Care home staff were left 'stressed and anxious' about accepting patients from hospitals with unknown Covid-19 status and had concerns about controversial do not attempt cardiopulmonary resuscitation (DNA-CPR) orders during the pandemic, according to a new survey from the Queen’s Nursing Institute (QNI).

The report from the QNI is based on a survey conducted in May and June 2020 to assess the effect of the Covid-19 pandemic on the UK’s nursing and residential homes.

The majority of respondents found the early months of the pandemic a challenging experience and stated that their work and wellbeing had been worse or much worse than at normal times.

According to the report, 43% of respondents reported receiving residents from the hospital with an unknown Coivd-19 status during March and April 2020 and 21% said that their home accepted people discharged from hospital who had tested positive for Covid-19.

Some respondents also raised serious ethical and professional concerns about GPs, Clinical Commissioning Groups and hospital trusts making resuscitation decisions without first speaking to residents, families and care home staff or trying to enact ‘blanket’ DNA-CPR decisions for whole groups of people.

The majority (95%) said there had been no changes in the decision making around DNA-CPR, but 16 respondents reported negative changes which they found challenging.

This included “blanket DNA-CPR” decisions, or decisions taken about resuscitation status by others without discussion with residents, families or care home staff or that they disagreed with some of the decisions on legal, professional or ethical grounds.

Care home staff wellbeing suffered due to challenging issues

Professor Alison Leary MBE, Director of the ICNO and Professor of Healthcare and Workforce Modelling at London South Bank University, said: "It is clear from this survey that the care home workforce has faced very challenging issues. Many have felt unsupported and their wellbeing has suffered. We need to support this workforce to face the challenges ahead.”

Other issues highlighted included lack of guidance on personal protection and poor access to pay if they became ill. While two thirds of respondents said they ‘always’ had access to appropriate personal protective equipment (PPE) and most others said that it was usually available, a small minority were not provided with PPE and had to improvise, by obtaining it themselves or by making it.

The majority of survey respondents found it easy to access hospital care for their residents when this was required; however, a substantial minority found this difficult or very difficult. Additionally, a substantial number found it difficult to access District Nursing and GP services.

Dr Crystal Oldman CBE, the QNI’s Chief Executive commented: “The care being delivered in a home can at times be as intensive as in a hospital – in particular for end of life care – and it is hugely skilled work. As the majority of respondents to this survey indicate, the people living in their care homes need a combination of support for complex physical and cognitive needs.

“Overall, as would be expected, the picture presented is of an extremely stressful and anxious period for professionals working to care for and protect their residents. The positives represent a silver lining to this cloud and there are numerous testaments to the skill, dedication, professionalism and teamwork that Care Home Nurses have displayed in 2020. In addition, this brief insight into the experiences of the nurses provides an opportunity to consider and plan for the support systems that may be needed in the anticipated second wave of Covid-19.

“More needs to be done to understand the effect of Covid-19 on the workforce and residents in care homes. Urgent attention must be paid to the sector if the workforce is to withstand the additional demands of the pandemic, particularly in planning, guidance and employment practices.”

Key findings of the care home survey 

Most respondents reported caring for older people (97, 60%) with just under a third reporting caring for a mixture of residents of different ages and needs (48, 29%). Most (70%; 114) respondents were Registered Nurses (RN) and 28% (46) were managers. 78% of respondents were over the age of 45 (128).

The majority (71%) reported it was easy or somewhat easy to access end of life medication/services for residents who required it, with 12% reporting it difficult or very difficult.

Some saw Covid-19 as a positive focus for change in talking about end of life care and a discussion of practice or ceiling of care, for example, moving to a recommended summary plan for emergency care and treatment (RESPECT) process or a reason to initiate conversations around dying and residents’ wishes.

Around 20% of responses reported positive or mixed sentiment around the experience of working through Covid-19, for example pride in their colleagues or new workforce opportunities. 80% of responses reported very negative experiences.