito; intervenções voltadas a facilitar a comunicação entre os residentes e seus familiares/amigos e entre esses e o enfermeiro; além de intervenções de apoio emocional aos profissionais/cuidadores e aos residentes.

Conclusão

Diante da pandemia covid-19, os cuidados de enfermagem são imprescindíveis para prevenir e controlar a disseminação do SARS-CoV-2.

Palavras-Chave:
Pessoa idosa; Enfermagem gerontológica; Cuidados de enfermagem; Instituição de longa permanência para pessoas idosas; Infecções por Coronavírus

INTRODUCTION

COVID-19, a flu-like infectious respiratory disease, is caused by the novel coronavirus (SARS-CoV-2) and presents with dry cough, fever, dyspnea, myalgia or fatigue and, in more severe cases, with pneumonia, potentially requiring intensive care. The condition is highly transmissible and spreads easily¹,².

The disease had a major global impact due to the large number of infected individuals and notified deaths which, in June 2023, reached 768,237,788 confirmed cases and 6,951,677 related deaths worldwide. Brazil ranks sixth in number of confirmed cases (37,693,506) and second in deaths (704,320)³. However, these figures may be underestimated given the low number of tests made available, coupled with under notification.

Amid this global health emergency, the older population is the most vulnerable to complications due to changes inherent to the aging process²,⁴-⁷. Studies show that the lethality of the disease rises with older age as a result of immunosenescence, rendering older individuals more susceptible to infectious-contagious diseases and unfavorable prognoses⁸-¹⁰.

The mortality rate due to COVID-19 in 2021 led to a higher incidence of deaths among people aged >80 years (14.8%), compared to those in the 70-79 (8.0%) and 60-69 (8.8%) years age groups¹¹,¹². These figures were even greater among residents of Long-Term Care Facilities (LTCFs), where the lethality rate for octogenarians exceeded 15%¹³.

This scenario can be explained by the LTCF setting, including in the national milieu, where residents have a profile of predominantly older individuals with chronic comorbidities, in use of polypharmacy, and with varying digress of dependence, requiring frequent contact with caregivers, health professionals and visitors¹⁴. Moreover, these facilities can be overcrowded, have inadequate physical infrastructure, and staff who are not adequately qualified to cater for the needs of residents¹⁵,¹⁶.

COVID-19 serves as an alert regarding the need to provide quality safe care to older people residing in LTCFs. In this scenario, nurses play a central role in organizing and managing care in LTCFs. This group of health professionals helps reduce the spread of the virus in these environments via strategies to prevent and control infection, and through health education actions, using their close ties with older individuals to promote self-care with autonomy¹⁰,¹⁷.

In view of the context of LTCFs, complexity of the aging process and repercussions of COVID-19 on the older adult population, particularly those residing in these facilities, implementing effective strategies to protect this high-risk group is paramount¹⁰.

Therefore, the objective of this study was to identify the scientific evidence on nursing care for older residents of LTCFs in the context of the COVID-19 pandemic.

METHOD

A scoping review was conducted based on the recommendations from the Joanna Briggs Institute Reviewer’s Manual¹⁸ and according to the recommendations in the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation¹⁹. A study protocol was devised containing the following information: study type, objective, research question, inclusion and exclusion criteria, sample composition, data collection, data extraction and synthesis of information gathered.

The research question was developed using the PCC strategy, where: P (population)= older people; C (concept)= nursing care; C (context)= COVID-19; and defined as: “What is the nursing care for older residents of LTCFs amid the COVID-19 pandemic?”.

In August 2022, a previous search of the Biblioteca Virtual em Saúde (BVS) – Virtual Health Library was carried out to check the uniqueness of the study and devise a search strategy. In September 2022, the bibliographic search of the literature was performed on the following databases: Literatura Latino Americana e do Caribe em Ciências da Saúde (LILACS via BVS), Medical Literature Analysis and Retrieval System Online (MEDLINE® via PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL® - EBSCO), and Web of Science^TM, accessed via the CAPES (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) journals site.

The Grey literature search included the following sites and repositories: Sociedade Brasileira de Geriatria e Gerontologia (Brazilian Society of Geriatrics and Gerontology); Associação Brasileira de Enfermagem- ABEn (Brazilian Association of Nursing), Agência Nacional de Vigilância Sanitária- ANVISA (National Health Surveillance Agency), Brazilian Ministry of Health, Portugal National Health Service, Ministry of Health - Spain, WHO, National Front for Strengthening LTCF and the Universidade Federal do Rio Grande do Norte Repository.

