To the Editor:
Nursing home (NH) residents are particularly vulnerable to contracting Coronavirus Disease 2019 (COVID-19) because of congregate living and need for personal care. They are also more at risk for adverse outcomes due to advanced age and medical comorbidities.
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The Centers for Medicare and Medicaid Services (CMS) has issued multiple guidelines to prevent the spread of COVID-19 and reduce mortality in NHs, including caregivers use of personal protective equipment, resident cohorting, suspending visitation, and ongoing testing of staff.3
The Indiana State Department of Health (ISDH) conducted statewide NH staff testing in June 2020.
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This effort represented significant investment of resources with logistical challenges that required NH staff cooperation. Nationally, NH staff will continue to be regularly tested for COVID-19, yet we know little about the staff perspective on testing. We surveyed NH staff following Indiana's statewide testing effort to assess attitudes and beliefs about mandatory COVID-19 testing and vaccination.IHCA
2020. Urgent: ISDH issues nursing facility staff COVID-19 testing dates and FAQ - IHCA. Published online on June 8, 2020.
2020. Urgent: ISDH issues nursing facility staff COVID-19 testing dates and FAQ - IHCA. Published online on June 8, 2020.
https://www.ihca.org/resource/urgent-isdh-issues-nursing-facility-staff-covid-19-testing-dates-and-faq/
Date accessed: August 12, 2020
Methods
Testing occurred June 1 to 30, 2020. Facilities either had ISDH staff test on-site or kits were distributed to test staff within 24 hours. Samples were collected via nasopharyngeal or interior nares swabs for a polymerase chain reaction (PCR)-based COVID-19 test. A total of 47,277 staff registered for testing and 28% had unique e-mail addresses. After excluding staff aged <18 years, 18,802 staff formed the sampling frame. A geographically diverse random sample of 4296 were invited to complete a 19-item online questionnaire developed by the investigators. The study was approved by the Indiana University Institutional Review Board.
Results
Overall, 242 (5.6%) staff responded to the survey. Respondent demographics and responses to key questions are in Table 1. Most (n = 167, 69.0%) had no concerns about regular COVID-19 testing and believed testing was “easy” (n = 148, 61.2%), although 50.4% (n = 122) noted testing was “uncomfortable.” Potential barriers to ongoing testing if done outside the workplace included time (n = 135, 55.8%) and cost (n = 106, 43.8%). Among respondents who did not see the importance of regular testing (n = 54, 22.3%), free-text answers anecdotally suggested belief that testing asymptomatic staff has little value if staff are correctly following infection protocols. Many staff have concerns about vaccines, with 26.5% (n = 64) stating they would wait to be vaccinated, 17.8% (n = 43) unsure of whether they will agree to vaccination once available, and 12.4% (n = 30) will refuse vaccination outright.
Table 1Nursing Home Staff Demographics, Attitudes, and Experiences With COVID-19 Testing
| Overall (N = 242) | Clinical staff (n = 111) | Administration (n = 27) | Support staff (n = 45) | Other/Unknown (n = 59) | |
|---|---|---|---|---|---|
| Age, y | |||||
| 18–35 | 79 (32.6) | 38 (34.2) | 22 (37.3) | 14 (31.1) | 5 (48.2) |
| 36–50 | 88 (36.4) | 40 (36.0) | 20 (33.9) | 15 (33.3) | 13 (48.2) |
| 51–64 | 63 (26.0) | 28 (25.2) | 15 (25.4) | 12 (26.7) | 8 (29.6) |
| 65+ | 12 (5.0) | 5 (4.5) | 2 (3.4) | 4 (8.9) | 1 (3.7) |
| Race | |||||
| White | 203 (83.9) | 88 (79.3) | 23 (85.2) | 41 (91.1) | 51 (86.4) |
| Black | 21 (8.7) | 12 (10.8) | 2 (7.4) | 2 (4.4) | 5 (8.5) |
| Other | 18 (7.4) | 11 (9.9) | 2 (7.4) | 2 (4.4) | 3 (5.1) |
| Ethnicity | |||||
| Not Hispanic/Latino | 226 (93.4) | 107 (96.4) | 25 (92.6) | 43 (95.6) | 51 (86.4) |
| Hispanic/Latino | 4 (1.7) | 1 (0.9) | 1 (3.7) | 0 - | 2 (3.4) |
| Unknown | 12 (5.0) | 3 (2.7) | 1 (3.7) | 2 (4.4) | 6 (10.2) |
| Nursing home location | |||||
| Urban | 165 (68.2) | 77 (69.4) | 14 (51.9) | 32 (71.1) | 42 (71.2) |
| Rural | 76 (31.4) | 33 (29.7) | 13 (48.2) | 13 (28.9) | 17 (28.8) |
