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Category 11: Lack of access to equipment

On occasion, nurses lacked the right materials for in-home care, such as disinfectants, gloves and aprons. (Wendt 2022) (U)

Further exacerbating this challenge was the limited availability of adequate hand hygiene products in patients鈥� homes. (Osakwe 2021) (C)

Many home health aides experienced challenges with having an adequate supply of personal protective equipment (PPE) during the pandemic. Some noted structural barriers related to the home health care office being closed when their shifts end, making it hard to get access to supplies. (Osakwe 2021) (U)

Many home health care workers also reported that they lacked adequate PPE from their agencies, including masks and gloves, which they felt was essential for care. (Sterling 2020) (U)

It was also noted that accessing pandemic resources, such as PPE, was a challenge. Home-based care providers described not being well-connected or prioritized in terms of public health resources. Community-based organisations were found to be more available as a support to acquire PPE than government resources. (Bell 2022) (U)

Some agencies even reported having a stockpile in place due to previous experience with communicable disease outbreaks. (Bell 2022) (U)

The participants explained that at the beginning of the pandemic they were not allowed to wear protective gear in the form of masks or face shields when in close contact with patients because of the scarcity of protective gear, which worried them. (Emmesj枚 2022) (C)

The authorities had stated that this protective gear was unnecessary when working with older patients, and there was a nationwide lack of protective gear. The participants explained how they had been told that protective gear needed to go to hospitals instead, because of the scarcity of it.

(Emmesj枚 2022) (C)

Some participants bought their own protective gear when it was not supplied by the municipality or primary health care center. When the protective gear was allowed to be worn, the participants were relieved since it was a relief easing the worry of infection. (Emmesj枚 2022) (C)

After protective gear was permitted, the way RNs and MICM-physicians worked changed. Protective gear was used constantly when the RNs and MICM-physicians were within two meters of a person during work, and the participants became less worried about infecting someone or being infected themselves. (Emmesj枚 2022) (C)

One challenge that was particularly prevalent at the start of the pandemic was the lack of equipment. One nurse told how they ordered huge amounts of infection control equipment and yet received only small numbers. (Moi 2022) (U)

Caregivers described the additional economic burden of the pandemic measures. This situation highlights one way in which pandemic response measures disproportionately impacted people with low incomes, who are often older people with fixed incomes. (Baumbusch 2022) (C)

There was also scarcity of supplies that they were already using, and now stores were limiting purchases or sold out entirely. She also shared how stores increased prices in response to pandemic demand. (Baumbusch 2022) (C)

F11.3: Although most administrators reported having sufficient supplies of PPE, some aides described shortages or difficulties obtaining it. (Franzosa 2022) (U)

Category 12: Lack of access to clear information, guidelines and communication

Nurses, professional caregivers and clients found that different protocols were given by different institutions, hospitals and colleagues, resulting in fragmentation, variation, discrepancies or conflicting information. [鈥�] Furthermore, these nurses, caregivers and clients recognized differences between home-based nursing care teams in dealing with certain situations, guidelines and protocols,[...] At times, these nurses and professional caregivers doubted the accuracy of the information they received. (Wendt 2022) (U)

Nurses indicated that they had reservations regarding whether the World Health Organisation鈥檚 recommended 鈥楩ive Moments for Hand Hygiene鈥� 鈥榝it鈥� the home-based nursing care environment (Wendt 2022) (U)

Generally, in offices or in the nurses鈥� cars, cleaning or disinfecting wipes were available, but the nurses doubted the right ways (method and materials) and times to clean [electronic devices]. Thus, these wipes were used in only a few instances. (Wendt 2022) (C)

Nurses sometimes experienced untimely or incomplete transfers of clients鈥� health records when clients were transferred from other care environments to their homes. For instance, this can occur when a client carries a multidrug-resistant organism. (Wendt 2022) (C)

Although some agencies adapted quickly to the pandemic by providing workers with COVID-19鈥搑elated information on a weekly or daily basis, others reportedly barely communicated about the pandemic. (Sterling 2020) (U)

Home-based care providers and their patients鈥� experienced frustration around the lack of clear and consistent information from public health officials on health, safety, and wellbeing during the novel pandemic. The delayed timing and execution of pandemic messaging hindered both providers鈥� and patients鈥� preparedness. [...] Providers felt they were not able to pass along adequate information to patients, as the information was uneven and, in some cases, conflicting. Likewise, the lack of response from public health authorities left home-based care provider agencies confused on what care measures were appropriate given the uncertainty around the virus. (Bell 2022) (U)

To cope with this lack of information, home-based care provider agencies turned to the Centers for Disease Control and Prevention (CDC) or their own infection control plans; however, the novelty of the virus left many to question what to do to protect themselves and their patients in the onset of the pandemic. (Bell 2022) (U)

Among Spanish-speaking participants, gaining access to COVID-19 related information necessary to facilitate patient care was a challenge. Spanish-speaking home health aides preferred working with Spanish-speaking patients. Another home health aide expressed how language posed a barrier to effective communication with non-Spanish-speaking home health care nurses. [...] Because of limited English proficiency, Spanish-speaking home health aides had to locate resources to facilitate communication with patients, families and the health care team, and to understand COVID- 19 related information. Many Spanish-speaking home health aides thus relied on their family members to translate care plans or clinical information. (Osakwe 2021) (U)