For selection of controlled and non-controlled descriptors, the terms were consulted in the Descritores em Ciências da Saúde - DeCS, the Medical Subject Headings (MeSH) and the List of Headings of the CINAHL. For each database, the controlled and non-controlled descriptors “aged”, “aged, 80 and over”, “elderly”, “Nursing Care”, “Coronavirus”, “Covid-19” and “SARS-CoV-2” were combined using the Boolean operators AND and OR, as per the search terms (Chart 1). The LTCF descriptor was adopted as an inclusion criterion.

Chart 1
Search terms, sites and repositories used for study selection (n=14). Teresina, Piaui state, Brazil, 2022.

LILACS via BVS

((mh:(Idoso)) OR ("Pessoa idosa")) AND ((mh:(Enfermagem)) OR (Enfermagem)) AND (("Covid-19") OR (Coronavírus) OR ("Sars-Cov-2"))

MEDLINE® via PubMed

(((("aged"[All Fields]) OR ("aged, 80 and over"[MeSH Terms])) OR ("elderly"[All Fields])) AND ("nursing care"[MeSH Terms])) AND ("coronavirus"[MeSH Terms])

CINAHL® - EBSCO

(coronavirus OR covid-19 OR sars-cov-2) AND (aged OR ( aged, 80 and over [mesh] ) OR elderly AND nursing care AND coronavirus OR covid-19 OR sars-cov-2)

Web of ScienceTM

(TS=(aged) OR TS=("aged, 80 and over") OR TS=((elderly)) AND TS=(("nursing care")) AND (TS=(Coronavirus) OR TS=("Covid-19") OR TS=("SARS-CoV-2 "))

Sites and repositories

Sociedade Brasileira de Geriatria e Gerontologia / Brazilian Society of Geriatrics and Gerontology

Associação Brasileira de Enfermagem / Brazilian Association of Nursing (ABEn)

National Health Surveillance Agency (ANVISA)

Ministry of Health

Portugal National Health Service

Ministry of Health – Spain

World Health Organization

Frente Nacional de Fortalecimento das ILPI/ National Front for Strengthening LTCIs

Universidade Federal do Rio Grande do Norte Repository

Data collection was performed in three stages: the first employed controlled and non-controlled descriptors adapted for the databases searched; the second applied the descriptors to other databases, sites and repositories to broaden the search; and the third and final stage entailed a search of the list of references from the sources used, including the Gray literature.

Studies involving LTCF residents aged over 60 years and that addressed the subject were included. There were no restrictions for publication date or language. Abstracts published in events annals, studies not answering the research question, and duplicate articles were excluded.

Screening was carried out by two independent reviewers, with the involvement of a third researcher in cases of disagreement. No calibration was performed. Titles and abstracts were first screened to select articles that satisfied the research question and met the inclusion and exclusion criteria. The short-listed records were retrieved and texts read in full. Ineligible articles were excluded, giving a total of 14 articles for inclusion in the review (Figure 1).

Figure 1
Flow diagram of study selection process for review, PRISMA-ScR. Teresina, Brazil, 2022.

Lastly, information on title, country, study type and nursing care were extracted and compiled in a synthesis chart. A critical and descriptive analysis of the data was performed by thorough reading, with results grouped under categories.

RESULTS

The initial search led to the retrieval of 121 publications from the databases and 118 from other sources involving Gray literature for a total of 239 eligible studies. After reading of titles and abstracts, 75 duplicates were removed. Of the remaining studies (n=164), a further 150 were excluded after applying the selection criteria (off-topic). Thus, a total of 14 studies were included in the review, comprising 4 from the databases and 10 from the grey literature, as depicted in Figure 1.

The studies reviewed were from 5 different countries, predominantly Brazil²,²³-²⁹,³³ (64.28%), the United States of America (USA)²⁰,²¹ (14.28%), as well as Portugal³⁰, Spain³¹ and Switzerland³², with the latter 3 accounting for 1 study each (7.14%) (Chart 2).

Chart 2
Records retrieved by scoping review, according to title, type and country (n=14). Teresina, Piaui state, Brazil, 2022.