| Unknown | 1 (0.4) | 1 (0.9) | 0 - | 0 - | 0 - |
| Describe your most recent experience of being tested. (Check all that apply) | |||||
| Uncomfortable | 122 (50.4) | 60 (54.1) | 12 (44.4) | 21 (46.7) | 29 (49.2) |
| Easy process | 148 (61.2) | 72 (64.9) | 17 (63.0) | 29 (64.4) | 30 (50.9) |
| Fast process | 121 (50.0) | 65 (58.6) | 12 (44.4) | 19 (42.2) | 25 (42.4) |
| Painful | 34 (14.1) | 15 (13.5) | 4 (14.8) | 6 (13.3) | 9 (15.3) |
| Not upsetting at all | 26 (10.7) | 16 (14.4) | 2 (7.4) | 3 (6.7) | 5 (8.5) |
| Upsetting in some way | 17 (7.0) | 7 (6.3) | 1 (3.7) | 3 (6.7) | 6 (10.2) |
| Frustrating | 15 (6.2) | 5 (4.5) | 2 (7.4) | 3 (6.7) | 5 (8.5) |
| Other | 5 (2.1) | 1 (0.9) | 0 - | 1 (2.2) | 3 (5.1) |
| No response | 8 (3.3) | 4 (3.6) | 1 (3.7) | 1 (2.2) | 2 (3.4) |
| Do you think it is important for nursing home staff to get tested on a regular basis for coronavirus? | |||||
| Yes | 172 (71.1) | 80 (72.1) | 17 (63.0) | 35 (77.8) | 40 (67.8) |
| No | 54 (22.3) | 24 (21.6) | 8 (29.6) | 8 (17.8) | 14 (23.7) |
| Prefer not to answer | 16 (6.6) | 7 (6.3) | 2 (7.4) | 2 (4.4) | 5 (8.5) |
| Do you have concerns about getting tested yourself on a regular basis for coronavirus? | |||||
| Yes | 55 (22.7) | 30 (27.0) | 2 (7.4) | 11 (24.4) | 12 (20.3) |
| No | 167 (69.0) | 74 (66.7) | 23 (85.2) | 31 (68.9) | 39 (66.1) |
| Prefer not to answer | 20 (8.3) | 7 (6.3) | 2 (7.4) | 3 (6.7) | 8 (13.6) |
| What barriers do you have to testing outside of work? (Check all that apply) | |||||
| Time | 135 (55.8) | 66 (59.5) | 13 (48.2) | 19 (42.2) | 30 (50.9) |
| Cost | 106 (43.8) | 50 (45.1) | 10 (37.0) | 23 (51.1) | 23 (39.0) |
| Transportation | 34 (14.1) | 17 (15.3) | 2 (7.4) | 8 (17.8) | 7 (11.9) |
| No barriers | 30 (12.4) | 14 (12.6) | 2 (7.4) | 5 (11.1) | 9 (15.3) |
| Other | 10 (4.1) | 3 (2.7) | 1 (3.7) | 0 - | 6 (10.2) |
| Prefer not to answer | 27 (11.2) | 10 (9.0) | 4 (14.8) | 4 (8.9) | 9 (15.3) |
| Willingness to be tested and vaccinated for coronavirus | |||||
| Tested and vaccinated | 114 (47.1) | 49 (44.1) | 16 (59.3) | 21 (46.7) | 28 (47.5) |
| Tested, but not vaccinated | 60 (24.8) | 32 (28.8) | 5 (18.5) | 13 (28.9) | 10 (17.0) |
| Not tested, but vaccinated | 5 (2.1) | 1 (0.9) | 0 - | 1 (2.2) | 3 (5.1) |
| Not tested or vaccinated | 17 (7.0) | 8 (7.2) | 0 - | 3 (6.7) | 6 (10.2) |
| Prefer not to answer | 46 (19.0) | 21 (18.9) | 6 (22.2) | 7 (15.6) | 12 (20.3) |
| Once a coronavirus vaccine is available | |||||
| Will wait to get vaccinated | 64 (26.5) | 26 (23.4) | 10 (37.0) | 13 (28.9) | 15 (24.4) |
| Will get vaccinated as soon as possible | 58 (24.0) | 24 (21.6) | 7 (25.9) | 14 (31.1) | 13 (22.0) |
| Unsure | 43 (17.8) | 24 (21.6) | 3 (11.1) | 6 (13.3) | 10 (17.0) |
| Will not get vaccinated | 30 (12.4) | 17 (15.3) | 1 (3.7) | 4 (8.9) | 8 (13.6) |
| Prefer not to answer | 47 (19.4) | 20 (18.0) | 6 (22.2) | 8 (17.8) | 13 (22.0) |
Values are n (%).
∗ Includes certified nursing assistants, registered nurses, physical/occupational/speech therapists, licensed practical nurses, and physician assistants.
† Includes staff involved in providing services such as dietary, activities, housekeeping, and social services.
Discussion
Our survey of NH staff demonstrates that most NH staff are willing to undergo regular COVID-19 testing, but 1 in 4 had concerns or questioned the importance. Recent CMS guidelines specify NH staff must be tested at least monthly, and more often in areas with high levels of community COVID-19 activity, with facilities penalized for noncompliance.
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Without facility-based testing, staff face barriers such as time and cost to getting tested, thus underscoring the importance of providing workplace testing. Although CMS has begun distributing point-of-care antigen testing machines, concerns about the accuracy and availability and cost of test supplies remain.Centers for Medicare and Medicaid Services
Interim Final Rule (IRC), CMS-3401-IFC, additional policy and regulatory revisions in response to the COVID-19 public health emergency related to long-term care (LTC) facility testing requirements and revised COVID-19 focused survey tool. Published online August 26, 2020.
