Aside from early in the pandemic, most nursing homes have not been invaded by COVID-19, even when the virus has run riot in nearby cities – and the question is why. Why is it that even when adjacent communities that are home to health care workers and residents’ families alike have high rates of COVID carriers, regional nursing homes usually continue to be COVID free? I believe the answer to this question is relevant for everyone, and not just for those associated with nursing homes.
Nursing homes’ strategies for coping with the pandemic have been qualitatively different from those of governments. Governments, not only in Israel, have adopted accordion-like compression and expansion tactics: the more widespread the virus, the more stringent the social and economic restrictions imposed on the public. Then, as better control of the virus is attained and restrictions are lifted, the social accordion expands. Nursing homes in Israel, on the other hand, after a period of initial adjustment, and following the first lockdown, have tended to try to maintain an equilibrium, with only minimal variations of policy. Rather than changing established rules, they have focused on enforcing compliance with them. Thus, for example, during the recent lockdown, in the two nursing homes where I work, families were still able to visit, provided they complied meticulously with the Corona-related precautions.
Two metaphors come to mind when dealing with and understanding the potential pitfalls of living with the pandemic: dieting and traffic accidents.
The diet metaphor: Let us imagine that I am overweight, go on a diet and slim down within a few months. However, in the months following the initial period of success, I, like most dieters, put the weight back on again.
Why do such diets tend to fail?
- The diet itself is unsustainable; that is, a person may temporarily manage to follow it, but its demands are too onerous or too unhealthy to stick with indefinitely.
- The dieter expects a quick fix, whereas in reality, to be successful, a diet invariably requires a major behavioral shift and long-term changes in outlook and lifestyle.
To apply this metaphor to COVID-19 policies: governments need to introduce regulations that are implementable over time. Both they and the populations they serve must accept the unpleasant fact that, like a diet, these regulations will succeed only if sustained for an indefinite period.
Now let us look at how governments try to minimize traffic injuries and deaths: Every year people are maimed and killed in traffic accidents. The only way to stop this is to ban driving altogether. Since this solution is unacceptable, societies therefore compromise by taking calculated risks, regulating driving to facilitate maximal usage of the roads with minimal injuries and fatalities.
What does this have to do with learning to live with Corona?
In theory one might seek to stop COVID-19 in its tracks. However, as this would mean a complete shutdown of society for an indefinite period, as a solution it is both unreasonable and unfeasible.
The other extreme – to ignore the virus and let it run its natural course – is equally unpalatable. Two countries that come closest to implementing this approach are Brazil and the USA. While not all COVID-19 deaths and morbidity (sickness) can be prevented, if we strive for a balance (as with traffic injuries and fatalities) we can often attain a significantly lower rate of illness and death at the cost of just a moderate number of social and economic impositions.
Acculturation: I regard families’ and health care workers’ successful long-term adjustment to the pandemic as acculturation. What is remarkable about this adjustment is that it is not demographic: even those who live in ethnic communities where viral spread is extensive have remained healthy, because they have adopted social behaviors that prevent their catching the virus. Individual responsibility is a key factor in success here. On a national scale, we can observe successful acculturation of this kind in several Asian countries which, through cooperation and compliance, have limited viral damage more effectively than we have in the West.
Stakeholders: In a nursing home the main stakeholders are the residents, their families, the health care workers, the nursing home administration and the ministry of health. Since all of these have a vested interest in preventing viral infiltration, all have a shared goal. However, to minimize potential danger, each individual stakeholder must behave responsibility by putting up with the restrictions and cumbersome behavior necessary to contain viral spread.
- Families have realized that, to keep their loved one safe, family visits must be rigidly controlled and coordinated with the administration, and necessary social precautions must be observed. It is not easy for a loving son or daughter to have a time limit imposed on their visit to dad or mom, to be with them only in a designated space within the nursing home rather than in the resident’s room, and to have to wear a mask and observe social distancing without being able to hug, feed or even touch. While this has been agonizingly difficult, we have found that all the families have come to appreciate the importance of their cooperation as the only viable compromise.
- Health care workers have had to become accustomed to washing their hands frequently, to wearing masks, gloves and often a gown for long periods, and also to taking appropriate precautions while away from the nursing home. No veteran workers have so far introduced the virus into the nursing homes where I have been working throughout these long months.
- Residents do not really have a choice, and they pay a high price for the social isolation imposed by COVID-19 precautions. We have noted an increase in general deterioration and more anxiety, confusion and depression since the onset of the pandemic. Because of this, it behooves us all to prefer strict compliance with less extreme social measures over more drastic action, such as forbidding family visits altogether, as was done during the first lockdown.
- The administration must take the lead in helping staff to follow the required protocols. This can be done by explaining, emphasizing, and reiterating their importance and by ample provision of the supplies necessary for their implementation. Non-compliance issues with workers or family members must be addressed immediately and consistently. Administrators should express appreciation and gratitude to those who cooperate, and show understanding when individuals encounter personal problems due to the pandemic. While all these points are important, the administrative staff should above all lead by personal example. Doing so sends a clear message that we are all in this imbroglio together.
On a countrywide scale, the stakeholders are the public at large, the government and the ministry of health – all of us.
Why is there such a difference in behavior between inside the nursing home and outside it? There are two important reasons. One is that those who deal with the frail have no choice but to take the stark potential dangers of COVID-19 very seriously. Secondly, the stakeholders associated with a nursing home are bound by a sense of community. They all know one another. There is a personal commitment and an awareness of the obligation to the social fabric and the welfare of others connected to the nursing home that is apparently absent on the national scale.
In countries in which public leaders have flouted their own regulations, I only see two unpleasant reasons for such non-compliance: Either the regulations are too stringent, or the leadership does not appreciate that if there is not across the board compliance including themselves, the likelihood of failure of viral containment will be unfortunately greater.
The conclusions to be drawn from this analysis of the best way to live with the pandemic both within a nursing home context and in general are: to accept that we are in this together for the long term and to try to comply with the basic communal impositions of mask-wearing, social distancing and avoidance of large gatherings, especially indoors.