Citation	Title	Type	Country
20	Coronavirus Disease19 in Geriatrics and Long-Term Care: an update	Article	USA
21	Coronavirus Disease 2019 in Geriatrics and Long-Term Care: The ABCDs of COVID-19	Article	USA
22	COVID-19 e o cuidado de pessoa idosas: recomendações para instituições de longa permanência	Manual	Brazil
23	Recomendações para o enfrentamento da disseminação da COVID-19 em Instituições de Longa Permanência para Pessoa idosas	Article	Brazil
24	Prevenção e controle de infecções por coronavírus em Instituições de Longa Permanência para Pessoa idosas	E-BOOK Chapter	Brazil
25	Precauções nos casos de óbito por COVID-19 em Instituição de Longa Permanência para Pessoa idosas (ILPI)	E-BOOK Chapter	Brazil
26	Orientações para a prevenção e o controle de infecções pelo novo coronavírus (sars-cov-2) em Instituições de Longa Permanência para Pessoa idosas (ILPI).	Technical Note	Brazil
27	Comunicação aos trabalhadores de enfermagem das Instituições de Longa Permanência de Pessoa idosas (LTCF) para o enfrentamento da disseminação do COVID-19	Technical Report	Brazil
28	Telemonitoramento a instituições de longa permanência para pessoa idosas frente às infecções por coronavírus e COVID-19	Article	Brazil
29	Prevenção e controle de infecções pelo novo coronavírus (SARS-CoV-2) a serem adotadas nas Instituições de Longa Permanência de Pessoa idosas (ILPI).	Technical Report	Brazil
30	Orientação nº 009/2020	Technical Note	Portugal
31	Recomendaciones a residencias de mayores y centros sociosanitarios para el COVID-19	Technical Report	Spain
32	Infection Prevention and Control guidance for Long-Term Care Facilities in the context of COVID-19	Technical Report	Switzerland
33	Relatório Técnico da Frente Nacional de Fortalecimento às Instituições de Longa Permanência para Pessoa idosas	Technical Report	Brazil

• Source: Data from search, 2022

With regard to design type, studies were predominantly technical reports²⁷,²⁹,³¹-³³ (35.7%), scientific articles²⁰,²¹,²³,²⁸ (28.5%), e-book chapters²⁴,²⁵ (14.2%), technical notes²⁶,³⁰ (14.2%) and a manual²² (7.4%) (Chart 2). The profile of the interventions is outlined in Chart 3.

Chart 3
Characteristics of publications according to nursing care interventions in long-term care facilities amid COVID-19 (n=14). Teresina, Piaui state, Brazil, 2022.

NURSING CARE
Managerial Interventions
Describe facility standards and routines in a dedicated protocol for prevention and treatment made readily available to team20,22,23,26.
Replan care routines, distributing activities throughout working day so as to avoid crowding among older people and staff23,27.
Allocate dedicated staff to care for residents placed in isolation23,27,30.
Establish flow diagram showing identification, assessment, precautionary measures and procedures for suspected and confirmed cases in the facility27.
Develop and implement measures for preventing and controlling spread of virus within the facility21,22,26.
Ensure provision of PPE for team and residents23,27,33.
Provide means for hand-washing with water and liquid soap; toilet/basin with liquid soap dispenser; paper towel holders; paper towels; rubbish bins with lids and operated without hand contact22.
Managerial Interventions
Provide dispensers containing 70% alcohol-based hand sanitizer gel in LTCF entrance, busy indoor spaces, bedrooms and bathrooms23,27,31.
Supervise hand sanitizing and use of surgical masks by staff when delivering direct care to older people22,23,30,33.
Tele-monitor those without nurse, aiding caregivers in recognizing the main routes of transmission and measures to prevent spread of the infection, and also help in early detection of suspected cases of the virus in professionals and residents21,28.
Assess the vaccination cards of residents and professionals/caregivers to ensure these are up-to-date with all available vaccines 22,23,26,27,33.
Oversee and reinforce cleansing and disinfection of surfaces and utensils used by residents (plates, cups, cutlery etc.)21-24,31,33, besides cleaning of indoor spaces, including final cleaning in rooms22,25,26, keeping the spaces well-ventilated26,31,33.
Educational Interventions
Train LTCF professionals in the use, removal and disposal of PPE, hand cleansing and on measures to be implemented in virus prevention and control21-23,26,27,29,30,32,33.
Guide residents on measures for preventing and controlling spread of virus23,26,27,29,30,32,33.
Advise residents to refrain from sharing personal use items (hair brushes, nail clippers, towels, bedding etc.)26,29,31-33.
Display posters with guidance on hand cleansing measures, respiratory hygiene and coughing etiquette in strategic locations of the facility22,24-26,29,31-33.
Affix notices to bedroom doors describing the precautions and PPE necessary for use in the event of a suspected or confirmed case23.
Care Interventions
Care Interventions
Interventions for Communication with Family
Encourage the use of alternative mechanisms for interaction between residents and family or friends during the period of restricted visiting23,26,27,29,32,33.
Set up times for contact with the family within the nursing routine23.
Provide family members with reports on the general health status of residents by telephone or internet23,27.
Interventions for Psychological Support
Promote psychological and physical wellbeing of professionals/caregivers23,32,33.
Implement measures stimulating workers on actions favoring awareness and attention level at stressing times and emotional support22,23.
Assess signs of Burnout Syndrome in professionals/caregivers, implementing strategies for decompressing the professional to reduce safety risks of residents, offering channel for emotional support and clearing up doubts around the disease20,23,27.
Foster measures to minimize deleterious emotional issues arising from lockdowns, attenuating feelings of missing loved ones among residents and family members/friends22,33.
Offer emotional and practical support through informal networks (family) and health professionals to residents with suspected or diagnosed COVID-1922,32.