Interim Final Rule (IRC), CMS-3401-IFC, additional policy and regulatory revisions in response to the COVID-19 public health emergency related to long-term care (LTC) facility testing requirements and revised COVID-19 focused survey tool. Published online August 26, 2020.
https://www.cms.gov/files/document/qso-20%5f38-nh.pdf
Date accessed: August 31, 2020
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Centers for Medicare and Medicaid Services
FAQs about COVID-19 testing in skilled nursing facilities. Published online August 5, 2020.
FAQs about COVID-19 testing in skilled nursing facilities. Published online August 5, 2020.
https://www.cms.gov/files/document/covid-faqs-snf-testing.pdf
Date accessed: August 30, 2020
Some staff expressed beliefs that asymptomatic testing of staff is not important. Notably, 29.6% (n = 8) of administrators noted ongoing testing was not important compared with 21.6% (n = 24) of clinical staff. Any division between staff and administrators could result in testing noncompliance, and failure to identify asymptomatic staff could have significant consequences for residents.
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Coupling education with mandatory staff testing as a condition of employment and in-facility, less-invasive testing methods (ie, nasal swabs or salvia vs nasopharyngeal swabs) may ensure compliance. Answers varied among staff positions with future vaccine uptake, 3.7% (n = 1) of administrators will not get vaccinated compared with 15.3% (n = 17) of clinical staff. As noted by our results, when a vaccine is available, assurances of safety and efficacy will be necessary for NH staff uptake. Prior research has noted NH staff have poorer influenza vaccination rates compared with other health care workers.8
Thus, if a safe and effective vaccine becomes available, significant resources and strategy will likely be needed to promote uptake among NH staff.Cdc.gov
2020. Influenza vaccination information for health care workers | CDC.
2020. Influenza vaccination information for health care workers | CDC.
https://www.cdc.gov/flu/professionals/healthcareworkers.htm
Date accessed: August 11, 2020
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Limitations include a low response rate (5.6%); however, the distribution of respondents versus nonrespondents did not differ by race, ethnicity, or urbanicity; certified nursing assistants were underrepresented (16.5% responding vs 27.5% overall). Despite a low response rate, these data have value in understanding the experiences and attitudes of NH staff about COVID-19 testing, and potential vaccination. Federal and state officials and industry leaders have been grappling with the best approaches to ongoing testing during this pandemic, weighing likelihood of benefit with cost and supply issues. The attitudes and beliefs of staff, who provide the day-to-day care for NH residents, are key to understanding strategies required for successful implementation of ongoing testing programs.
References
- Long-term care facilities and the coronavirus epidemic: Practical guidelines for a population at highest risk.J Am Med Dir Assoc. 2020; 21: 569-571
- COVID-19 in older adults: transfers between nursing homes and hospitals.The Journal of Geriatric Emergency Medicine. 2020; 1
- Nursing home reopening recommendations for state and local officials. Published online on May 18, 2020.(Available at:)
- 2020. Urgent: ISDH issues nursing facility staff COVID-19 testing dates and FAQ - IHCA. Published online on June 8, 2020.(Available at:)https://www.ihca.org/resource/urgent-isdh-issues-nursing-facility-staff-covid-19-testing-dates-and-faq/Date accessed: August 12, 2020
- Interim Final Rule (IRC), CMS-3401-IFC, additional policy and regulatory revisions in response to the COVID-19 public health emergency related to long-term care (LTC) facility testing requirements and revised COVID-19 focused survey tool. Published online August 26, 2020.(Available at:)https://www.cms.gov/files/document/qso-20%5f38-nh.pdfDate accessed: August 31, 2020
- FAQs about COVID-19 testing in skilled nursing facilities. Published online August 5, 2020.(Available at:)https://www.cms.gov/files/document/covid-faqs-snf-testing.pdfDate accessed: August 30, 2020
- Facility-wide testing for SARS-CoV-2 in nursing homes - seven U.S. jurisdictions, March-June 2020.MMWR Morb Mortal Wkly Rep. 2020; 69: 1095-1099
- 2020. Influenza vaccination information for health care workers | CDC.(Available at:)https://www.cdc.gov/flu/professionals/healthcareworkers.htmDate accessed: August 11, 2020
- Influenza vaccination rates and beliefs about vaccination among nursing home employees.Am J Infect Control. 2015; 43: 100-106
Article info
Publication history
Published online: November 05, 2020
Footnotes
This work was supported by the US Department of Health and Human Services, Centers for Medicare and Medicaid Services (Funding Opportunity 1E1CMS331488). The opinions expressed in this article are the authors' own and do not reflect the view of the US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Kathleen T. Unroe is the CEO of Probari, a health care start-up designed to disseminate a successful registered nurse–based clinical care model in NHs.
Identification
Copyright
© 2020 Published by Elsevier Inc. on behalf of AMDA - The Society for Post-Acute and Long-Term Care Medicine.