F7.6 To prevent transmission, the participants explained that they followed the authorities鈥� restrictions, even if the recommendations changed often. The changing directives were seen as challenging, but the RNs and MICM-physicians worried less about transmission if they knew that they were following up-to-date recommendations. The MICM-physicians or RNs held information or visited personnel meetings to answer questions from the ANs [assistant nurses] about COVID-19, as the participants noticed that the ANs needed additional l knowledge to ease their worries about infecting others. (Emmesj枚 2022) (C)

The routines for the protective equipment were interpreted differently and changed rapidly. There were differences in which protective equipment was used and how it was handled, whether it was put on in or outside the home, and where the material was then disposed of or cleaned. Using the protective equipment caused physical problems in the work environment. Participants said that they needed to manage it outside the home and it could be cold to clean the equipment in the cars in winter. (Tavemark 2022) (C)

Nurses experienced a significant lack of information and explicit guidelines at the start of the pandemic. When the public guidelines emphasized the extensive benefits of using a face mask, the nurses were instructed not to use one. (Moi 2022) (U)

Significant uncertainty was prevalent both nationally and locally and the uncertainty was reinforced in their specific work situation. (Moi 2022) (U)

Category 13: Restricted access to Covid-19 testing

Home health aides indicated that they wanted to know if their patient or patient鈥檚 family had tested positive for COVID-19 but emphasized that this information was not available. They also expressed concern regarding the lack of information about the COVID-19 status of other home health aide colleagues who also care for their patient and how this might put them at risk for exposure to COVID-19. (Osakwe 2021) (U)

In addition to uncertainty regarding the COVID-19 status of others, HHAs worked with a fear of not knowing their own COVID-19 status because they had not been tested. [鈥�] Home health aides expressed frustration with the limited information they received from home health care nurses or their agency about getting tested. (Osakwe 2021) (U)

While home health aides expressed concerns about lack of access to testing, many HHAs appreciated the daily screening COVID-19 which their agencies conducted via telephone. (Osakwe 2021) (C)

Some agencies asked participants to perform daily 鈥渟elf-assessments.鈥� Self-assessments, which were usually automated by phone, were intended to screen home health care workers for COVID-19 symptoms. Depending on how they answered, workers would be encouraged to go to work or to call their doctor. (Sterling 2020) (U)

Category 14: Limited opportunities provided for staff training and knowledge transfer

Several participants with a role in infection prevention and control (IPC) talked about their lack of formal training, as well as the limited number of resources focused on IPC specifically in home health care. (Pogorzelska-Maziarz 2020) (U)

Furthermore, a high workload played a negative role in knowledge transfer. Beyond this, the fact that employees are not paid for time spent on knowledge transfer was seen as an impediment. (Wendt 2022) (U)

Working alone made it very difficult for nurses to observe their colleagues or to discuss infection prevention practices. In such cases, the implementation and evaluation of new information or policy changes were problematic. (Wendt 2022) (U)

Having an agency dedicate time and money toward staff education (whether preemptive or reactive) was viewed as critical for clinicians to be able to provide quality care to their patients. (Pogorzelska-Maziarz 2020) (U)

A number of participants viewed their prior training as a contributing factor to their preparedness during the pandemic. They described how frequent contact with patients with infectious conditions prior to the COVID-19 pandemic contributed to a sense of mastery in infection control practices. The education they received prior to the onset of the pandemic provided them with foundational knowledge in infection control practices, particularly around use of personal protective equipment (PPE) and protocols intended to minimize the spread of infection such as hand hygiene. (Bell 2022) (U)

Category 15: Importance of home health care agency infection prevention and control preparedness and coordination

Yet, not all agencies, or providers felt as prepared. While some agencies did have a pandemic plan, providers were either not familiar with its details or felt their infection control plan fell short given the unknown needs of this novel pandemic. (Bell 2022) (C)

Several participants described specific ways in which agencies have improved teamwork and care coordination. (Pogorzelska-Maziarz 2020) (U)

Furthermore, having leadership support and encouragement allowed staff members to take on IPC as a key initiative. (Pogorzelska-Maziarz 2020) (U)

Finally, some agencies described utilizing real-time data, such as data from their electronic medical records, as a key to success because they were able to direct their often-limited resources to target specific areas for improvement, often related to IPC. (Pogorzelska-Maziarz 2020) (U)

To get information about the spread of infection in the municipality, the staff had a review of the infection situation at the unit every morning and afternoon. At the daily meetings, the content of the day鈥檚 home visits was prioritized with the support of the manager, something that was perceived as valuable, especially at the beginning of the pandemic. At these meetings, it was also verified that everyone had been informed in the event of an infection. Nurses and unit heads had a great responsibility, but it was not clear who they should inform. (Tavemark 2022) (U)

As well as challenges associated with obtaining enough equipment, participants experienced the importance of how their immediate superior and their district manager acted after the outbreak of the pandemic. Many had positive experiences with their manager regarding how they dealt with the challenges. (Moi 2022) (U)

The participants had gained a much better understanding of infection control than previously, in addition to the increased attention from the wider society. Infection control routines were drawn up in all the districts and participants felt the routines to be clear. They had gained knowledge and experience that gave them increased confidence to confront new pandemics. (Moi 2022) (U)