• Source: Data from search, 2022

Overall, managerial interventions featured in 11 studies and educational interventions in 10, followed by care and care subdivisions into: control and prevention (=12), residents with suspected condition (n=9), dealing with corpse in the event of death (n=4); and also interventions involving the family (n=6); and psychological support interventions (n=6), as outlined in Chart 3.

DISCUSSION

The majority of the studies reviewed in the present investigation were derived from Grey literature (technical reports, technical notes, manual and E-BOOK chapters), content which has not been screened by reviewers or an Editorial board and, thus, with lower visibility³⁴. This scenario points to the need for more national and international scientific output on the subject.

Brazil ranked highest in number of publications on nursing care in LTCFs amid the COVID-19²²-²⁸,³³, although this is a global discussion. In Brazil, LTCF are linked to the welfare system, dispensing with need for a compulsory nurse, despite the key role of this professional in care settings, irrespective of whether this is stipulated by law. Consequently, in 2019, the Federal Nursing Board recommended the deployment of nurses in LTCF, in a move to ensure risk-free quality care³⁵.

Of the different care initiatives found in the studies of older people in LTCF amid the pandemic, managerial actions highlight education, the essence of nursing, as the key component for preventing and controlling spread of the disease²⁰,²²,²³,²⁶,²⁷,²⁹,³⁰,³²,³³.

Of the variety of duties of nurses, educating contributes as an incentive for self-care, fostering autonomy and co-participation, besides improving adherence to the health measures proposed. Amid the pandemic, this role proved challenging because of the barrage of unreliable information disseminated, detracting focus from the pertinent effective measures for preventing contamination by the novel coronavirus³⁸,³⁹.

Concerning the managerial care of residents with suspected or confirmed diagnosis of COVID-19²⁰-²⁴,²⁶,²⁷,²⁹-³³, the most notable actions were management of waste, cleaning and disinfecting of spaces within the LTCF²⁰-²⁴,²⁶,³¹,³³, as well as handling corpses of deceased individuals who had succumbed to the disease²¹,²⁵,²⁷,³¹.

Nursing care integrates actions of managing waste, the care environment, and care of the individual, from conception to death, coordinating efforts with the other professionals toward implementing interventions tailored to each situation⁴⁰.

Communication with the family, including using technology as a collaborative tool, proved an element of the interventions which was essential for allowing loved ones, kept at a distance due to the suspension of visits, to stay in closer touch with the residents²³,²⁶,²⁷,²⁹,³²,³³, while also providing residents, family members and workers with psychological support²²,²³,³²,³³.

Nurses are responsible for care management at LTCFs, in charge of strategies for training of collaborators (both professionals and non-professionals, besides family members)²⁷, essential in managing care of residents who have tested positive for COVID-19, those suspected of having the disease, and uninfected individuals. The underlying goal of these interventions is to prevent spread, through proper use of Personal Protective Equipment (PPE), hand-washing, and safe observation of recommendations, protocols and health guidance, in a bid to contain the chain of transmission of the disease²¹-²³,²⁶,²⁷,²⁹,³⁰,³²,³³.

It is clear that, within these facilities, the staff and caregivers of the older residents represent the main vehicle of transmission of SARS-CoV-2, since they typically work at more than one service and sometimes, although asymptomatic, carry the virus, readily spreading it to high-risk populations²⁰,²¹. This was illustrated in 2019 by an inspection report by the Federal Board of Nursing which indicated that 500,161 professionals from the category worked more than one job⁴¹.

These findings point to the need for daily monitoring of signs of symptoms of respiratory infection within LTCFs²⁰-²³,²⁶,²⁷. This assessment should be carried out, especially in newly admitted or readmitted residents, with a focus on prevention practices so as to avoid the spread of the virus among other residents ²²,²³,²⁶,²⁷,³⁰-³².

To this end, it is recommended that symptomatic professionals/caregivers take sick leave from the LTCF for up to 14 days from the onset of symptoms, even after vaccination and the presence of new variants of the virus²⁰,²²,²³,²⁷,³⁰-³³,⁴¹. Residents suspected of having the virus or with a confirmed diagnosis of COVID-19 and that do not require hospital admission, should be placed in isolation within well-ventilated private rooms with own bathroom, keeping all doors closed and windows open²²,²³,²⁶,³⁰-³³.

However, given the fact that most national facilities are overcrowded, with shared environments that increase the risk of transmission³³, physical distancing of at least 1 meter between beds should be adopted²²,²³,²⁶,³⁰,³¹,³³.

Moreover, nurses need to manage the headcount in order to minimize staff shortages caused by absenteeism as a result of symptomatic professionals being placed on sick leave, and also to dedicate professionals to delivering care to residents who are suspected or confirmed COVID-19 cases²³,²⁷,³⁰,³¹.

Also within the scope of nursing interventions is preparing the corpse in the event of death in the LTCF, a procedure requiring the use of all PPEs (head covering, protective glasses and face shield, N95 mask or equivalent, impermeable cape or gown, gloves and boots) and hand-washing²³,²⁵,³¹. Natural body orifices must also be blocked to prevent leakage of bodily fluids²³,²⁵, given that the COVID-19 virus survives in fluids after death of the individual³⁶.

With regard to visits to the LTCFs, it is recommended these be suspended during the pandemic²⁰,²²,²³,²⁷,²⁹,³². Therefore, nurses need to incorporate strategies to maintain closer ties between residents and family into their care plan to keep the social support network active, with the use of communication tools such as smartphones, tablets, computers, social media and others²³,²⁶,²⁷,²⁹,³³,.

Providing patient care during the pandemic poses a challenge for health professionals, who must deal with, on a daily basis, intense psychic anguish, manifesting as generalized anxiety disorders, sleep disturbances, fear of becoming sick and contaminating colleagues and family members³⁷. This scenario is no different in LTCFs, where the pandemic further exacerbates preexisting mental and physical burnout of the carer. Thus, an important intervention is the promotion of physical and mental wellbeing of these professionals/caregivers²²,²³,³²,³³.

Regarding unfavorable outcomes, evidence shows that older residents with higher level of dependence and greater number of comorbidities are more likely to have a poorer prognosis³⁵. Therefore, quality humanized integral nursing interventions are essential for this age group residing in LTCF during pandemics, because this approach can help control and prevent the spread of the COVID-19 virus in these services²¹,²²,²⁶,²⁷,³¹,³³.

A limitation of this study was the lack of solid evidence on nursing care for older individuals in LTCF amid the pandemic, given that most of the publications were derived from the Grey literature. It should be noted that these recommendations are subject to changes given the constant updating of information on this novel virus.

CONCLUSION

The present study revealed that the scope regarding nursing care for older people in LTCF amid the COVID-19 pandemic needs expanding.

The nursing care was categorized under the categories: managerial, educational and care interventions, related to the prevention and control of the spread of SARS-Cov-2, in addition to suspected and confirmed cases and handling corpses in the event of death, with communication and health education proving the stand out categories.

Taken together, the results reiterate the importance of having a nurse on the LTCF team, because this professional is involved on all fronts, not only the COVID-19 pandemic, but other conditions affecting the older population.

• No funding was received in relation to the present study.

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Edited by

Edited by: Marquiony Marques dos Santos

Publication Dates

• Publication in this collection
  27 Oct 2023
• Date of issue
  2023

History

• Received
  22 Apr 2023
• Accepted
  17 Aug 2023